**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure a copy of the advance directive was maintained in the medical record for one of three final sampled residents (Resident 5) reviewed for advance directives. This failure had the potential for Resident 5's decisions regarding his healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directive reviewed 1/2/25, showed prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative about the existence of any written Advance Directives. Further review of the P&P showed information about whether or not the resident has executed an advance directive shall be display prominently in the medical record. Medical record review for Resident 5 was initiated on 4/14/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE], and 1/16/25. Review of Resident 5's POLST dated 1/16/25, showed Resident 5's advance directive was not available. Review of Resident 5's H&P examination dated 1/17/25, showed Resident 5 had fluctuating capacity and could make needs known. Review of Resident 5's Interdisciplinary Care Conference notes dated 1/21/25, showed Resident 5's Family Member 1 stated the resident had an advance directive and would bring in a copy of the advance directive. Review of Resident 5's medical record failed to show a copy of the advance directive was maintained in Resident 5's medical record. On 4/15/25 at 1024 hours, an interview and concurrent medical record review for Resident 5 was conducted with the SSD. The SSD verified there was no copy of Resident 5's advance directive in the medical record, nor was it uploaded in Resident 5's EMR. The SSD stated Resident 5 had an advance directive and should have followed up and obtained a copy of the resident's advance directive. The SSD further stated a copy of the advance directive should have been maintained in Resident 5's medical record and should have been readily retrievable by the facility staff. On 4/16/25 at 0853 hours, the DON was informed and acknowledged the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one nonsampled resident (Resident 41). * The facility failed to ensure a physician's order was obtained, a care plan was formulated, the assessment was completed, and the appropriate instructions were obtained to maintain the appropriate care of a heart monitoring machine for Resident 41. These failures had the potential for the residents to not receive the necessary care and services to maintain their highest physical well-being. Findings: Review of the facility's P&P titled General Equipment Use Guidelines dated 3/4/25, showed the residents admitted with equipment to follow the manufacturer guidelines for use and management. On 4/14/25 at 0913 hours, an observation and concurrent interview was conducted with Resident 41 in her room. Resident 41 was observed with a machine on top of her bed plugged in to the electrical wall outlet and with a pillowcase on top. Resident 41 stated she had a heart condition and needed a machine to monitor her heart which automatically transmitted the data to the contracted company. Resident 41 stated she would lay down on top of the machine placed on her bed, turned on the machine, and the machine monitored her heart. Medical record review for Resident 41 was initiated on 4/15/25. Resident 41 was admitted to the facility on [DATE], with a clinical diagnosis of heart failure. Review of Resident 41 's Order Summary Report dated 4/15/25, admission Evaluation dated 3/26/25, and Care Plan Report failed to show a documented evidence a physician's order was obtained for the use, care and maintenance of the heart monitor machine, a care plan was formulated, and the presence of Resident 41 's heart monitor machine was documented when the resident was admitted to the facility. On 4/15/25 at 0914 hours, a follow-up interview was conducted with Resident 41. Resident 41 stated she brought her heart monitor machine from home to monitor her heart and was using it every day. Resident 41 was asked if the facility staff assisted her on taking care and checking the functionality of the machine. Resident 41 stated no. On 4/15/25 at 1436 hours, an interview and concurrent medical record review for Resident 41 was conducted with LVN 3. LVN 3 was asked about Resident 41 's condition. LVN 3 verified Resident 41 had a heart problem and was receiving medication. LVN 3 was asked about Resident 41's heart monitor machine at bedside. LVN 3 acknowledged and verified she was not aware about Resident 41 's heart monitor machine at bedside. LVN 3 verified there was no physician's order, no care plan, and no documentation of the heart monitor machine were documented. LVN 3 acknowledged there should have been a physician's order obtained, care plan formulated, and documentation of the heart monitor machine. On 4/ 16/25 at 1122 hours, an interview and concurrent medical record review for Resident 41 was conducted with the DON. The DON was asked about the facility's process of the residents' own machine brought from home. The DON stated per facility's P&P, they would follow the recommendation from the manufacturer's guidelines in care and management of the machine. The DON was asked what should have been documented about the resident's machine use. The DON stated there should have been a physician's order, a formulated care plan, and an assessment for the functionality of the machine use of the resident. The DON was informed of Resident 41 's heart monitor machine at the resident's bedside with no physician's order, care plan, and assessment for the functionality of the machine documented. The DON verified the findings and stated there should have been a physician's order obtained, a care plan formulated, and an assessment for the functionality of the machine documented when Resident 41 was admitted to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for one of 14 final sampled residents (Resident 2). * The facility failed to administer the oxygen therapy treatment as ordered by the physician for Resident 2. This failure had the potential for the resident to not receive oxygen as ordered and adequate respiratory care. Findings: Review of the facility's P&P titled Oxygen Management revised 10/28/19, showed oxygen therapy is administered to the resident only upon the written order of a licensed physician or in the event of an emergency until a physician order can be received. The licensed nurse is to check for physician's order for oxygen and liters/minute to be administered. On 4/14/25 at 0949 hours, during the initial tour observation, Resident 2 was observed lying in bed with oxygen via nasal cannula which was attached to the oxygen machine concentrator with setting noted at 1 liter per minute. During the observation, the oxygen tubing was labeled and dated; however, the nasal cannula was not placed on the resident's nares. Medical record review for Resident 2 was initiated on 4/14/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 2/8/25, showed Resident 2 had no capacity to make health care/ medical decisions; however, the resident could make simple needs known. Review of Resident 2's Order Summary Report dated 4/14/25, showed a physician's order dated 2/7/25, for oxygen at 2 liters per minute via nasal cannula every shift to keep oxygen saturation level greater than 92%. Review of Resident 2's care plan report dated 2/10/25, showed a care plan problem for altered respiratory status and the intervention included to administer oxygen at 2 liters per minute via nasal cannula. On 4/14/25 at 0949 hours, an observation and concurrent interview for Resident 2 was conducted with IP 2. IP 2 verified the oxygen setting was at 1 liter per minute and the nasal cannula was not on the resident's nares. IP 2 acknowledged the findings and placed the nasal cannula to Resident 2's nares. On 4/14/25 at 1049 hours, an interview for Resident 2 was conducted the IP 2 who stated the oxygen concentrator was replaced due to malfunction issue, and the dial to set the amount of oxygen administration was not working. On 4/17/25 at 1010 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above findings and stated the physician's order for the oxygen administration for Resident 2 should have been followed. On 4/17/25 at 1251 hours, an interview was conducted with the DON. The DON was informed and acknowledged all of the above findings. The DON stated the physician's order for the oxygen administration for Resident 2 should have been followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the licensed nurses followed their P&P for medication administration for three of 14 final sampled residents (Residents 9, 10, and 36). * The facility failed to ensure the physician was notified when the medication, Biotene (medication spray to relieve dry mouth, tongue, and throat) was not available for Resident 9 and missed three doses on 4/5/25, and two doses on 4/6/25. The facility failed to ensure Resident 36's IV medication Ertapenem (antibiotic administered intravenously to treat serious infections) was administered on 3/12, 3/18, 3/19, and 4/16/25. * The facility failed to ensure the physician's orders for the route of medication administration for Resident 10 were accurate. The medication route was ordered to be oral instead of via the GT. These failures had the potential to negatively affect the residents' health. Findings: 1. Review of the facility's P&P Manual for Long Term Care: Medications revised 10/2018 under Ordering and Receiving Medications from Pharmacy - Promptness of Availability of New Orders, page 14, showed all new drug orders other than those specified here- in, should be available the day ordered by the physician unless the drug would not normally be started until the next day. Review of the facility's P&P Manual for Long Term Care: Medications revised 10/2018 under Charting Doses Administered - General Principles, page 33, showed medications charted as unavailable should notify pharmacy, central supply as soon as possible, and/or get orders from MD to hold medication, or start when available. On 4/14/25 at 0845 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with Resident 9. Resident 9 stated she had chemotherapy for cancer and was stopped when she fell twice at home. Medical record review for Resident 9 was initiated on 4/16/25. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's MOS dated 3/30/25, showed a BIMS score of 15, which meant Resident 9 was cognitively intact. Review of Resident 9's Order Summary Report dated 4/15/25, showed a physician's order dated 4/5/25, for Biotene dry mouth moisturizing mouth/throat solution one spray by mouth three times a day for dry mouth. Review of Resident 9's April 2025 MAR showed documentation of code 9 (chart code meaning: other/ see progress notes) on the following: - dated 4/5/25 at 0900, 1300, and 1700 hours; and - dated 4/6/25 at 0900 and 1300 hours. Review of Resident 9's progress note dated 4/5/25, showed Resident 9 complained of dry mouth, physician was made aware and ordered Biotene medication three times a day for dry mouth. The progress notes on 4/5/25 at 1214 hours and 4/6/25 at 0918 hours, showed waiting on the order and pending delivery, respectively. There were progress notes documented for the entries on 4/5/25 at 1300 hours and 1700 hours. In addition, there was no progress note documented for 4/6/25 at 1300 hours to explain the MAR documentation coded as 9. On 4/16/25 at 0920 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 9 verbalized that she was uncomfortable of her dry mouth and requested to have the Biotene medication. LVN 1 stated if the medication was not available, she will notify the physician. On 4/16/25 at 0928 hours, an interview and concurrent medical record and facility record review for Resident 9 was conducted with LVN 2. LVN 2 stated, usually if a medication was not delivered at night, she will call the pharmacy and ask when the medication will be delivered and will call the physician if the medication will not be available indefinitely. Reviewed with LVN 2 the facility's P&P on Charting Doses Administered on medications charted as unavailable showed, should notify the pharmacy or central supply ASAP, and/or get orders from the MD to hold the medications, or start when available. LVN 2 stated, But like this order of Biotene, it would not be necessary, to notify the resident's physician. On 4/16/25 at 1200 hours, an interview and concurrent medical record and facility document review for Resident 9 was conducted with the DON. The DON verified the documented entries in MAR for the Biotene medication dated 4/5 and 4/6/ 25, as not administered pending delivery and should have informed the physician as outlined in the facility's Medication P&P. 2. Review of the facility's P&P Manual for Long Term Care: Medications revised 10/2018 under Charting Doses Administered- General Principles page 33 and Charting Routine Medication Administration page 34, showed: - each dose administered to a Resident 5hall be properly recorded in the resident's medical record; - the initials of the nurse must be recorded on the front of the MAR in the proper column for the correct date and time of administration for each routine medication given. Review of Resident 36's medical record was initiated on 4/14/25. Resident 36 was admitted to the facility on [DATE]. Review of Resident 36's diagnoses showed Resident 36 had UTI as the admitting diagnosis and ESBL Resistance. Review of Resident 36's Order Summary Report dated 4/15/25, showed a physician's order dated 4/13/25, for Ertapenem (an antibiotic medication to treat infections) Sodium Solution reconstituted 1 gram intravenously every 24 hours for UTI, ESBL for 24 days. Review of Resident 36's MAR for March and April 2025 showed undocumented Ertapenem IV administration as follows: - dated 3/12, 3/18, 3/19, and 4/16/25. On 4/17/25 at 0906 hours, an interview and concurrent medical record review for Resident 36 was conducted with RN 1. RN 1 verified there was no documentation to show Resident 36 received the Ertapenem medication as ordered by the physician for 3/12, 3/18. 3/19, and 4/16/25, a total of four doses. RN 1 further stated, Let me check it out. On 4/17/25 at 0919 hours, an interview and concurrent medical record review for Resident 36 was conducted with the DON. The DON verified the missing MAR documentations for the Ertapenem medication on 3/12, 3/18, 3/19, and 4/16/25. The DON stated, It is not signed. The DON further stated what was not documented was not done or not administered and will speak to the licensed nurses. The DON also stated the licensed nurses had to document right after administering the medications. 3. Review of the facility's P&P titled Medication Administration dated 10/2018 showed the complete act of medication administration included the licensed nurse to verify the medication to the prescriber's orders. Prior to the medication administration, the licensed nurse must compare the resident's MAR to the medication label. On 4/17/25 at 0808 hours, a medication administration observation for Resident 10 was conducted with LVN 2. LVN 2 was observed administering all the medications ordered by the physician for 0900 hours via the GT to Resident 10. Medical record review for Resident 10 was initiated on 4/15/25. Resident 10 was initially admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 4/4/25, showed Resident 10 had an enteral feeding tube and had a medical diagnosis of dysphagia. Review of Resident 10's Nutritional Evaluation V6 dated 4/4/25, showed Resident 10 should have the NPO diet due to the resident's swallowing problems. Review of Resident 1 O's Order Summary Report, showed the following physician's orders: - dated 4/2/25, to administer 650 mg of Tylenol (pain medication) by mouth every four hours as needed for general pain. - dated 4/2/25, to administer 30 ml of milk of magnesia (laxative medication) by mouth as needed for bowel management daily if no bowel movement in three days. - dated 4/5/25, to administer 30 ml of pro-stat (supplement) oral liquid by mouth one time a day for skin healing. Review of Resident 10's MAR for April 2025 showed Resident 10 was administered the Pro-Stat protein supplement from 4/6 to 4/17/25 at 0900 hours, and signed for by the licensed nurses as administered via the oral route. On 4/17/25 at 0829 hours, an interview and concurrent medical record review for Resident 10 was conducted with LVN 2. LVN 2 reviewed Resident 10's medical record and verified the above findings. LVN 2 stated Resident 10 had a GT, and all of Resident 1 O's medications should be administered via GT. LVN 2 further stated the ordered route for the above medications should be changed to accurately reflect the care the resident was receiving, which was to receive the medications via GT. On 4/17/25 at 0832 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 1. RN 1 reviewed Resident 10's medical record and verified the above findings. On 4/17/25 at 1145 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings for Resident 10.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. A plan to maximize recruitment and retention of direct care staff; and 3. A contingency plan for staffing needs. These failures had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed. Findings: According to the CMS QSO-24-13-NH dated 6/18/24, with an implementation date of 8/8/24, showed CMS had issued a revised guidance for long-term care facility assessment requirement. The Facility Assessment should address and included the active involvement of the direct care staff in developing the Facility Assessment. Also included a plan to maximize the recruitment and retention of the direct care staff member, and a contingency plan for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited, to the availability of direct care nurse staffing or other resources needed for resident care. Review of the Facility's assessment dated [DATE], failed to show the direct care staff member, direct care representatives, residents, residents' representatives, and residents' family members were actively involved in developing the Facility Assessment; and a plan to maximize recruitment and retention of the direct care staff, or include a contingency plan for the staffing needs. On 4/16/25 at 1454 hours, an interview and concurrent review of the Facility Assessment was conducted with Administrator. The Administrator verified there were no direct care staff, direct care representatives, residents, residents' representatives, and residents' family members actively involved in developing the Facility Assessment. The Administrator further verified there were no plan to maximize the recruitment and retention of the direct care staff or include a contingency plan for the staffing needs. The Administrator verified the Facility assessment dated [DATE], and acknowledged the Facility Assessment was not updated based on the latest update from CMS

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled resident (Resident 2) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 2 with the contracted hospice. The hospice calendar did not show complete SN and HA visits were provided as per the physician's orders. Furthermore, the facility failed to ensure staff awareness of the facility's hospice designee/coordinator. These failures posed the risk of Resident 2 not receiving the necessary hospice care and services. Findings: Review of the facility's P&P titled Palliative/End of Life Care Protocol revised 3/24/21, showed the community and hospice will identify the specific services that will be provided by each entity and this information will be communicated with the resident and family, and in the plan of care. Review of the Nursing Facility Services Agreement between the facility and Hospice Provider A with the effective date of 4/21/23, showed the following: - Inpatient Clinical Record. Facility shall maintain an inpatient clinical record for each Hospice Patient that includes a record of all Inpatient Services furnished and events regarding care that occurred at Facility. A copy of the inpatient clinical record shall be available to Hospice at the time of discharge. Review of the facility's documents showed the hospice coordinator/designee was the SSD. Medical record review for Resident 2 was initiated on 4/14/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 2/8/25, showed Resident 2 had no capacity to make health care/medical decisions; however, the resident could make simple needs known. Review of Resident 2's Order Summary Report dated 4/14/25, showed a physician's order dated 3/19/25, to admit to Hospice Provider A on routine level of care for primary hospice diagnosis of Alzheimer's disease. Review of Resident 2's care plan report dated 4/1/25, showed the interventions included Hospice Provider A staff discipline visit frequencies as follows: SN visits one time a week and three times a week as needed for symptom management and HA visits two times a week for personal care/AOL care support. On 4/17/25 at 1010 hours, an interview was conducted with LVN 1. LVN 1 was asked regarding the SN and HA visit frequency. LVN 1 stated the SN came once a week and as needed but unsure how often the HA came to the facility and visited Resident 2. LVN 1 verified the hospice calendars for March and April 2025 were not completely marked and did not show the days of SN and HA visits. LVN 1 stated the hospice calendar should have been marked accurately to know when the hospice team would see Resident 2. Furthermore, LVN 1 was asked who the facility's hospice designee/coordinator was, and responded that it was the DON. On 4/17/25 at 1251 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the facility's hospice designee/coordinator was the SSD.

Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Log was accurate. In addition, the facility failed to ensure the Surveillance Data Collection Form was complete and accurate to determine whether the resident's infection meet the McGeer's criteria for true infection. These failures posed the risk for not identifying resident infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other resident in the facility. Findings: Review of the facility's P&P titled Surveillance of Infections Protocol revised 9/24/24, showed the facility will track and trend for potential/actual infections and will monitor and take measures to prevent or minimize a potential outbreak. The Infection Control Surveillance Log is maintained by IP. The IP/DON/Designee will review the log and will trend all validated infections using the McGeer's criteria monthly. The Infection Control Committee will monitor and report to the QAPI Committee at least quarterly. 1. Review of the facility's monthly Infection Prevention and Control Surveillance Log showed inaccurate documentation for January and February 2025: For January 2025, the total number of residents who were screened as HAI were 13 and CAls were 13. In addition, the total number of the residents who did not met the criteria for true infection were 10. However, the Infection Control Monthly Summary for January 2025 showed the total number of the residents who were assessed as HAis were nine and GAis were six. The total number of the resident who did not met the criteria for true infection was five. The data from the surveillance log did not match to the monthly reported data of infections of the facility. The reported percentage rate of infection of the facility was inaccurate for January 2025. For February 2025, the total number of the residents on the surveillance log who were screened as HAi's were nine and GAis were 15. In addition, the total number of the residents who did not met the criteria for true infection were 14. However, the Infection Control Monthly Summary for February 2025 showed the total number of the residents who were assessed as HAis and GAis had no data reported. The total number of the residents who did not met the criteria for true infection was five. The data from the surveillance log did not match with the monthly reported data of infections of the facility. The reported percentage rate of infection of the facility was inaccurate for February 2025. 2. Review of the facility document titled Surveillance Data Collection Form for Residents 47, 98,445, and 447 showed the following information: For Resident 47, the Surveillance Data Collection Form dated 1/15/25, showed Resident 47 was administered with Flagyl (antibiotic) 500 mg every 12 hours for three days and cefuroxime (antibiotic) 250 mg by mouth every 12 hours for three days for pneumonia. The McGeer's criteria were met; however, the Surveillance Data Collection Form failed to show if Resident 47 had HAI or CAI. For Resident 98, the Surveillance Data Collection Form dated 2/3/25, showed Resident 98 was administered with cefuroxime (antibiotic) 500 mg by mouth every 12 hours for two days for UTI. The McGeer's criteria were not met; however, the Surveillance Data Collection Form failed to show if Resident 98 had HAI or CAI. For Resident 445, the Surveillance Data Collection Form dated 2/6/25, showed Resident 445 was administered with Flagyl (antibiotic) 500 mg every 12 hours for three days and Macrobid (antibiotic) 100 mg by mouth twice a day for seven days for UTI. The McGeer's criteria were met; however, the Surveillance Data Collection Form failed to show if Resident 445 had HAI or CAI. For Resident 447, the Surveillance Data Collection Form dated 1/29/25, showed Resident 447 was administered with Fluconazole (antibiotic) 100 mg tablet once a day for five days for UTI. The McGeer's criteria were met however, the Surveillance Data Collection Form failed to show if Resident 447 had HAI or CAI. On 4/17/25 at 0841 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated she used the McGeer's criteria to determine for a true infection for the residents. The IP stated the infection control summary was reported to the QAPI and used to determine the trend of the infection rate in the facility. The IP was informed of the reported numbers for the HAI and CAI on each month from the surveillance log not matching with the total numbers on the infection control monthly summary report for January and February 2025. The IP verified the numbers were inaccurate. The IP stated the numbers of the infection should have matched to the monthly summary report to ensure an accurate information about the infection control of the facility. The IP was asked to review the Surveillance Data Collection Form for Residents 47, 98, 445, and 447. The IP verified and acknowledged the forms were incomplete. On 4/17 /25 at 1253 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified and acknowledged the above findings.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils had smooth cleanable surface and in good condition. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Resident Diet Information dated 4/14/25, showed 38 of 40 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Dish and Utensil Procedure revised date 3/3/20, showed the dishes, trays and utensils shall be routinely checked for stains or spots. Chipped or cracked dishes, trays shall be discarded. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 4/14/25 at 0804 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the RD and Chef de Cuisine. The following was observed and verified by the RD and Chef de Cuisine: - Three white basting brush used for butter spread were discolored, had frayed bristles and worn out. - Four rubber spatulas with red handles used for mixing food were stained, discolored, and worn out. - One white plastic spatula was chipped, cracked at the edges, old and worn out. - One stainless steel spatula with black handle was peeling and partially melted. - One clear plastic spatula was old and worn out. - Two stainless steel ice cream scoop was discolored, old and worn out. - One stainless steel spatula with white handle was deformed at the edges and handle was discolored and worn out. - Two slotted stainless steel serving spoon with black handle was peeling, discolored, and partially melted. - Two scoops with black handle used for food portioning was peeling, old and worn out. - One scoop with cream handle used for food portioning was discolored, peeling, old and worn out. The RD and Chef de Cuisine acknowledged the above findings and stated the worn out and old utensils should have been replaced and discarded for infection control purposes. 2. Review of the facility's P&P titled Dish and Utensil Procedure revised date 3/3/20, showed the cutting boards need to be washed and sanitized between each use. Replace cutting boards once lined with knife marks and they are un-sanitizable. Color-coded cutting boards are desirable designating boards for raw products versus cooked products. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 4/14/25 at 0804 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the RD and Chef de Cuisine. The white and yellow cutting boards were observed fuzzy, heavily marred and had deep groves. The RD and Chef de Cuisine verified the findings and stated the cutting boards should have been replaced for infection control purposes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and facility P&P review, the facility failed to ensure one of 13 final sampled residents (Resident 33) was accurately assessed as being capable to self-administer the medications. * Resident 33 had the nasal spray bottle left on his overbed table and self-administered the nasal spray. This failure had the potential for unsafe medication administration. Findings: Review of the facility's P&P titled Self-Administration of Medications dated 10/24/23, showed as part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clinically appropriate for the resident. On 4/2/24 at 0900 hours, one opened bottle of 30 ml oxymetazoline hydrochloride (afrin) nasal spray was observed on Resident 33's overbed table. Resident 33 stated he had been using the medication one time every day to help relieve his stuffy nose. Medical Record Review for Resident 33 was initiated on 4/2/24. Resident 33 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 33 had BIMS score of 9 (moderately impaired). Review of Resident 33's physician's orders for April 2024 showed no order for nasal spray. Review of Resident 33's Assessments for Self-Administration of Medications dated 3/20/24, showed the question asking if the resident expressed an interest in the self-administration of medication with the answer no. On 4/2/24 at 0925 hours, an interview and concurrent medical record review was conducted LVN 4. LVN 4 stated he was unaware the nasal spray bottle was at the bedside. Resident 33 was not assessed for self-administration of the medication and no care plan was developed for the administration of the nasal spray. LVN 4 stated there was no physician's order for the nasal spray administration. LVN 4 verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and the facility P&P review, the facility failed to ensure the notification of change for one of one resident reviewed for weight loss (Resident 14). This failure resulted in a delay of Resident 14's significant weight loss being communicated to the resident's physician, responsible party, and RD, which had the potential to negatively impact the resident's well-being. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated October 2023 showed If a resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Review the facility's P&P titled Nutrition Management Program revised 5/31/21, showed a weight change is significant per RAI manual definition with a weight loss of 5% and/or 5 lbs. in one month. The P&P also showed the following tasks at the time of identification of weight loss: - A referral is made to dietary. - The physician is notified of the weight loss. - Notification to the resident's family. Medical record review for Resident 14 was initiated on 4/2/24. Resident 14 was initially admitted to the facility on [DATE], discharged to the acute care hospital on 3/21/24, and readmitted to the facility on [DATE]. Review of Resident 14's Weight and Vitals Summary dated 4/4/24, showed the following weights: -On 2/23/24, a weight of 142.6 lbs. -On 2/28/24, a weight of 140 lbs. -On 3/7/24, a weight of 140.8 lbs. -On 3/15/24, a weight of 140 lbs. -On 3/26/24, a weight of 0.0 lbs. -On 3/29/24, a weight of 132.4 lbs. (a 5.4% and 7.6 lbs. weight loss from 2/28/24) -On 4/3/24, a weight of 131.6 lbs. (a 6.5% and 9.2 lbs. weight loss from 3/7/24, and a 7.7% and 11 lbs. weight loss from 2/23/24) Review of Resident 14's medical record failed to show the resident's physician, responsible party, and RD were notified of the resident's weight loss. On 4/4/24 at 0929 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed Resident 14's weights and verified the resident's weight was triggered for a weight loss of more than 5% on 3/29/24. RN 1 verified Resident 14's medical record failed to show the resident's change of condition for weight loss was reported to the resident's physician, responsible party, and the RD. On 4/4/24 at 1128 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated for a significant weight change, the charge nurse or clinical nurse supervisor should notify the physician, RD and resident's responsible party once the weight change was identified. The DON reviewed Resident 14's medical record and verified the resident's weight loss on 3/29/24, was not reported to the resident's physician, responsible party, and RD once it was identified, and should have been.

Based on observation, interview, and facility P&P review, the facility failed to ensure services provided met the professional standards of care for one when LVN 4 failed to properly take a blood pressure for one nonsampled resident (Resident 543). This failure posed the risk for not obtaining accurate blood pressure reading for this resident. Findings: Review of the facility's P&P titled Blood Pressure, Measuring dated 10/2010 showed the purpose of this procedure is to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins, and chambers of the heart. The policy further showed to expose the resident's arm by rolling the sleeve up about five inches above the elbow. When locating the pulsation, place the diaphragm of the stethoscope firmly against the skin, and hold the diaphragm in place with hand. On 4/3/24 at 0813 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 took Resident 543's blood pressure prior to the administration of metoprolol (antihypertensive medication). LVN 4 wrapped the blood pressure cuff on the resident's left upper arm and placed the diaphragm of the stethoscope on the left brachial artery over Resident 543's sweater. On 4/3/24 at 0834 hours, an interview was conducted with LVN 4. LVN 4 verified the resident's sleeve should have been pulled up and the diaphragm of the stethoscope should have been placed on the skin. On 4/3/24 at 1424 hours, an interview was conducted with the DON. The DON verified the blood pressure cuff and diaphragm of the stethoscope were to be placed on the skin when taking a blood pressure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the timely intervention for one of one resident reviewed for weight loss (Resident 14). This failure had the potential to result in continued nutritional decline and negative outcomes. Findings: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated October 2023 showed If a resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status. Review the facility's P&P titled Nutrition Management Program revised 5/31/21, showed a weight change is significant per RAI manual definition with a weight loss of 5% and/or 5 lbs. in one month. The P&P also showed the following tasks at the time of identification of weight loss: - A referral is made to dietary. - The Nutritional Services Director and/or the Registered Dietician (RD) will complete an assessment Medical record review for Resident 14 was initiated on 4/2/24. Resident 14 was initially admitted to the facility on [DATE], discharged to the acute hospital on 3/21/24, and readmitted to the facility on [DATE]. Review of Resident 14's Weight and Vitals Summary dated 4/4/24, showed the following weights: - On 2/23/24, a weight of 142.6 lbs. - On 2/28/24, a weight of 140 lbs. - On 3/7/24, a weight of 140.8 lbs. - On 3/15/24, a weight of 140 lbs. - On 3/26/24, a weight of 0.0 lbs. - On 3/29/24, a weight of 132.4 lbs. (a 5.4% and 7.6 lbs. weight loss from 2/28/24) - On 4/3/24, a weight of 131.6 lbs. (a 6.5% and 9.2 lbs. weight loss from 3/7/24, and a 7.7% and 11 lbs. weight loss from 2/23/24) Review of Resident 14's Nutritional Screen V3.1 - 101 evaluation dated 3/28/24, showed the resident was noted to have decreased PO (oral) intake since readmission; however it was improved on 3/28/24. The plan was to increase the resident's health shakes from twice a day to three times a day. Review of Resident 14's Nutritional Evaluation V6-103 dated 3/29/24, showed the resident's admission weight listed for the previous admission's weight was 140 lbs on 3/15/24. The most recent weight was listed as 0.0 lbs on 3/26/24. The evaluation showed Resident 14's ideal weight range was 139-169 lbs. The summary note showed the resident was now receiving health shakes three times a day to provide an additional 600 calories and 18 grams of protein a day. The note showed there were no recommendations at the time, and to monitor the resident's weights for significant changes. Review of Resident 14's Nutritional Services Note dated 3/29/24, showed the resident returned from a recent hospitalization and the resident's weight was 140 lbs. on 3/15/24. The document showed the resident was at a healthy weight with a target maintenance goal weight of 135-145 lbs. Resident 14's medical record failed to show the nutritional services or RD's intervention after the resident's weight loss was identified. Review of the facility's Report of Dietary Consultant Visit dated 4/3/24, showed a list of the residents that the RD saw and showed the RD calculated the monthly and weekly weight variances. The document failed to show Resident 14 was reviewed by the RD. On 4/4/24 at 0929 hours, an interview and concurrent record review was conducted with RN 1. RN 1 stated the RNA weighed the residents, entered the weight on a paper log, and gave the weight log to the desk nurse who would then enter the weights in the electronic health record. RN 1 stated herself and the RD had a weekly Nutritional At Risk (NAR) meeting every Wednesday and reviewed all the residents triggered with weight changes. RN 1 stated the last NAR was done on 3/27/24, and yesterday's review was rescheduled for today, since the RD was on vacation. RN 1 reviewed Resident 14's weights and verified the electronic health record (EHR) triggered the resident for weight loss. When asked if there was any documentation to show Resident 14's weight loss was reported and addressed, the RN stated no. RN 1 stated they would discuss it at today's NAR meeting. On 4/4/24 at 1128 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the process for the residents readmitted from the acute care hospital was to be weighed on readmission or the day after. The DON verified Resident 14 was readmitted on [DATE], and the first recorded weight was on 3/29/24. The DON stated there was nothing in the resident's record to show they refused their weight being checked. The DON stated significant weight changes should be addressed within that week since the RD made rounds weekly. The DON stated the RD covering for the regular RD's vacation saw the residents yesterday. The DON reviewed the RD's packet given to her by the RD and verified Resident 14 was not seen. The DON reviewed Resident 14's medical record and verified there was nothing to show the resident's weight loss was addressed. On 4/24/24 at 1201 hours, an interview and concurrent medical record review was conducted with RD 1. RD 1 stated they usually were at the facility every Monday and Wednesday, but they were on vacation from 3/30/24-4/3/24, and another RD covered for them. RD 1 stated the covering RD came in on Wednesday, 4/3/24, and RD 1 was planning on coming in on Friday 4/5/24, to see the residents. RD 1 sated their usual process was to come in twice a week, run a weight report with the EHR system to identify residents with weight changes, with a 3 lbs weight change being the standard. RD 1 stated Resident 14's weight loss should have been on the weight report yesterday for the covering RD to know to review the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 26) reviewed for oxygen use was provided with the appropriate respiratory care. The facility failed to ensure Resident 26's oxygen tubing was labeled and not touching the floor. These failures had the potential to affect the respiratory health and well-being of Resident 26. Findings: Review of the facility's P&P titled Oxygen Management revised 5/31/21, showed the oxygen is administered under orders of the attending physician, except in the case of an emergency. The general guidelines concerning oxygen safety during oxygen administration include nasal cannulas, masks and tubing should be changed every seven days, dated, time and initialed. On 4/2/24 at 1023 and 1548 hours, Resident 26 was observed wearing a nasal cannula attached to a portable oxygen tank with a setting of one liter per minute. Part of the oxygen tubing was observed touching the floor. Medical record review for Resident 26 was initiated on 4/2/24. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Order Summary Report dated 4/3/24, showed a physician's order dated 3/27/24, to administer oxygen at one to three liters per minute via nasal cannula every shift to keep the oxygen saturation level greater than 92%. Another physician's order dated 2/20/24, showed to change the oxygen nasal cannula every Sunday night or as needed when in use. On 4/3/24 at 1010 hours, an observation and concurrent interview for Resident 26 with RN 1 was conducted. Resident 26 was observed in the activity room wearing a nasal cannula with the oxygen setting at two liters per minute. RN 1 verified Resident 26 was on oxygen therapy. RN 1 was asked when the oxygen tubing was last changed. RN 1 stated the facility had an order for the oxygen tubing to be changed every Sunday and as needed. RN 1 verified there was no label on the resident's oxygen tubing. Also, the part of the oxygen tubing was observed on the floor. RN 1 stated the oxygen tubing should have been labeled and not touched the floor. On 4/4/24 at 1104 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed of the above findings and was verified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of 13 final sampled residents (Resident 13). * The facility failed to ensure Resident 13's oxycodone-acetaminophen (narcotic pain medication) was accurately reconciled. The oxycodone-acetaminophen tablets removed as shown on the Controlled Drug Record was not recorded as administered on the electronic MAR. This failure had the potential for drug diversion. Findings: Review of the facility's P&P titled Controlled Drugs revised 10/2018 showed each dose removed from the supply of controlled drugs shall be signed, dated, and timed out on the proof of count sheet on the line representing that particular dose prior to resident administration. Nurses must sign out, not just initial. Proof of count sheets shall be easily accessible by the medication nurse. Medical record review for Resident 13 was initiated on 4/2/24. Resident 13 was admitted to the facility on [DATE]. Review of the Internal Medicine H&P examination dated 3/1/24, showed Resident 13 had the capacity to understand and make decisions. Review of the Order Summary Report dated 4/3/24, showed a physician's order dated 3/14/24, to administer oxycodone-acetaminophen 10-325 mg one tablet by mouth every four hours as needed for moderate to severe pain. On 4/3/24 at 1119 hours, a controlled medication reconciliation for Resident 13 was conducted with LVN 3. Review of Resident 13's Controlled Drug Record showed oxycodone-acetaminophen was signed out on 3/30/24 at 1322 hours, and 4/1/24 at 1400 hours. Resident 13's medication bubble pack (a package used to dispense medication) for oxycodone-acetaminophen showed 15 tablets remaining, which matched with the number of oxycodone-acetaminophen tablets in the Controlled Drug Record. However, review of Resident 13's electronic MARs for March and April 2024 failed to show documented evidence the oxycodone-acetaminophen was administered to Resident 13 on 3/30/24 at 1322 hours, and 4/1/24 at 1400 hours, as shown in the Controlled Drug Record. LVN 3 verified the above finding. On 4/3/24 at 1411 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above finding. The DON stated the licensed nurses should sign both the Controlled Drug Record and MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the proper disposal and storage of medications as evidenced by: * The facility failed to ensure the medications administered orally were stored separately from the externally used medications in one of two medication carts (Medication Cart A). * The facility failed to ensure the discontinued medications were properly disposed in one of one medication room (Medication Room A). In addition, the facility failed to ensure the medications administered orally were stored separately from the externally used medications in Medicaiton Room A. * The facility failed to ensure safe storage of one Theraworx Muscle Cramp (use to relieve muscle cramps and spasms) foam found at Resident 639's bedside cabinet. These failures had the potential to result in unsafe medication administration, cross-contamination of the medications, and unsafe handling and storage of the residents' medications. Findings: Review of the facility's P&P titled Storage of Medications revised 10/2018 showed external use drugs in liquid, tablet, capsule, or powder form shall be separated from drugs for internal use such as on a different shelf or separated by bins/partitions. Example: Separate oral tablets/capsules from oral liquids from internals (enema/suppositories) from ophthalmic drops from optic drops from injectable medications and from inhaled medications. In addition, the policy showed drugs shall be accessible only to personnel designated in writing by the licensee. 1. On 4/3/24 at 1153 hours, an observation and concurrent interview was conducted with LVN 4 in Medication Cart A. The following was observed: - two open boxes of Restasis (medication use to treat chronic dry eyes) eye drops were stored next to three boxes of levalbuterol (medication use to prevent or relieve wheezing, shortness of breath, coughing or chest tightness)inhalation solution. LVN 4 verified the findings. 2. On 4/3/24 at 1322 hours, an observation and concurrent interview was conducted with LVN 2 in Medication Room A. The following was observed: - One waste disposal bin with a blue top was observed with multiple whole tablets inside. - Three boxes of Refresh Tears (medication use for temporary relief from dry eyes) eye drops were stored next to three boxes of carbamide peroxide (medication use to treat earwax build up) ear drops, one bottle of loratadine (medication use to treat symptoms of allergies) and multiple bottles of Milk of Magnesia. LVN 2 verified the findings. LVN2 stated the facility did not use any liquid to dissolve the tablets, and the staff were trained to discard the tablets inside the disposal bin and lock the cabinet. On 4/3/24 at 1412 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above finding. The DON stated non-narcotic medications should be placed in the disposal bin and a dissolvent was used to dissolve the tablets. On 4/4/24 at 1053 hours, a follow-up interview was conducted with the DON. The DON stated the facility used the Drug Disposal System Rx Destroyer solution to dissolve the medications inside the disposal bins. The DON stated the facility disposed of the medications daily and weekly as necessary. 3. During the initial tour of the facility on 4/2/24 at 0946 hours, an observation and concurrent interview was conducted with Resident 639. Resident 639 was observed with one bottle of Theraworx Muscle Cramps foam on top of the bedside cabinet. Resident 639 stated her family member brought in the Theraworx Muscle Cramps foam, but she had not used it at the facility. Medical record review for Resident 639 was initiated on 4/2/24. Resident 639 was admitted to the facility on [DATE]. Review of Resident 639's MDS dated [DATE], showed Resident 639 was cognitively intact. On 4/2/24 at 0953 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the above finding and stated it was her first time to see the medication. On 4/4/24 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above finding.

Based on observation, interview, facility personnel file, and facility document review, the facility failed to ensure the Food and Nutrition Services Director who was responsible to oversee the main kitchen which produced food for the skilled nursing facility was competent in managing the day-to-day functions of the food services department. The failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice, may jeopardize the health and well-being of the 40 residents who received food prepared in the kitchen. Findings: Review of the facility's Resident Assessment Report (CMS-802) dated 4/2/24, showed 40 of 40 residents residing in the facility received food prepared in the kitchen. Review of the facility's personnel file for the Food and Nutrition Services Director (FNSD) included the facility's document titled Food and Nutrition Services Director, Job Description signed and dated by the Food and Nutrition Services Director on 6/23/23, showed the Food and Nutrition Services Director was primarily responsible for providing effective food and nutrition services in the skilled nursing facility, staffing, training, QAPI (Quality Assurance Performance Improvement), budget preparation, and compliance and ongoing resident documentation. Principle duties included in part, educates, coaches' food and nutrition team members, organizes, directs, and supervises day-to-day department operations, assures efficiency of food serving; compliance with local, state and federal standards; sanitation, and hygiene and health standards of personnel. The FNSD personnel file did not include documentation of food service training such as a certification from the American National Standards Institute- Conference for Food Protection to show training in food service safety and sanitation guidelines. Review of the facility's document titled Summary of Report of Meeting, Type of Meeting: Inservice dated 4/3, 6/7, 7/5, and 11/9/23, showed the Chef and kitchen staff were educated on hair restraints, cooling monitor log, and following recipes. Review of the facility's document titled Competency Checklist-Cook dated 5/2023 showed the Chef was competent on the cooling monitor log, dry, refrigerated and freezer storage chart, food handling, and hairnets/beard protectors. Review of the facility's document titled Sanitation Review Audit dated 2/28/24 and 3/29/24, signed and completed by the Registered Dietitian (RD) showed food use-by-dates, food bins free of scoops, hair restraints and trash containers not covered were concerns in the kitchen. During the annual recertification survey from 4/2/24 to 4/5/24, multiple issues were found in the main kitchen, including: lack of a thawing process for meats as per the facility's P&P, failure to discard expired food, lack of monitoring of cooling for TCS (time/temperature for safety foods), lack of adequate hair and facial hair covering, food preparation equipment was not in good condition, a food storage bin was not free of a scoop, a dry food storage container was not sealed, food preparation equipment was not air dried, food was not properly stored in the freezer, refuse was not stored appropriately in the kitchen, and puree recipes were not followed. Cross references to F803; F812, examples #1, #2, #3, #5, #6, #7, #8, #9, #10; and F814, example #1. On 4/4/24 at 1004 hours, an interview was conducted with the FNSD. The FNSD was asked about her food service training background. The FNSD stated she was trained as a clinical Registered Dietitian and had food service experience. When asked how she monitored the day-to-day kitchen activities, the FNSD stated she did kitchen walk through, in-serviced staff, and made observations. The FNSD was not able to provide written documentation of kitchen inspections. The FNSD stated the RD did monthly kitchen inspections. The FNSD was asked about the Chef's responsibilities. The FNSD stated the Chef was responsible to oversee the back of the house activities; supervise cooks and food preparation. The FNSD was asked how she assessed the Chef's competency. The FNSD stated employee competency was evaluated once a year. On 4/4/24 at 1032 hours, an interview was conducted with the Administrator. The Administrator was asked how she ensured the department heads were competent in their job functions. The Administrator stated she assessed the department head's competency by the department head's experience, knowledge of the policy and procedures, and outside oversight of the consultant Dietitian. The Administrator stated the FNSD should be monitoring and training the kitchen staff.

Based on observation, interview, and facility document review, the facility failed to ensure the resident menu was followed when the puree procedure for meat and vegetables was not followed. This failure posed the risk for an inconsistent product and to not meet the nutritional needs of the five residents who received puree diets. Findings: Review of the facility's recipe: Pureed Vegetables (undated) showed Number of Servings: five. Ingredients: Seasoned Vegetables two and ½ cup, Cooked and Drained (Reserve liquid). Food Thickener: one and ½ (half) teaspoon. The Directions were as follows: 1. Remove portions required from regular prepared recipe; drain and reserve cooking liquid. Place in food processor or blender and process until smooth. 2. If necessary, add a small amount of reserved cooking liquid or hot water. 3. If needed, gradually add thickener and process until smooth in consistency. Note: volume of liquid required may vary slightly, depending on the texture of the product. Note: Amount of thickener will vary slightly. Start with one and ½ teaspoon and add more gradually until desired texture is achieved. 4. Scrape down the side with a rubber spatula and reprocess for 30 seconds. 5. Ensure mixture achieves smooth, lump free and extremely thick consistency. 6. Serve using appropriate scoop size. Review of the facility's recipe: Pureed Fish/Meat/Poultry - three ounces (undated) showed Number of Servings: five. Ingredients: Meat Product, Cooked ¾ lb. (pound), three ounces, Reserved Cooking Liquid or Broth, Hot one cup. Food Thickener one and ½ Teaspoon. The Directions were as follows: 1. Remove required portion amounts from regular prepared recipe; place in food process or blender. If necessary, debone meat prior to blending. Note: remember to weight meat only; do not include cooking juices or gravy. 2. Process until meat is smooth in consistency. Gradually add broth or gravy and thickener to meat while processing. (All liquid may not be required, depending on the texture of the meat). Note: volume of the liquid required may need to be adjusted, depending on the texture and moisture of the product. Note: Amount of thickener will vary slightly. Start with one and ½ teaspoon and add more gradually until desired texture is achieved. 3. Scrape down sides with rubber spatula; reprocess for 30 seconds. 4. Ensure mixture achieves smooth, lump free and extremely thick consistency. Note: For dry meat and fish. Dry meat such as roast pork or baked chicken may be pureed with one ounce of gravy per serving in addition to the cooking liquid or broth. On 4/3/24 at 1031 hours, an observation of the lunch meal puree food preparation and concurrent interview was conducted with [NAME] 3. [NAME] 3 stated he was preparing five portions of the puree green beans. [NAME] 3 added four #8 scoops (two cups) of the green beans, one cup of the chicken broth and ½ Tablespoon (equivalent to one and ½ teaspoon) to the blender. The green bean mixture was blended. [NAME] 3 stated the puree vegetables should be ice cream consistency. [NAME] 3 stated the vegetable mixture was too runny and added another ½ Tablespoon of thickener and blended the product. The puree green beans were then put in the hot holding box at 165 degrees Fahrenheit (F). Cook 3 proceeded with the puree food preparation and stated he was preparing five portions of the puree pork. [NAME] 3 stated each serving of the pork was three ounces. [NAME] 3 used a # six scoop (equivalent to 5.5 ounces) to measure five serving of pork into the blender. [NAME] 3 added one cup of the broth and ½ tablespoon (equivalent to one and ½ teaspoon) to the blender. The pork mixture was blended. [NAME] 3 stated since the pork was dry, he needed to add more of the chicken broth. [NAME] 3 added ½ cup of the chicken broth to the pork mixture and blended it. After blending the pork mixture, [NAME] 3 stated the pork mixture was too runny and he needed to add more thickener. [NAME] 3 added another ½ tablespoon of the thickener and blended the pork mixture. On 4/4/24 at 1500 hours, the puree food preparation procedure was discussed with the Administrator, FNSD, RD, and Chef. The FNSD, RD and Chef acknowledged the puree procedure was not followed correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to honor the food preference for one of two sampled residents (Resident 17) reviewed. This failure had the potential for inadequate nutrition. Findings: Review of the facility's P&P titled Initial Resident Visitation/Nutritional Screening dated 9/2/21, showed obtain food preferences, allergies or intolerance and note on Dietary interview/pre-screen (FORM 101) or other designated form and tray card. The interview form is filed in the medical record, preferably. Medical record review for Resident 17 was initiated on 4/2/24. Resident 17 was admitted to the facility on [DATE], and readmitted on [DATE]. On 4/2/24 at 0845 hours, a concurrent observation and interview was conducted with Resident 17. Resident 17 almost finished her breakfast and had one glass of cranberry juice on her breakfast tray. Resident 17 stated she did not like the cranberry juice and had mentioned this to the staff, but she still was provided with cranberry juice. On 4/2/24 at 0900 hours, LVN 4 was summoned to the room. Resident 17 told LVN 4 that she had been served the cranberry juice for breakfast. LVN 4 stated he would update her preference and wrote down no cranberry juice on her diet card. Review of Resident 3's diet order for breakfast dated 4/3/24, showed Resident 17's beverage was cranberry juice. On 4/3/24 at 0845 hours, a concurrent observation and interview was conducted with Resident 17. Resident 17 was observed finished her breakfast and stated they still served cranberry juice. On 4/3/24 at 0915 hours, an interview was conducted with LVN 4. LVN 4 stated this morning they still served cranberry juice and he took it out because Resident 17 stated she did not like it. LVN 4 was asked about Resident 17's diet card showed the resident's beverages was cranberry juices. LVN 4 did not know why it was not updated. LVN 4 verified the findings. On 4/4/24 at 1500 hours, an interview was conducted with the FNSD. The FNSD stated the nurse could give a slip with any staff or could verbally talk to any kitchen staff to update the residents' food preferences.

Based on observation, interview, and facility P&P review, the facility failed to ensure the P&P for the resident's food brought by the visitors was followed. * The facility failed to ensure the safe food handling guidelines were communicated to the resident's family/visitors who brought the resident food from the outside. This failure had the potential to cause foodborne illness to the residents who received food brought by the visitors. Findings: Review of the facility's P&P titled Food from Outside Sources dated 2020 showed if the food is brought in by the visitors, friends, family members or other guests, the community should help them understand safe food handling practices as summarized in Safe Food Handling Guide for Visitors and Staff (DOC 403). On 4/2/24 at 1506 hours, an interview was conducted with LVN 1. LVN 1 stated she normally educated the resident's family members/visitors regarding the resident's diet only and not on safe food handling. LVN 3 further stated she did not know any document they ave for the family members/visitors regarding for safe food handling. On 4/3/24 at 1447 hours, an interview was conducted with the DON. The DON stated the RNs, LVNs, and CNAs received an in-service training regarding the outside food and safe food handling; however, the facility had not provided the residents' family members/visitors with the Safe Food Handling Guide for Visitors and Staff (DOC 403). The DON further stated it was overwhelming for the family members/visitors to read the DOC 403.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the complete and accurate medical records for three of six residents reviewed for advanced directives (Residents 14, 26, and 35). * Residents 14, 26, and 35's POLST were incomplete. This failure had the potential for the resident's advanced directive status not being communicated to the health care staff in the event of an emergency for these residents. Findings: 1. Medical record review for Resident 14 was initiated on 4/2/24. Resident 14 was readmitted to the facility on [DATE]. Review of Resident 14's Internal Medicine History and Physical examination dated 3/27/24, showed Resident 14 did not have capacity (to understand and make decisions). Review of Resident 14's POLST form dated 3/25/24, showed the POLST was a legally valid physician's order, and to send the form with the resident whenever they are transferred or discharged . Resident 14's POLST also showed Section D - Information and Signatures was incomplete when asked to select if the resident had an advance directive, and if the advance directive was available and reviewed. The POLST was signed by the physician on 3/25/24. Review of Resident 14's Social Services Evaluation - V6 dated 3/28/24, showed Resident 14's POLST form was completed and on file, the resident did not have an advanced directive, the resident's capacity fluctuates, and a blank advanced directive form was provided to the resident's family. On 4/3/24 at 1336 hours, an interview and concurrent medical record review were conducted with the SSD. The SSD verified they left Resident 14's POLST - Section D incomplete because they were hoping the resident would eventually have capacity, and if the SSD left the section blank, it just meant there was not an advanced directive. The SSD stated if they selected the check box that showed there was no advanced directive, and the resident was later able to formulate an advance directive, they would have to complete a new POLST to update the changes. 2. Medical record review for Resident 35 was initiated on 4/2/24, Resident 35 was admitted to the facility on [DATE]. Review of Resident 35's Internal Medicine History and Physical examination dated 3/1/24, showed Resident 35 had capacity (to understand and make decisions). Review of Resident 35's POLST form dated 3/1/24, showed the POLST was a legally valid physician's order, and to send the form with the resident whenever they were transferred or discharged . Resident 35's POLST also showed Section D - Information and Signatures was incomplete when asked to select if the resident had an advance directive, and if the advance directive was available and reviewed. The POLST was signed by the physician on 3/1/24. Review of Resident 35's Social Services Evaluation - V6 dated 3/1/24, showed Resident 35's POLST form was completed and on file, the resident did not have an advanced directive, and a blank advanced directive form was provided to the resident. On 4/3/24 at 1336 hours, an interview and concurrent medical record review were conducted with the SSD. The SSD verified they left Resident 35's POLST - Section D incomplete, and if the SSD left the section blank, it just means there was not an advanced directive. The SSD stated if they selected the check box that showed there was no advanced directive, and the resident later could formulate an advance directive, they would have to complete a new POLST to update the changes. 3. Medical record review for Resident 26 was initiated on 4/2/24. Resident 26 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 26 had severe cognitive impairment. Review of Resident 26's POLST dated 2/20/24, showed the POLST was signed by the physician and the treatment of the resident was selected in the event Resident 26's health conditions worsen. However, Section D of the POLST showed the advance directive was incomplete. Review of Resident 26's Social Services Evaluation - V6 dated 2/23/24, showed the POLST form was completed, and Resident 26 had an advance directive. On 4/3/24 at 1343 hours, an interview and concurrent medical record review for Resident 26 was conducted with the SSD. The SSD stated the POLST form was to be completed upon admission of the resident to the facility. The SSD verified Resident 26's POLST was incomplete and stated she was waiting for the resident's family to submit the advance directive and it was pending. On 4/4/24 at 1104 hours, an interview and concurrent medical record review for Resident 26 was conducted with the DON. The DON was informed and verified the above findings. The DON stated the expectation was for all the resident's documents be completed.

2. Review of the facility's P&P titled Hand Washing and Hand Hygiene dated 11/2020 showed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. On 4/03/24 at 0834 hours, a medication pass observation and concurrent interview was conducted with LVN 4. LVN 4 was observed putting on gloves, touching the bedside table, then administering the eye drops to both of Resident 543's eyes using the same tissue. LVN 4 stated the gloves should have been changed and hand hygiene should have been performed after touching the bedside table. LVN 4 further stated they should have used a different tissue for each eye when administering eye drops. On 4/03/24 at 1424 hours, an interview was conducted with the DON. The DON verified the gloves should be changed after touching the bedside table and two different tissues need to be used when administering eye drops in both eyes. 3. Review of the facility's P&P titled Hand Washing and Hand Hygiene dated 11/2020 showed the facility considers hand hygiene the primary means to prevent the spread of infections. In most situations, the preferred method of hand hygiene is with alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-85% ethanol or isopropanol after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. On 4/2/24 at 1213 hours, CNA 4 was observed in Room A touching the floor mat with bare hands. CNA 4 grabbed a meal tray and delivered the meal tray to Room B. CNA 4 did not perform hand hygiene after touching the floor mat in Room A. On 4/2/24 at 1215 hours, an interview was conducted with CNA 4. CNA 4 acknowledged she moved the floor mat without gloves. CNA 4 verified she did not perform hand hygiene after touching the floor mat in Room A. CNA 4 stated she did not know if she should perform hand hygiene. When asked if she had training on hand hygiene, CNA 4 stated she had hand hygiene training before. On 4/4/24 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above finding. Based on observation, interview, facility document review, and facility P&P review, the facility failed to establish and maintain the infection prevention and control program designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to ensure the water management program was established and implemented to include the implementation of measures to prevent the growth of Legionella and other opportunistic pathogens; and a way to monitor the measures they had in place * The facility failed to ensure the staff changed gloves after touching the bedside table and prior to administering eye drop medications for Resident 543 * CNA 4 failed to perform hand hygiene after touching the floor mat with bare hands in Room A These failures had the potential to increase the risk for the spread of infection. Findings: Review of the facility's P&P titled legionella monitoring dated 5/2020 showed infection control committee supports the administrator, Director of nursing and Plant Operation Director with implementation and oversight of this policy including any investigation of issues. Under the section for Control Measures and General Awareness protocol: The facility has considered the ASHRAE ( American Society of Heating, Refrigerating and Air-Conditioning Engineers) industry standard and the CDC ( Center and Disease Control) toolkit to evaluate the current facility control measures and determine awareness protocols. Example of systems: resident bathrooms (faucet- hot and cold shower), decorative fountains, evaporative cooling water, ice machine water, hot water storage tanks ( domestic and laundry), emergency water storage container, water filters, showerheads and hoses, eye wash station. According to CDC's guidelines for Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings dated 6/26/15, control measures and limits should be established for each control point. You will need to monitor to ensure your control measures are performing as designed. Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and a maximum value. Examples of chemical and physical control measures and limits to reduce the risk of Legionella growth: Water quality should be measured throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring, Water heaters should be maintained at appropriate temperatures, Decorative fountains should be kept free of debris and visible biofilm, Disinfectant and other chemical levels in cooling towers and hot tubs should be continuously maintained and regularly monitored. Surfaces with any visible biofilm (i.e., slime) should be cleaned. Under section Your program team should establish procedures to confirm, both initially and on an ongoing basis, that the water management program is being implemented as designed. This step is called verification. Your program team should establish procedures to confirm, both initially and on an ongoing basis, that the water management program effectively controls the hazardous conditions throughout the building water systems. This step is called validation. On 4/4/24 at 1000 hours, an interview was conducted with Infection Preventionist 1. Infection Preventionist 1 stated she was not aware of the part for implementation and oversight of the legionellae monitoring including any investigation of issues. On 4/4/24 at 1030 hours, an interview and concurrent facility document review was conducted with the Plant Operation Manager. The Plant Operation Manager was asked to show their water management program. The Plant Operation Manager stated if there was no standing water, he did not need to do ongoing testing and control measures. When asked if he could provide any documentation regarding any control measures and general awareness protocol, he stated he did not need to do ongoing control measure. The Plant Operation Manager stated he did the water temperature check for each resident room monthly. The Plant Operation Manager was asked for the following: - documentation if any measures was not met, the corrective action and the contingency response plan. - temperature checks being part of control measures. - when or how the control measures would be applied. The Plant Operation Manager was unable to provide the documentation and verified the finding.

Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the meat thawing process was followed. * The facility failed to ensure the expired food was discarded. * Time/Temperature Control for Safety (TCS) foods (food that required time and temperature controls to limit the growth of illness causing bacteria) were not monitored to ensure the proper cool down process was followed. * Two of two ice machines were not clean. * The facility failed to ensure hair and beard restraints were worn by dietary personnel inside the main kitchen. * The facility failed to ensure the food preparation equipment were in good condition. * The facility failed to ensure a storage container was free of a scoop. * The facility failed to ensure a dry food storage container was properly sealed. * The facility failed to ensure the food preparation equipment were properly air dried prior to storage. * The facility failed to ensure proper labeling and dating of the opened food in the freezer. * The facility failed to ensure the drying rack was clean. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's Resident Assessment Report (CMS-802) dated 4/2/24, showed 40 of 40 residents residing in the facility received food prepared in the kitchen. 1. According to USDA Food Code 2022, Section 3-501.13, Thawing, showed freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/ or produce toxins. Review of the facility's P&P titled Meat Cookery and Storage revised 5/20/20, showed the meat which needs defrosting should be pulled three days prior to service and defrosted in a dry, cool area at 41 degrees Fahrenheit (F) or less. Date meat when pulled for defrosting. Review of facility's P&P titled Food Storage revised 8/29/23, showed all products should be inspected for safety and quality and be dated upon receipt, when opened, and when prepared. Any expired or outdated food products should be discarded. Date meat when taken out of freezer. Follow meat pull schedule when available in menu program. On 4/2/24 at 0830 hours, during the initial tour of the kitchen, an observation of the walk-in refrigerator and concurrent interview was conducted with the FNSD. The following items were observed: - 51 lbs of chicken breasts with no use by date or freezer pull date; - 40 lbs of chicken thighs with a received date of 3/21/24, but with no use by date or freezer pull date; - 12 lbs. of turkey breasts with a received date of 3/11/24, but with no use by date or freezer pull date; - two 12 lbs. of sealed packs of beef tenderloin with a received date of 3/21/24, but with no use by date or freezer pull date; and - two boxes of 10 lbs of cod fish with no use by date or freezer pull date. All food items were completely thawed. The FNSD stated the food from the freezer in the process of thawing should be labeled with the received date, use by date, and freezer pull date. The FNSD verified the above findings. 2. According to U.S. Food and Drug Administration, the fresh poultry (chicken and turkey whole and parts) should be kept in the refrigeration for one to two days. These short but safe time limits will help keep refrigerated food to 40 degrees F from spoiling or becoming dangerous. Review of the facility's P&P titled Food Storage revised 8/29/23, showed all products should be inspected for safety and quality and be dated upon receipt, when opened, and when prepared. Any expired or outdated food products should be discarded. Review of the facility's P&P titled Meat Cookery and Storage revised 5/20/20, showed the meat which needs defrosting should be pulled three days prior to service and defrosted in a dry, cool area at 41 degrees F or less. Date meat when pulled for defrosting. On 4/2/24 at 0830 hours, during the initial tour of the kitchen, an observation of the walk-in refrigerator was conducted. 51 lbs of completely thawed chicken breasts with no received date, no use by date, and no freezer pull date was observed. 40 lbs of completely thawed chicken thighs with the received date of 3/21/24, had no use by date and no freezer pull date observed. On 4/3/24 at 1015 hours, an observation of the walk-in refrigerator was conducted with the Chef. The 40 lbs of chicken thighs with the received date of 3/21/24, and with no use by date and no freezer pull date observed on 4/2/24, were still stored in the walk-in refrigerator. The Chef stated the chicken thighs were never stored in the freezer but put directly in the walk-in refrigerator when received. The Chef further stated normally, the chicken breasts were stored upon receipt in the freezer, then transferred to the refrigerator and thawed. When asked what happened to the undated chicken breasts observed on 4/2/24, the Chef stated the chicken breasts had been transferred to the cook's preparation refrigerator for dinner service on 4/5/24. When asked, the Chef stated he was not sure what the shelf life of the raw chicken was. The Chef checked the posted facility guidelines titled Refrigerated Storage Chart revised 8/29/19, for the fresh meat, fish, and poultry. The Refrigerated Storage Chart showed unopened fresh chicken was good for two days in the refrigerator. On 4/3/24 at 1020 hours, the undated chicken breasts observed on 4/2/24, were observed in the cook's preparation refrigerator, unpacked in a tray, and covered with a plastic wrap. The chicken breasts were labeled with a preparation date of 4/2/24, and a use by date of 4/5/24 for dinner. On 4/3/24 at 1027 hours, an interview was conducted with the FNSD. The FNSD stated she thought the 51 lbs. of thawed chicken breasts and 40 lbs. of thawed chicken thighs had been discarded on 4/2/24. The FNSD discarded the chicken breasts prepared in a tray and the 40 lbs. of chicken thighs. 3. According to the USDA Food Code 2022, Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) within two hours from 135 degrees Fahrenheit (F) to 70 degrees F; and (2) within a total of six hours from 135 degrees F to 41 degrees F or less. On 4/3/24 at 1003 hours, an interview was conducted with [NAME] 3 and the Chef. [NAME] 3 stated the chicken would be cooked to use for the chicken salad as a meal alternative. [NAME] 3 stated they did not have a cool down log to monitor the cool down process. The Chef stated they cooked the chicken in the oven, put the cooked chicken and other salad ingredients in the robot coupe (a device to mince or puree meat) to blend, then stored the chicken salad in the refrigerator. The Chef further stated they did not monitor the temperature of the chicken salad. A clip board with more than 20 blank forms titled Cooling Monitoring Forms were observed posted in the kitchen. 4. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact surfaces and utensils shall be clean to sight and touch. Review of the facility's P&P titled Ice Machine Service revised 7/1/20, showed the unit is to be cleaned and sanitized per manufactory guidelines as posted on machine on a quarterly basis to ensure that the unit is free of scale and lime buildup. If needed, unit can be cleaned on a more frequent basis. On 4/2/24 at 0945 hours, an observation of Ice Machine 1 located in the main kitchen and concurrent interview was conducted with the Plants Operation Manager and the Maintenance Technician. Ice Machine 1 was observed with a slimy yellow residue on the ice machine deflector (a device that directs ice from the machine into the ice storage bin) and on the groove in front of deflector when wiped with white paper towel. A yellow-white crusty residue was also observed surrounding the ice chute (area where ice is dispensed into the ice storage bin). The Plants Operation Manager stated the ice machine was cleaned every six months. The Plants Operation Manager stated they would work on cleaning the ice machine. On 4/2/24 at 1005 hours, an observation of Ice Machine 2 located in the nourishment station and concurrent interview was conducted with the Maintenance Technician. The interior frame of the ice machine door had a clear plastic-like residue. The clear plastic-like residue came off when wiped with a white paper towel. The Maintenance Technician stated the clear plastic-like residue was a silicon sealant. The Maintenance Technician further stated he would close Ice Machine 2 and remove the plastic residue. 5. According to the USDA Food Code 2022, Section 2-402.11 Hair Restraints, Effectiveness, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. Review of the facility's P&P titled Personal Hygiene/ Safety/Food Handling/ Infection Control revised 5/18/23, under the Head Covering Worn section, showed the following: - Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered. - Head covering must be clean. - Beards, mustaches, or any body hair that maybe exposed must be covered. On 4/2/24 at 0820 hours, during the initial tour of the kitchen, [NAME] 1 was observed to wear a baseball cap with exposed hair at the back of his head and uncovered facial hair. On 4/2/24 at 0955 hours, Cooks 2 and 3 were observed to wear a baseball cap with exposed hair at the back of his head and uncovered facial hair while pureeing resident's food. On 4/2/24 at 1150 hours, during the lunch meal tray line service, the Chef, Cooks 1, 2, and 3 were observed with uncovered facial hair. The Chef, Cooks 1, 2, and 3 were observed to wear a baseball cap with exposed hair at the back of their head. On 4/3/24 at 1003 hours, during an interview in the kitchen, [NAME] 3 was observed to wear a baseball cap with exposed hair at the back of his head and uncovered facial hair. On 4/3/24 at 1015 hours, an interview was conducted with the Chef. The Chef was noted to wear a baseball cap with exposed hair at the back of his head and uncovered facial hair. The Chef stated he was not aware a hair restraint was required if a baseball cap was worn. The Chef further stated he ordered beard restraints in the past but no longer ordered beard restraints. 6. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact surfaces and utensils shall be clean to sight and touch. On 4/2/24 at 0845 hours, during the initial tour of the kitchen and concurrent interview with the FNSD, the following items were observed: - two large and one small frying pans with thick black residue buildup on the cooking surface; - four muffin pans with a crusty thick black residue buildup on interior surface; and - three cutting boards were heavily marred with knife marks. The FNSD verified the above findings and stated they would throw the food equipment. 7. Review of the facility's P&P titled Food Storage under Dry Storage section revised 8/29/23 showed to remove food stored in bins from their original packaging, label and date all storage containers or bins and keep free of scoops. On 4/3/24 at 1031 hours, during the pureed meal preparation observation, [NAME] 2 left the spoon used for scooping the thickener in the container after touching it with gloved hands and touching multiple unclean surfaces. On 4/3/24 at 1040 hours, an interview was conducted with the Chef. The Chef stated the spoon used for scooping should never be left in the food container. He acknowledged the above findings. 8. Review of the facility's P&P titled Food Storage under Dry Storage section revised 8/29/23 showed any opened products should be placed in seamless plastic or glass containers with tight-fitting lids and labeled and dated. On 4/2/24 at 0840 hours, during the initial tour of the kitchen, an observation of the dry storage area was conducted with the FNSD. A chicken base plastic container was observed with the cover not sealed. The FNSD stated the product was open and she tried to close the cover, but it did not seal. The FNSD stated it was not good and she would discard the chicken base. 9. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air- Drying Required, showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. Review of the facility's P&P titled Dry Storage-Dishes and Utensils revised 2/1/12, showed the dishes must be stored to promote air drying that is to use dish racks or trays with plastic mesh that allow air to circulate, and air dry the dishes. On 4/2/24 at 0845 hours, during the initial tour of the kitchen with the FNSD, the robot coupe and blender were observed to be stored with the top on, and the inside of each equipment was still wet. The FNSD verified the findings and stated the equipment were not air dried properly. 10. Review of the facility's P&P titled Food Storage, under the Meat/Poultry and Foods section, revised 8/29/23, showed the food should be stored in their original containers if designed for freezing. Food to be frozen should be stored in airtight containers or wrapped in heavily-duty aluminum foil or special laminated papers. The P&P also showed to label and date all food items. On 4/2/24 at 0820 hours, during the initial tour of the kitchen, an observation of the walk-in freezer and concurrent interview was conducted with [NAME] 1. One box of cookies gourmet sugar was observed with an opened interior plastic bag. The cookies appeared freezer burned (a condition caused by air reaching the surface of the food). The box was not labeled with an open date. [NAME] 1 stated the cookies were no longer good. 11. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, Food-Contact surfaces and utensils shall be clean to sight and touch. According to the USDA Food Code 2017, Section 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 4/2/24 at 0845 hours, during the initial tour of the kitchen, the drying rack was observed with yellow and black debris. The FNSD verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed obtain and maintain the copy of advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions), and failed to provide the information regarding the rights to formulate the advance directives for three of 12 final sampled residents (Residents 1, 31, and 192). * The facility failed to review the copy of advance directives provided by Resident 31 and resident's representative, and ensure it was complete to show the resident's wishes and instructions for healthcare. * The facility documented in Resident 192's POLST the resident had a legally recognized decisionmaker, however, the facility failed to ensure the copy of the resident's advance directive for healthcare was obtained and maintained in the resident's medical record. * The facility failed to provide Resident 1 with the written information regarding the advance directive and ensure Resident 1's rights to formulate the advance directive. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored. Findings: Review of the facility's P&P titled Advance Directives dated 5/5/21, showed the following: - Upon admission, determine whether the resident has an advance directive and, if not, determine whether the resident wishes to formulate an advance directive, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so; - Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/ her family members and/ or his/ her legal representative, about the existence of any written advance directives; - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record; - If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives; and - Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 1. Medical record review for Resident 31 was initiated on 7/31/23. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's MDS dated [DATE], showed Resident 31 was cognitively intact. Review of Resident 31's Physician Orders for Life-Sustaining Treatment (POLST) dated 2/3/21, showed Section D Information and Signatures was left blank, and failed to show whether Resident 31 had an advance directive or not. Review of the Social Services Evaluation - V 3 dated 6/4/23, under the Advance Directives section, showed Resident 31 did not have and advance directive and requested ADHC (advance directive for healthcare), have not received was typed in the comment section. Review of Resident 31's electronic medical record showed a copy of Resident 31's advance directive. However, further review of the advance directive showed only the last three pages were available. The last three pages only showed the sections for definitions, signature, special witness requirements and the notary. The copy of advance directive did not show Resident 31's wishes and instructions for healthcare. Further review of Resident 31's medical record failed to show a complete copy of the resident's advance directive. On 8/1/23 at 1014 hours, an interview and concurrent medical record review for Resident 31 was conducted with the Social Services Manager. The Social Services Manager verified the above findings. The Social Services Manager stated Resident 31 had an advance directive, and the Resident 31's family member emailed her a copy of the advance directive. The Social Services Manager stated a copy of Resident 31's advance directives was scanned and uploaded in the resident's electronic medical record. When asked to verify the copy of Resident 31's advance directives, the Social Services Manager checked the copy of the advance directive in the electronic medical record, and verified it was incomplete. The Social Services Manager acknowledged she did not verify whether the copy of Resident 31's advance directive was complete or not before uploading into the electronic medical record. The Social Services Manager verified the copy of Resident 31's advance directive did not show Resident 31's wishes and instructions for healthcare. 2. Medical record review for Resident 192 was initiated on 7/31/23. Resident 192 was initially admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 192's MDS dated [DATE], showed Resident 192 had a moderately impaired cognition. Review of Resident 192's POLST dated 7/27/23, under Section D Information and Signatures, showed discussed with the legally recognized decisionmaker was checked off but failed to show whether Resident 192 had an advance directive or not. Review of Resident 192's medical record failed to show a social services evaluation. Further review of Resident 192's medical record failed to show a copy of Resident 192's advance directive was obtained, or an attempt was made to obtain Resident 192's advance directive. On 8/1/23 at 1018 hours, an interview and concurrent medical record review for Resident 192 was conducted with the Social Services Manager. The Social Services Manager verified the above findings. The Social Services Manager stated the POLST and advance directive should be initiated upon admission, and follow-up within 48 hours. The Social Services Manager stated if a follow-up has been done, it will be documented in the social services evaluation, which was to be completed within five days from admission. When asked if Resident 192 had an advance directive, the Social Services Manager stated she spoke to Resident 192's family member and Resident 192 had an advance directive. When asked for documentation to show Resident 192 had an advance directive, the Social Services Manager stated this was not documented because she has not done the social services evaluation for Resident 192. 3. Medical record review for Resident 1 was initiated on 7/31/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 was cognitively intact. Review of Resident 1's POLST dated 2/3/21, under Section D Information and Signatures, showed discussed with the resident (resident has capacity) was checked off, but failed to show whether Resident 192 had an advance directive or not. Review of the Social Services Evaluation - V 3 dated 7/14/23, under the Advance Directives section, showed Resident 1 did not have and advance directive, and the evaluation form did not show Resident 1 was given information on advance directive. Further review of Resident 1's medical record failed to show documentation Resident 1 was provided with written information regarding advance directives. On 8/1/23 at 1008 hours, an interview and concurrent medical record review for Resident 1 was conducted with the Social Services Manager. When asked about the facility's process regarding resident advance directives, the Social Services Manager stated she would inquire as to whether the resident had formulated an advance directive upon admission of the resident to the facility. The Social Services Manager stated if the resident had not yet formulated an advance directive and wished to formulate an advance directive, she would provide the resident with written information regarding how to formulate an advance directive if the resident had not yet formulated an advance directive and wished to formulate an advance directive. The Social Services Manager reviewed Resident 1's medical record and verified there was no documentation regarding whether Resident 1 had formulated an advance directive or wished to formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of five unnecessary medication final sampled residents (Resident 3). * The facility failed to develop the comprehensive person-centered care plan to address the use of PICC (peripherally inserted central catheter - intravenous access used for a prolonged period of time) line for Resident 3. This failure had the potential risk of not providing appropriate, consistent, and individualized care to the resident. Findings: Review of the facility's P&P titled Nursing Services - Care Plan dated 3/24/20, showed the facility shall implement each resident's care plan according to the resident's needs, physician orders, resident preferences and facility protocols as indicated. The care plans updated upon significant change in status, quarterly and annually. On 7/31/23 at 1415 hours, Resident 3 was observed sitting on his bed awake. Resident 3 stated he had an infection on his bone (jaw) and was receiving an antibiotic through the IV line. Resident 3 was able to show his PICC line on his right upper arm and a single lumen PICC line was observed. Medical record review for Resident 3 was initiated on 8/1/23. Resident 3 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 8/1/23, showed a physician's order dated 6/28/23 to inspect the IV site every shift for redness, tenderness, edema, and leaking. Another physician's order dated 7/25/23, showed to change the PICC line dressing on RUA (right upper arm) every night shift on Sundays and as needed. A physician's order dated 6/28/23, showed to administer Ertapenem Sodium Reconstituted (antibiotic) 1 gm intravenously every 24 hours for osteomyelitis for 40 days. Review of Resident 3's Admission/readmission Evaluation - V 4 form dated 6/28/23, showed under section 4b, Body Check, Resident 3 was admitted with LUE (left upper extremity) PICC line. Review of Resident 3's plan of care failed to show a care plan was formulated addressing Resident 3's use of RUA PICC line. However, a care plan problem addressing for the use of LUE PICC dated 8/1/23 was formulated but the interventions included to change the dressing on the RUA PICC line. Further review of Resident 3's medical record showed on the Nurses admission summary dated [DATE], Resident 3 was admitted to the facility with a PICC line on RUE (right upper extremity). On 8/2/23 at 1424 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 stated Resident 3 had a PICC line on the right upper arm and the dressing was changed every seven days. RN 1 stated Resident 3 was on IV antibiotic for oral infection. RN 1 verified the care plan formulated for Resident 3's use of the PICC line on the right upper was not formulated. RN 1 stated there should have been a care plan formulated when Resident 3 was admitted to the facility and formulate a care plan correctly based on the resident problem. On 8/3/23 at 1001 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON verified the care plan developed for Resident 3's use of PICC line was wrong. The DON stated she expected the care plans would reflect the residents care and needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 12 final sampled residents (Resident 10) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 10 with the contracted hospice. There was no physician's order to indicate the frequency of licensed staff and CHHA visits. The hospice forms such as the hospice certification, comprehensive plan of care, assessment, and the calendars for the months of June, July, and August 2023 were not in the hospice binder or Resident 10's medical records. This failure had the potential for Resident 10 to not receive the appropriate care and treatment. Findings: Review of the facility's P&P titled Hospice/Palliative/End of Life Care Guidelines revised 5/7/21 showed to coordinate care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the Hospice SNF Agreement between the facility and Hospice Provider A dated 3/2020 showed under III. Hospice Services 3.1.2. Design and Maintenance of Plan of Care: a. Residential Hospice Patient. In accordance with applicable federal and state laws and regulations, Hospice shall coordinate with Nursing Facility to develop a Plan of Care for each Residential Hospice Patient. Hospice shall furnish Nursing Facility with a copy of the Plan of Care, including services to be provided and anticipated frequency of visits, soon after the patient's admission as a Hospice Patient. Medical record review for Resident 10 was initiated on 7/31/23. Resident was admitted to the facility on [DATE]. Review of Resident 10's Order Summary Report showed a physician's order dated 6/14/23, to admit Resident 10 for hospice services provided by Hospice Provider A. There was no physician's order to show the frequency of the licensed staff and CHHA visits. Review of Resident 10's Interdisciplinary Care Conference dated 6/21/23, showed Nursing, Nutritional Services, Administration, Social Services, and Resident 10's family attended the meeting. However, it did not show a hospice representative attended the meeting. a. Review of Resident 10's medical record failed to show the current hospice written certification form, and updated hospice plan of care while Resident 10 was receiving hospice services. b. Upon inspection of the hospice tab sections in Resident 10's physical chart, the following was observed: -There were no copies of the hospice certification, assessment, and comprehensive plan of care; -The aide care plan was blank; and -The monthly calendars were dated January/February and February/March 2023 and were blank. However, Resident 10 was admitted under hospice services on 6/14/23. On 8/2/23 at 0908 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated Resident 10 care was collaborative between the hospice and facility services. RN 1 verified the hospice documents such as the copy of the hospice recertification, assessment, plan of care, and updated calendars were not in Resident 10's medical record. RN 1 stated the missing documents should be in Resident 10's medical record to show the tentative plan of the RN, CNA, SSD, and chaplain for Resident 10's care. On 8/2/23 at 1001 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON confirmed the hospice documents such as a copy of the hospice recertification, assessment, plan of care, and updated calendars were not in Resident 10's medical record. The DON stated it was expected for the hospice documents to be completed and in resident's chart. The DON stated the physician's orders should show frequency of visitation from hospice team. On 8/2/23 at 1331 hours, an interview was conducted with the Social Services Manager. The Social Services Manager stated she coordinated with the hospice team regarding Resident 10's care and services. The Social Services Manager stated the hospice documents to show Resident 10's plan of care should be in the resident's medical record. The Social Services Manager verified the hospice representatives did not attended the interdisciplinary care conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 12 final sampled residents (Residents 10 and 19) and one nonsampled resident (Resident 191)'s side rails were properly assessed and the least restrictive alternative measures were implemented or attempted prior to the use of side rails. * The facility failed to ensure the least restrictive alternative measures were implemented or attempted for Resident 10 prior to the use of the assist rail. In addition, there was no assessment conducted by the IDT for Resident 10 prior to the use of the assist rails as per the facility's P&P. * The facility failed to ensure the least restrictive alternatives were attempted prior to the initiation of the assist rails for Resident 191. In addition, there was no assessment conducted by the IDT for Resident 191 prior to the use of assist rails as per the facility's P&P. * The facility failed to ensure the least restrictive alternative measures were implemented or attempted for Resident 19 prior to the use of the assist rail. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: Review of the facility's P&P titled Proper Use of Assist Rails Guidelines revised 7/6/21, showed an assessment will be made by the IDT to determine the resident's symptoms, risk of entrapment, and reason for using assist rails. When used for mobility, or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand, and toilet, risk for entrapment from the use of assist rails, and that the bed's dimensions are appropriate for the resident's size and weight. Less restrictive interventions that will be incorporated in care planning include: providing restorative care to enhance abilities to stand safely and to walk, placing the bed lower to the floor and surrounding the bed with a soft mat, providing staff monitoring at night with periodic assistance with toileting for residents attempting to arise to use the bathroom, and/or furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information. 1. On 7/31/23 at 0859 hours and 8/1/23 at 0850 hours, Resident 10 was observed laying in bed with left side bed grab rail elevated. Medical record review for Resident 10 was initiated on 7/31/23. Resident was admitted to the facility on [DATE]. Review of Resident 10's MDS dated [DATE], showed Resident 10 had moderately impaired cognition and required extensive assistance of two staff for bed mobility and transfer. Review of Resident 10's Order Summary Report for July and August 2023, showed a physician's order dated 6/17/23, for left side assist rail to help promote self-turn and reposition every shift. Review of Resident 10's Bed Rail Utilization assessment dated [DATE], under Fall and Entrapment Risk Determination section showed Resident 10 with an answer of yes on questions for high risk for fall, had history of falls in the last year, had impaired cognition, delirium, seizures disorder or other medical condition that increases risk, had specialty mattress, and taking medication that may alter safety or level of consciousness. Under Mobility Assessment section showed an answer yes on side rail being considered in order to increase bed mobility and promote resident independence only. Under the Interdisciplinary Team Recommendations section showed bed rails were recommended, and the bed rail to be used was the left assist rails. However, the IDT representative names and dates were missing. The assessment form did not show any least restrictive interventions prior to the use of the assist rails. In addition, the assessment form did not show an assessment by the IDT was conducted prior to the use of the assist rails. Further review of the medical record did not show documented evidence of any least restrictive alternatives were attempted, and IDT assessment was conducted prior to the use of the left assist rails. On 8/1/23 at 0901 hours, an observation and concurrent interview was conducted with CNA 5. CNA 5 verified Resident 10 had a left bed assist rail. CNA 5 stated the left bed assist rail was used to help Resident 10 with turning. On 8/1/23 at 1129 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 10 left bed assist rail was elevated while she was laying in bed. LVN 1 stated Resident 10's left bed assist rail is for bed mobility. On 8/2/23 at 1001 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings. The DON verified there were no documented evidence to show least restrictive alternative measures were in Resident 10's medical records. Cross reference to F909, example #1. 3. Review of the facility's P&P titled Proper Use of Assist Rails Guidelines revised 7/6/21, showed to ensure the safe use of assist rails and is prohibited unless necessary to treat a resident's medical symptoms. The criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. On 7/31/23 at 0940 hours, and 8/1/23 at 0836 hours, Resident 19 was observed in bed with right upper side rail elevated. Medical record review for Resident 19 was initiated on 8/1/23. Resident 19 was admitted on [DATE] to the facility. Review of Resident 19's MDS dated [DATE], showed Resident 19 required extensive assistance of one staff for bed mobility. Review of Resident 19's Order Summary Report for the month of August 2023, showed a physician's order dated 5/1/23 for the use of right assist rail to allow resident to participate in repositioning while in bed. Review of the Resident 19's Assessment for Assist Rails form dated 4/26/23, failed to show the documentation for the attempts of least alternative measures were implemented. On 8/1/23 at 1145 hours, an interview with CNA 1 was conducted. CNA 1 confirmed Resident 19's right side rail were elevated when Resident 19 was in bed. CNA 1 stated Resident 19 used the right-side rail when turning in bed. On 8/2/23 at 1026 hours, an interview and concurrent medical record review for Resident 19 was conducted with LVN 1. LVN 1 stated Resident 19 used the right-side rail for repositioning in bed. LVN 1 stated the licensed nurse completed the side rail assessment, asked for physician's order, and obtained informed consent for the use of any side rails. LVN 1 added, use of alternative prior to side rail use and two staff verifying, depending to the performance of the resident, then brought up to the IDT and the final answer coming from the IDT. LVN 1 verified there was no least restrictive alternatives attempted prior to installation of the side rail for Resident 19. LVN 1 stated there should have been an alternative attempted before using the side rail. On 8/3/23 at 1008 hours, an interview and concurrent medical record review for Resident 19 was conducted with the DON. The DON verified the above findings. Cross reference to F909, example # 3. 2. Review of the facility's P&P titled Proper Use of Assist Rail Guidelines revised 7/6/21, showed the following: -The use of assist rails will be determined by the IDT, physician, and resident's ability to use the assist rail to improve function or as requested; - An assessment will be made by the IDT to determine the resident's symptoms, risk of entrapment and reason for using assist rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility, ability to change positions, transfer to and from bed or chair, and to stand and toilet, risk of entrapment from the use of assist rails, and the bed's dimensions are appropriate for the resident's size and weight; - Less restrictive interventions that will be incorporated in care planning include: providing restorative care to enhance abilities to stand safely and to walk, placing the bed lower to the floor and surrounding the bed with a soft mat, providing staff monitoring at night with periodic assistance with toileting for residents attempting to arise to use the bathroom, and /or furnishing visual and verbal reminders to use the call bell for residents who can comprehend this information; - Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of assist rails; and - When assist rail usage is appropriate, the facility will assess the space between the mattress and assist rail to reduce the risk for entrapment (the amount of space may vary, depending on the type of bed and mattress being used). On 7/31/23 at 0849 hours, during the initial tour of the facility, Resident 191 was observed lying in bed with the right assist rail elevated. When asked about the right assist rail, Resident 191 stated she used it to turn and reposition, but she did not use the assist rail much because she did not have strength on her right side. Medical record review was initiated on 7/31/23. Resident 191 was admitted to the facility on [DATE]. Review of Resident 191's Order Summary Report showed a physician's order dated 7/25/23, for side rail to the right side of the bed to increase bed mobility and promote resident independence. Review of Resident 191's Bed Utilization assessment dated [DATE], under Fall and Entrapment Risk Determination, showed for the questions whether resident had history of falls, whether resident had an impaired cognition, delirium, seizure disorder or other medical condition that increases risk, and whether resident takes any medication that may alter safety or level of consciousness, the yes column was checked. Under the Other Concerns or Comments section, showed assist in bed mobility also used to ease placement of bed pan by using unaffected leg to lift pelvis. Under the Interdisciplinary Team Recommendations section showed bed rails were recommended, and the bed rails to be used was the right assist rails. However, the IDT representative names and dates were missing. The assessment form did not show any least restrictive interventions prior to the use of the assist rails. In addition, the assessment form did not show an assessment by the IDT was conducted prior to the use of the assist rails. Further review of the medical record showed no documented evidence any least restrictive alternatives were attempted, and IDT assessment was conducted prior to the use of the right assist rails. On 8/1/23 at 0830 hours, 8/2/23 at 0840 hours, and 8/3/23 at 0822 hours, Resident 191 was observed lying in bed with the right assist rail elevated. On 8/2/23 at 0841 hours, an observation for Resident 191 and concurrent interview was conducted with CNA 4. Resident 191 was observed lying in bed with the right assist rail elevated. CNA 4 verified Resident 191 had right assist rail elevated on the bed. When asked if Resident 191 was using the right assist rail, CNA 4 stated Resident 191 hold on to the assist rail when she turned Resident 191 to the right side when she was providing care to Resident 191. On 8/2/23 at 1059 hours, an interview and concurrent medical record review for Resident 191 was conducted with RN 1. RN 1 verified the above findings. When asked if there were any least restrictive interventions prior to the use of assist rails, RN 1 stated Resident 191 was assisted with bed mobility and use of bedpan. When asked if there was an IDT assessment for Resident 191 prior to the use of side rails, RN 1 acknowledged she completed the Bed Rail Utilization Assessment form for Resident 191, and there was no IDT assessment conducted prior to the use of side rails. Cross reference to F909, example #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Psychotropic Medication Use revised 10/2018 showed thebehavior monitoring shall be initiated along with monitoring for possible side effects. The P&P also showed the nursing staff must have means to reference possible side effects of pertinent medications. Medical record review for Resident 541 was initiated on 8/1/23. Resident 541 was admitted to the facility on [DATE]. Review of Resident 541's Order Summary Report for July 2023 showed a physician's order dated 7/25/23, to administer one tablet of zolpidem tartrate (hypnotic/sedative) 10 mg by mouth at bedtime for insomnia manifested by inability to fall asleep. Further review of Resident 541's Order Summary Report showed a physician's order dated 7/25/23, to monitor the resident's behaviors and interventions for inability to fall asleep every shift related to the use of zolpidem. (Intervention codes: 0. None 1. Redirection 2. 1:1 3. Reposition 4. Offer snacks 5. Encourage self-expression 6. Take to activities 7. Offer toileting 8. Assess for pain) On 8/2/23 at 1055 hours, an interview and concurrent medical record review for Resident 541 was conducted with LVN 1. Concurrent review of Resident 541's MAR for July 2023 showed Resident 541 was administered zolpidem tartrate 10 mg, one tablet by mouth at bedtime for insomnia manifested by inability to fall asleep from 7/25/23 to 7/31/23. Concurrent review of Resident 541's Behavior Monitoring for July 2023 with LVN 1 showed the staff failed to document what interventions were provided on all shifts before zolpidem tartrate 10 mg was given. LVN 1 verified these findings and stated the staff should have documented administration of zolpidem, including the interventions provided to the resident in the MAR. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 12 final sampled residents (Residents 10, 392, and 541) were free from the unnecessary psychotropic medications (any drug that affects brain activity). * The facility failed to ensure Resident 10's episodes of behaviors for the use of quetiapine (antipsychotic medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and escitalopram (antidepression medication) were completed, accurate, summarized, and made available to the prescriber on a monthly basis to serve as reference for gradual dose reduction. * The facility failed to ensure Resident 392's episodes of behaviors for the use of risperidone (antipsychotic medication use to treat symptoms of schizophrenia or bipolar disorder (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) and temazepam (medication to treat sleeping problems) were accurate, summarized, and made available to the prescriber on a monthly basis to serve as a reference for gradual dose reduction. * The facility failed to ensure Resident 541's behavioral monitoring and interventions for the use of zolpidem (a sedative) was accurate. These failures have the potential of not providing the correct data to the prescriber in order to adjust the dose of the psychotropic medications for the residents. Findings: Review of the facility's P&P titled XXVIII. Psychotropic Medication Use revised 10/2018 showed monitoring will be completed on the Medication Administration Record by appointed nursing staff, such as tallying behaviors and adverse effect observed each shift. The nurse should review the resident's symptoms and effectiveness of the psychotherapeutic medication on a weekly basis as part of the licensed weekly summary and will summarize monthly for review by MD. 1. Medical record review for Resident 10 was initiated on 7/31/23. Resident was admitted to the facility on [DATE]. Review of Resident 10's physician's history and physical examination dated 6/15/23, showed Resident 10 had diagnoses of psychosis (a collection of symptoms that affects the mind, where there has been some loss of contact with reality) and depression (a constant feeling of sadness and loss of interest, which stops an individual doing normal activities). Review of Resident 10's MDS dated [DATE], showed Resident 10 had moderately impaired cognition. Review of Resident 10's Order Summary Reports for July and August 2023, showed the following physician's orders: - dated 6/14/23, to administer quetiapine fumarate 25 mg one tablet by mouth at bedtime for psychosis manifested by inconsolable crying. - dated 6/14/23, to monitor for behavior of psychosis manifested by inconsolable crying every shift for quetiapine medication. - dated 6/28/23, to administer escitalopram oxalate 20 mg one tablet by mouth one time a day for depression manifested by verbalization of sadness. - dated 6/28/23, to monitor for behavior of verbalization of sadness every shift for escitalopram medication. Review of Resident 10's MAR for July 2023 showed documentation of behavior monitoring for inconsolable crying were incomplete on 7/1, 7/2, 7/3, 7/4, 7/6,7/7, 7/8, 7/9, 7/10, 7/14, and 7/23/23. In addition, it showed documentation of behavior monitoring for verbalization of sadness were incomplete on 7/1, 7/2, 7/3, 7/4, 7/6,7/7, 7/8, 7/9, 7/10, 7/14, and 7/23/23. On 8/2/23 at 0908 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there were missing documentation from the licensed nurses in the MAR for July 2023 in monitoring Resident 10's behaviors of inconsolable crying and verbalization of sadness every shift. RN 1 stated the monitoring of behaviors should be complete and accurate so the physician can determine the effectiveness of the medication. On 8/2/23 at 1001 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON verified there were dates not completed in Resident 10's July 2023 MAR for monitoring behaviors for inconsolable crying and verbalization of sadness. The DON stated the documentation in the MAR should be complete or we would not be able to determine the exact number of behavior episodes for Resident 10. The DON stated the IDT met weekly to discuss the residents with psychotropic medications and their behaviors. The DON further stated the Social Services Manager psychotropic medication evaluation showed the summarization of the resident's behaviors. On 8/2/23 at 1331 hours, an interview and concurrent medical record review was conducted with the Social Services Manager. The Social Services Manager verified there were missing documentation in monitoring behaviors for inconsolable crying and verbalization of sadness in Resident 10's July 2023 MAR. The Social Services Manager stated she does not total the number of episodes of residents' exhibited behaviors on a monthly basis. The Social Services Manager stated the IDT reports individual information regarding the residents' behavior during their weekly meeting. When the Social Services Manager was asked how she reported residents' behavior to the psychiatrist to determine for gradual dose reduction (GDR), the Social Services Manager stated she looks at the information from the progress notes, MAR, and other IDT members report. 2. Medical record review for Resident 392 was initiated on 8/1/23. Resident 392 was admitted to the facility on [DATE]. Review of Resident 392's physician's history and physical examination dated 7/17/23, showed Resident 392 had diagnoses of psychosis and insomnia (difficulty in falling or staying asleep). Review of Resident Order Summary Report for July and August 2023 showed the following physician's orders: - dated 7/19/23, to administer risperidone 0.25 mg one tablet by mouth every 8 hours for psychosis manifested by striking out. Hold if patient is lethargic. - dated 7/16/23, to monitor for resistive to care for risperidone medication every shift. - dated 7/18/23, to administer temazepam capsule 15 mg by mouth at bedtime for insomnia manifested by episode of inability to sleep. Hold for sedation. - dated 7/16/23, to monitor for inability to sleep more than six hours at bedtime every shift for temazepam medication. Review of Resident 392's MAR for July and August 2023, showed the licensed nurses documented the checked marks under behavior monitoring for resistive to care and inability to sleep more than six hours every shift. The MAR did not indicate to tally the number of behavior episodes Resident 392 exhibited during each shift for resistive to care and hours of sleep. On 8/2/23 at 1001 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON verified Resident 392's July and August 2023 MAR behavior monitoring for the risperidone and temazepam medications showed the checked marks during each shift and did not show the number of episodes Resident 392 exhibit a behavior. The DON stated she would not be able to determine the number of episodes Resident 392 exhibited resistive to care or inability to sleep with the checked marks. The DON further stated the licensed nurses were expected to document the total number of episodes Resident 392 resisted to care or if unable to sleep during their shift. On 8/2/23 at 1331 hours, an interview and concurrent medical record review was conducted with the Social Services Manager. The Social Services Manager verified the above findings. The Social Services Manager verified Resident 392's MAR for July and August 2023 showed checked marks under each shift for monitoring episodes of resistive to care and inability to sleep more than six hours. The Social Services Manager further stated the documentation in the MAR was to monitor the behaviors of the residents to determine if a medication was effective. The Social Services Manager stated if the documentation was not complete or accurate, it would be difficult to determine if the resident was appropriate for the GDR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Storage of Medications dated 10/2018 showed drugs shall be accessible only to personnel designated in writing by the licensee. The facility failed to ensure medications were secured and attended. This failure had the potential for unauthorized access and drug diversions in the facility. During a concurrent observation and interview on [DATE] at 1000 hours with RN 1 in Medication Room A, multiple residents' belongings bags containing multiple prescription medications were observed on the counter. One unlicensed staff was observed inside Medication Room A. There were no licensed staff observed inside Medication Room A. RN 1 verified the findings and stated an unlicensed staff should not be inside the medication room with medications left unattended by a licensed staff. Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the opened tuberculin purified protein derivative (PPD) vial was labeled with opened date. This failure had the potential to negatively impact the residents' well-being. * The facility failed to ensure the discontinued medications for one of the 12 final sampled residents (Resident 10) was removed from the medication cart. This failure had the potential for medications to be accidentally administered and/or diverted. * Multiple prescription medications were left unattended inside Medication Room A with an unaccompanied unlicensed staff. This failure had the potential for unauthorized access and drug diversions in the facility. * The facility failed to ensure the medication carts were properly locked and secured. Medication Cart 1 was left unlocked and unattended. This had the potential for unauthorized persons to have access to the medications inside the medication cart. Findings: 1. Review of the facility's P&P titled I. Injectable Medications Revised 10/2018 showed that Tuberculin PPD (Mantoux) which has been opened and in use for one month should be discarded because oxidation and degradation may have reduced the potency. According to the Centers for Disease Control and Prevention (CDC), if a multi-dose has been opened or accessed (e.g needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. The manufacturer's manual for Aplisol showed that vials is use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency On [DATE] at 0947 hours, an observation of Medication Room A and concurrent interview with the RN 1 was conducted. The refrigerator was observed with one vial of PPD opened with no opened date. RN 1 verified the finding. 2. On [DATE] at 1405 hours, an inspection of Medication Cart 2 showed a clear plastic bag containing the following medications for Resident 10 : Haloperidol Lactate Concentrate 2 mg/ml, Loperamide HCl 2 mg and Ondansetron HCl 4 mg. Review of the facility's P&P titled XIII. Disposal of Medications Revised 11/2017 showed the disposal of the medication refers to legal disposition of excess unused, contaminated, expired, discontinued, wasted and decomposed medications, via contracted disposal arrangements of the facility. Review of Resident 10's Order Summary Report (Order Date Range [DATE]-[DATE]//23) dated [DATE] showed the following physician's orders : Started on [DATE] - Haloperidol Lactate Concentrate (antipsychotic) 2 mg/ml (as needed), discontinued on [DATE]. Started on [DATE] - Loperamide HCl (antidiarrhea) 2 mg (every six hours as needed for seven days), completed on [DATE]. Started on [DATE] - Ondansetron HCl (for nausea and vomiting) 4 mg (every six hours as needed for seven days), completed on [DATE]. LVN 1 verified the findings and stated the medications were discontinued on [DATE]. On [DATE] at 1119 hours, the DON was informed of the findings. When the DON was asked about the expectations regarding discontinued medications and storage in carts, she stated the discontinued medications should be discarded immediately. 4. On [DATE] at 1505 hours, Medication Cart 1 parked in the seating area near the rursing station was observed to be locked but the first left drawer was left open and unattended. A facility staff was observed passing by. On [DATE] at 1507 hours, LVN 4 was observed walking towards Nursing Station A. LVN 4 verified Medication Cart 1 was locked but the first left drawer was left open and unattended. When LVN 4 was asked to open the first left drawer, the drawer contained several insulin pens. When LVN 4 was asked to open the other drawers, LVN 4 was able to open the drawers. The drawers contained multiple bubble packs of medications. On [DATE] at 1510 hours, LVN 4 asked LVN 5 to check Medication Cart 1. LVN 5 stated she was in charge of Medication Cart 1. LVN 5 verified Medication Cart 1 was locked but the first left drawer was left open and unattended, and since a drawer was left opened, the other drawers could be opened even when the medication cart was locked. LVN 5 stated she would have to call the pharmacy to service Medication Cart 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to maintain the accurate medical record for one of the 12 final sampled residents (Resident 341). * Resident 341's I/O documented in the MAR was inconsistent with the I/O documented in the Intake/Output Record (Shift) form. This failure had the potential for Resident's 341 care needs not being met as his I/O information was inaccurate in the medical record. Findings: Medical record review for Resident 341 was initiated on 8/2/23. Resident 341 was admitted to the facility on [DATE]. Review of the Order Summary Report for 7/28 to 8/31/23 showed the following orders: - Fluid Restriction 2000 ml - Total Dietary 1200 ml: breakfast = 720 ml, lunch = 240 ml, and dinner = 240 ml - Total Nursing 800 ml: morning shift = 340 ml, afternoon shift = 340 ml, and night shift = 120 ml. - Monitor I/O for 30 days every shift. Review of Resident's 341's I/O on the MARs for July and August 2023 showed the I/O documentation in the MARs was not consistent with the I/O documentation on Resident's 341 Intake/Output records from 7/28 to 8/2/23, as follows: - The MAR showed the intake on 7/29/23 during the 3-11 shift was 250 ml; however, the Intake/Output record was 240 ml. - The MAR showed the output on 7/29/23 during the 11-7 shift was 50 ml; however, the Intake/Output record was 700 ml. - The MAR showed the intake on 7/30/23 during the 7-3 shift was 560 ml; however, the Intake/Output record was 340 ml. - The MAR showed the output on 7/30/23 during the 7-3 shift was 780 ml; however, the Intake/Output record was 200 ml. - The MAR showed the intake on 7/30/23 during the 3-11 shift was 340 ml; however, the Intake/Output record was 240 ml. - The MAR showed the intake on 8/1/23 during the 3-11 shift was 250 ml; however, the Intake/Output record was 420 ml. On 8/2/23 at 1248 hours, an interview and concurrent medical record review for Resident 341 was conducted with the LVN 1. LVN 1 stated the nursing staff had their own I/O records. The Intake/Output (Shift) forms were given to the CNAs at the start of the shifts. LVN 1 further stated the licensed nurses had stopped documenting the I/O in the MARs since June 2023. However, the MARs for July and August 2023 were shown to LVN 1 and confirmed he had documented the I/O in the MAR for 7/31/23 and 8/1/23. On 8/3/23 at 1351 hours, an interview and concurrent medical record review for Resident 341 was conducted with the DON. The DON confirmed the Intake/Output (Shift) forms were given to the CNAs at the start of the shifts and uploaded/scanned in the system. The Intake/Output (Shift) forms were filed in the resident's medical record. The Intake and Output Worksheets (Shift) from 7/28 to 8/2/23, and MARs for July and August 2023 were shown to the DON and confirmed the entries did not match. The DON stated the physician could only access the MARs remotely if the Intake and Output Worksheets were not uploaded/scanned into the system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure residents' entrapment assessments were accurate, complete, and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for all seven residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. An observation and concurrent interview, medical record review, and facility document review for Residents 10, 19, and 191, showed the residents' bed entrapment assessment were not accurate or the bed inspection gap measurement were recorded from bed to side rails. For example: 1. On 7/31/23 at 0859 hours and 8/1/23 at 0850 hours, Resident 10 was observed lying in bed with left side bed grab rail elevated. Medical record review for Resident 10 was initiated on 7/31/23. Resident was admitted to the facility on [DATE]. Review of Resident 10's MDS dated [DATE], showed Resident 10 had moderately impaired cognition and required extensive assistance of two staff for bed mobility and transfer. Review of Resident 10's Order Summary Reports for July and August 2023, showed a physician's order dated 6/17/23, for left side assist rail to help promote self-turn and reposition every shift. Review of Resident 10's Bed Rail Utilization assessment dated [DATE], under Fall and Entrapment Risk Determination section showed Resident 10 was high risk for fall, had history of falls in the last year, had impaired cognition, delirium, seizures disorder or other medical condition that increases risk, had specialty mattress, and taking medication that may alter safety or level of consciousness. Under Mobility Assessment section showed the side rail was being considered in order to increase bed mobility and promote resident independence only. Under the Interdisciplinary Team Recommendations section showed bed rails are recommended, and the bed rails to be used was the left assist rails. However, the IDT representative names and dates were missing. The assessment form did not show any least restrictive interventions prior to the use of the assist rails. In addition, the assessment form did not show an assessment by the IDT was conducted prior to the use of the assist rails. Further review of the medical record failed to show documented evidence of any least restrictive alternatives were attempted, and IDT assessment was conducted prior to the use of the left assist rails. Review of Resident 10's Bed System Measurement Device Test Results Worksheet dated 7/21/21, showed the left half bed rail encircled with Zones 1, 2, 3, and 4 with a P encircled; however, there were no measurements for the gaps in between the bed and side rail. Review of Resident 10's Monthly Skilled Nursing Room Checklist dated 7/25/23, under the Furniture/Beds section, failed to document if Resident 10's bed had side rail present. However, Resident 10's bed assessment was checked to ensure side rail for good condition and note areas around bed at risk for entrapment. On 8/2/23 at 1248 hours, an interview and concurrent facility document review was conducted with the Plant Operations Technician I. The Plant Operations Technician I verified there were no exact measurements documented in Resident 10's Bed System Measurement Device Test Results Worksheet. The Plant Operations Technician I stated he received notification from the nursing department to install bed side rail before the new admission arrived at the facility because it will be hard to install the bed rail if the resident was in the bed. The Plant Operation Technician I stated he completed an entrapment assessment to ensure the bed passed correctly. The Plant Operation Technician I further stated he was one of two people responsible for installing resident's bed side rail. The Plant Operation Technician I demonstrated how he would use the entrapment measuring device and stated he placed the measuring device in between the gap from the bed and side rail to make sure the measuring device did not go through the gap. The Plant Operation Technician I further stated if the measuring device did not go through the gap in between the bed and side rail, it meant the bed pass for the entrapment assessment. The Plant Operation Technician I also stated he did not measure the gaps from the head and foot of the bed nor documented exact measurements of the gaps in the Bed System Measurement Device Test Results Worksheet. The Plant Operation Technician I verified he was not familiar with the different zones for the bed inspection for entrapment assessment risk. On 8/2/23 at 1557 hours, an interview and concurrent facility document review was conducted with the Plant Operations Manager. The Plant Operations Manager verified and acknowledged the above findings. The Plant Operations Manager verified Resident 10's Monthly Skilled Nursing Room Checklist dated 7/25/23, under Furniture/Beds section, did not show if Resident 10's bed had a side rail present and was assessed for good condition. The Plant Operations Manager stated side rails should be documented in the form before inspection. Cross reference to F700, for example #1. 3. On 7/31/23 at 0940 hours and 8/1/23 at 0836 hours, Resident 19 was observed in bed with right upper side rail elevated. Medical record review for Resident 19 was initiated on 8/1/23. Resident 19 was admitted on [DATE] to the facility. Review of Resident 19's MDS dated [DATE], showed Resident 19 required extensive assistance of one staff for bed mobility. Review of Resident 19's Order Summary Report for the month of August 2023 showed a physician's order dated 5/1/23, for the use of right assist rail to allow the resident to participate in repositioning while in bed. Review of Resident 19's Bed System Measurement Device Test Results Worksheet dated 3/22/22, showed the bed was inspected and determined there was no risk for entrapment. However, there were no documentation of the measurements taken during the inspection of the bed. On 8/2/23 at 1248 hours, an interview and concurrent facility record review for Resident 19 was conducted with Plant Operations Technician 1. Plant Operations Technician 1 stated he was responsible on installing the side rails in bed of the resident. Plant Operations Technician 1 stated he received an instruction from the nurse to install the side rails before admission. Plant Operations Technician 1 stated the entrapment assessment was conducted with the use of the Bionix entrapment test device. Plant Operations Technician 1 stated he would put the kit in between the mattress and side rail; and if the measuring device fell through the gap, the gap was too wide and would need to be adjusted until the device did not fall through the gap. Plant Operations Technician 1 verified he was not familiar with the bed entrapment zones. Plant Operations Technician 1 was not able to show an entrapment assessment was completed for Resident 19's use of side rail. 2. Review of the facility's P&P titled Proper Use of Assist Rail Guidelines revised date 7/6/21, showed when assist rail usage is appropriate, the facility will assess the space between the mattress and assist rail to reduce the risk for entrapment (the amount of space may vary, depending on the type of bed and mattress being used). On 7/31/23 at 0849 hours, 8/1/23 at 0830 hours, 8/2/23 at 0840 hours, and 8/3/23 at 0822 hours, Resident 191 was observed lying in bed with the right assist rail elevated. Medical record review was initiated on 7/31/23. Resident 191 was admitted to the facility on [DATE]. Review of Resident 191's Order Summary Report showed a physician's order dated 7/25/23, for side rail to the right side of the bed to increase bed mobility and promote resident independence. Review of Resident 191's Bed Utilization assessment dated [DATE], showed fall and entrapment risk determination, mobility assessment and resident preference; however, the assessment did not include an entrapment assessment. Further review of Resident 191's medical record failed to show documented evidence an entrapment assessment related to the use of the side rails was completed. On 8/2/23 at 1248 hours, an interview and concurrent facility document review was conducted with the Plant Operations Technician I. The Plant Operations Technician I verified the above findings. When asked about the bed inspection process, the Plant Operations Technician I stated he checked the beds monthly and as needed. The Plant Operations Technician I stated he checked the functionality of the bed, the remote control, and the bed brakes. When asked about the assist rails, the Plant Operations Technician I stated he would get notification from the nurses to install the assist rails. The Plant Operations Technician I stated he was responsible for installing the assist rails, and stated he would even install the assist rails before a resident had been admitted to the facility. When asked about the different zones of possible entrapment, the Plant Operations Technician I stated he was not familiar with the different zones of possible entrapment, but he used a triangular cylinder-shaped measuring device and made sure the measuring device did not go through the gaps in between the bed and the side rails. When asked if he check the gaps within the rail (Zone 1), or the gaps under the rail, between the rail supports or next to a single rail support (Zone 2), or under the rail, at the ends of the rail (Zone 4), or the gaps between the head or foot board and the mattress end (Zone 7), the Plant Operations Technician I answered no. The Plant Operations Technician I stated he only checked the gaps between the assist rail and the mattress. Review of the Bed System Measurement Device Test Results Worksheet for Resident 191 dated 10/20/20, showed no rails. Review of the Monthly Skilled Nursing Room Checklist for Resident 191 dated 7/25/23, under the section Furniture/Beds, to ensure in good condition and note areas around bed at risk for entrapment, showed no side rails were present. The Plant Operations Technician I verified the above findings. The Plant Operations Technician I stated he went to Resident 191's room and observed the right assist rail was elevated and verified the Bed ID number. The Plant Operations Technician I verified the worksheet form showed no rails and the Plant Operations Technician I could not find any documentation the entrapment assessment was completed for Resident 191 related to the use of the assist rails. On 8/2/23 at 1536 hours, an observation of a resident bed, and concurrent interview and facility document review was conducted with the Plant Operations Manager, with the Administrator present. The Plant Operations Manager verified the above findings. The Plant Operations Manager stated the plant operations department was responsible for installing the assist rails and measuring the areas of entrapment. The Plant Operations Manager illustrated how he would inspect the bed side rails for entrapment using an empty resident bed with assist rails. When asked what were measured to assess the areas of entrapment, the Plant Operations Manager stated they only measure the gap between the mattress and the side rails. The Plant Operations Manager stated they would document the measurements in the worksheet forms provided by the measuring device company. When asked to show the documentation, the Plant Operations Manager showed the Bed System Measurement Device Test Results Worksheet previously shown by the Plant Operations Technician I. The Plant Operations Manager verified the worksheet form for Resident 191 showed no rails. The Plant Operations Manager verified there was no documentation to show an entrapment assessment for Resident 191 was conducted prior to the use of the assist rails. On 8/3/23 at 0858 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. When asked about the entrapment assessment, the DON stated the side rails assessment was completed by the nursing; however, it did not include the entrapment assessment. The DON further stated the maintenance department was responsible for installing the side rails and conducting the entrapment assessment. Cross reference to F700, example #2.

Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the foods in the kitchen was utilized once the food item was opened. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after 72 hours. * The facility failed to ensure a proper sanitary condition of the ice machine. * The facility failed to ensure hair restraints were correctly worn by the dietary staff working in the kitchen. * The facility failed to ensure the meat thawing in the refrigerator was labeled with the use-by date, and the date when the meat was pulled from the freezer. * The facility failed to ensure the bins containing the adaptive utensils (specialized forks, spoons and other specially designed cutlery with built-up handles to help people with disabilities to dine independently) were clean. * The facility failed to ensure cutting boards were kept in a sanitary condition. * The facility failed to ensure the handles of the basting spoons and spatula, and the top of the strainers were not melted. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility on 7/31/23, showed 32 of 33 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised 4/6/23 showed all products should be inspected for safety and quality, and be dated upon receipt, when open and when prepared. Use Use-By dates on all food stored in refrigerators and use dates according to the timetable in the Dry, Refrigerated and Freezer Storage Charts. On 7/31/23 at 0747 hours, during the initial tour of the kitchen, with the Consultant Dietitian present, the following items were obseved opened with no opened dates inside the walk-in refrigerator: - a container of buffalo wing sauce; - a container of queen olives; - a container of yellow mustard; - a container of thousand island dressing, and - a bag of flour tortilla. The Consultant Dietitian verified the above findings. On 8/2/23 at 1110 hours, an interview was conducted with the Food and Nutrition Director. The Food and Nutrition Director verified the findings and stated the food items should have been properly labeled and dated with the received date, opened date, and use-by date. 2. Review of the facility's P&P titled Food from Outside Sources revised 5/20/20 showed food brought in by the visitors, family, friends or other guests for residents is permitted allowing the resident the right to choose. Perishable food should be sealed and dated with a use-by date and placed in refrigeration. On 7/31/23 hours, an observation of the refrigerator used to store residents' food items brought in by the visitors, and concurrent interview was conducted with LVN 5. A note posted on the refrigerator showed All food needs to have resident's name and date, food will be thrown away if missing name and date. LVN 5 was asked to open the refrigerator used to store residents' food items brought in from visitors, and the following items were observed: - a container of creamer labeled with resident's name, and a use-by date of 7/19/23; - a container of peanut butter labeled with resident's name, and an opened date of 7/19/23; - a bag containing Vietnamese soup, meat and noodles labeled with resident's name and was dated 7/27/23; - a container of blackberry preserves labeled with resident's name, but not labeled with received date and no use-by date; - a bottle of Gatorade drink labeled with resident's name, but not labeled with received date and no use-by date; - a container of protein drink labeled with resident's name, but not labeled with received date and no use-by date; and - three containers of ice cream labeled with resident's name, but not labeled with received date and no use-by date. LVN 5 verified the above findings. LVN 5 stated the licensed nurses checked the temperature of the refrigerator and checked the contents of the refrigerator. LVN 5 stated they were supposed to label the food items with the resident's name, and the received date when they were placed into the refrigerator. When asked how long food items were allowed in the refrigerator, LVN 5 stated food was kept for 72 hours and disposed of afterwards. 3. Review of the Hoshizaki Instruction Manual revised 2/22/22, showed the following: - Under the section Maintenance Schedule showed the icemaker and dispenser unit/ ice storage bin should be cleaned and sanitized per the cleaning and sanitizing instructions in this manual, every six months; and - Under the section Cleaning and Sanitizing Instructions showed the cleaning solution is to dilute 9.6 fluid ounce (0.29 liter) of Hoshizaki Scale Away with 1.6 gallon (six liters) of warm water, and the sanitizing solution is to dilute 2.5 fluid ounce (74 ml or five tablespoons) of a 5.25.% sodium hypochlorite solution (chlorine bleach) with five gallons (19 liters) of warm water. On 3/13/19 at 0822 hours, an ice machine inspection, concurrent interview, and facility document review was conducted with Maintenance Technician III. A yellowish substance was observed on the ice chute inside the ice storage bin. The ice chute inside the ice storage bin was wiped with a white paper towel, and a yellow residue was observed on the paper towel. The Maintenance Technician III verified the above findings. The Maintenance Technician III stated the ice machine was cleaned and sanitized monthly with a sanitizing spray. Cross reference to F909. 4. According to the USDA Food Code 2022 Section 2-402.11 Hair Restraints, Effectiveness, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. Review of the facility's P&P titled Personal Hygiene/ Safety/ Food handling/ Infection Control revised 5/18/23, under the section Head Covering Worn, showed to wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered. On 8/1/23 at 1140 hours, during a trayline observation, Dietary Aides 1 and 2's hairs were not completely covered with the hair restraint. The Consultant Dietitian verified the above findings and stated their hair should be completely covered with the hair restraint. 5. Review of the facility's P&P titled Food Storage revised 4/6/23, under Frozen Meat/ Poultry and Foods, Thawing section, showed to thaw meat preferably by placing in deep pans and setting on the lowest shelf in the refrigerator. Date the meat when taken out of freezer, and follow meat pull schedule when available in the menu program. On 7/31/23 at 0747 hours, during the initial tour of the kitchen with the Consultant Dietitian present, a bin containing several pieces of raw beef were observed at the bottom shelf of the walk-in refrigerator. The bin containing beef was not observed labeled with a date to show when the beef was pulled out from the freezer, and no use-by date. The Consultant Dietitian verified the above findings and she would ask the Food and Nutrition Director about thawing the beef. On 8/2/23 at 1000 hours, an interview was conducted with the Food and Nutrition Director and the Chef de Cuisine. The Food and Nutrition Director and Chef de Cuisine verified the above findings. When asked about thawing, the Food and Nutrition Director stated they would pull the food item from the freezer and placed them inside the refrigerator. The Food and Nutrition Director stated they should label the bin with the date when the food items were pulled out from the freezer, and the use-by date. 6. According to the USDA Food Code 2022, 4-602.13, Non- Food Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 8/1/23 at 1207 hours, two cutlery bins with compartments used to store adaptive utensils were observed with brown and black particles. The Chef de Cuisine verified the above findings and stated the bins should be cleaned and washed daily. 7. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, showed surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. On 8/2/23 at 1020 hours, four cutting boards were observed to be heavily marred with knife marks, and with yellowish stain. The Chef de Cuisine verified the cutting boards needed to be replaced. 8. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, showed materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. a. On 8/1/23 at 1131 hours, two basting spoons, one slotted basting spoon, and a rubber spatula inside a bin were observed with melted handles. The Chef de Cuisine verified the findings. b. On 8/2/23 at 1000 hours, the top of the two silver-colored cone-shaped strainers hanging with the other strainers, were observed melted. The Food and Nutrition Director and the Chef de Cuisine verified the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and equipment instruction manual, the facility failed to maintain essential equipment in safe operating condition. * The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's specification. The facility used a sanitizing spray to clean and sanitize the ice machine, instead of the Hoshizaki Scale Away solution to clean and sodium hypochlorite solution (chlorine bleach) solution to sanitize the ice machine as per the ice machine instruction manual. This failure had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents. Findings: According to the CMS 672, Resident Census and Conditions of Residents completed by the Administrator and dated 7/31/23, 32 of 33 residents in the facility were served food prepared in the kitchen. According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Review of the Hoshizaki Instruction Manual for modular [NAME] revised date 2/22/22, showed the following: - Under the section maintenance schedule, the icemaker and dispenser unit/ ice storage bin should be cleaned and sanitized per the cleaning and sanitizing instructions in this manual, every six months - Under the section cleaning and sanitizing instructions, the cleaning solution is to dilute 9.6 fluid ounce (0.29 liter) of Hoshizaki Scale Away with 1.6 gallon (6 liters) of warm water, and the sanitizing solution is to dilute 2.5 fluid ounce (74 ml or five tablespoons) of a 5.25% sodium hypochlorite solution (chlorine bleach) with five gallons (19 liters) of warm water. Review of the Hoshizaki Instruction Manual for the ice storage bin revised 4/10/18, showed under the section cleaning and sanitizing instructions, the appliance must be cleaned and sanitized at least twice a year. The cleaning procedure showed to dilute 5 fluid ounce (148 ml) of Hoshizaki Scale Away with one gallon (3.8 liters) of warm water. The sanitizing procedure following the cleaning procedure showed to dilute approximately 0.5 fluid ounce (15 ml or one tablespoons) of a 5.25% sodium hypochlorite solution (chlorine bleach) with one gallon (3.8 liter) of warm water. Review of the Ice Machine Service Log showed on 7/19/23, emptied ice and sanitize. On 8/1/23 at 0850 hours, an observation of the ice machine and concurrent interview and facility document review was conducted with the Maintenance Technician. When asked how often the ice machine was cleaned and sanitized, the Maintenance Technician stated the ice machine was cleaned and sanitized monthly. When asked how to clean and sanitize the ice machine, the Maintenance Technician stated he took everything out, at least two days prior to the actual cleaning and sanitizing, removed the front panel of the ice machine covering the area where the ice was made, the ice storage bin door, and ice bin baffle (slanted component used to keep ice from falling out of the bin when the door was opened). When asked what solution the staff used to clean the ice machine, the Maintenance Technician stated he used the sanitizer spray for cleaning and sanitizing the ice machine. When asked if the facility used the Hoshizaki Scale Away solution and bleach solution to clean and sanitize the ice machine, the Maintenance Technician replied the facility only used the sanitizer spray to clean and sanitize the ice machine. A yellowish substance was observed on the ice chute in the ice storage bin. The Maintenance Technician stated the yellowish substance could be a calcium deposit and cannot be removed, as this ice machine was cleaned and sanitized on 7/19/23, to which he showed the ice machine cleaning log. The ice chute in the ice storage bin was wiped with a paper towel, and a yellow residue was observed on the paper towel. The Maintenance Technician verified the above findings. On 8/1/23 at 1447 hours, an interview was conducted with the Food and Nutrition Director. When asked what solution the staff used to clean the ice machine, the Food and Nutrition Director stated they used the sanitizer spray for cleaning and sanitizing the ice machine. On 8/2/23 at 1332 hours, an observation of the ice machine and concurrent interview and facility document review was conducted with the Plant Operations Technician I with the Administrator present. The Plant Operations Technician I stated he was responsible for cleaning and sanitizing the ice machine monthly. When asked what solution the staff used to clean the ice machine, the Plant Operations Technician I stated they used the sanitizer spray for cleaning and sanitizing the ice machine. When asked if the facility used the Hoshizaki Scale Away solution and bleach solution were used to clean and sanitized the ice machine, the Plant Operations Technician I replied the facility only used the sanitizer spray to clean and sanitized the ice machine. When asked if he was familiar with the ice machine instruction manual, the Plant Operations Technician I replied no. Review of the ice machine instruction manual showed to use the Hoshizaki Scale Away solution for cleaning and a bleach solution for sanitizing. The Plant Operations Technician I and Administrator verified the above findings. Cross reference to F812, example #3.