Based on observation, interview and record reviews, the facility failed to ensure nursing staff safely handled hazardous drug (HD-drugs that pose short- or long-term harm upon exposure to human via skin or inhalation) in accordance with Centers for Disease Control and Prevention (CDC- a federal agency leading the science-based, data-driven, service organization that protects the public's health) and National Institute for Occupational Safety and Health (NIOSH-a federal agency that is part of the CDC; NIOSH conducts research and makes recommendations for the prevention of work-related hazards, injury and illness) guidelines and facility's Policies and Procedures (P&P) for the safe handling of Hazardous Drugs with resident census of 35. This failure had the potential to pose health risk to the nursing staff and residents. Findings: During a medication pass observation with Licensed Vocational Nurse (LVN) 2, on 05/13/25 at 8:43 a.m., LVN 2 administered one tablet of finasteride (drug used to treat prostate disease) to Resident 6. LVN 2 with bare hands, removed the tablet from the bubble pack (bubble pack, also known as a blister pack or unit-dose packaging, where individual doses are sealed within pre-formed plastic cavities or blisters) labeled with the pharmacy's red HAZARDOUS DRUGS sticker, placed it into a medication cup and administered it to Resident 6. During a record review of Resident 6's Medication Administration Record (MAR- a legal document that listed all active drugs to be given by the nursing staff), dated May 2025, the MAR indicated Resident 6 was on finasteride as follows: Finasteride Oral Tablet 5 MG (MG- same as milligram, a unit of measure); Give 1 tablet by mouth one time a day . -Start Date- 4/4/25. The MAR order did not indicate using gloves or any other precautions when nursing staff was going to administer the drug. LVN 2 was not available for interview as she was off work for the rest of the survey week. During an interview with the Director of Nursing (DON) in her office, on 5/14/25 at 9:42 a.m., the DON stated nurses needed to follow facility's policy and wear gloves to minimize contact and to protect themselves when handling hazardous medications. During a review of facility's P&P titled Policies and Procedures (P&P) for the Safe Handling of Hazardous Drugs, dated 10/3/2019, the policy indicated Appropriate PPE (Personal Protective Equipment) must be worn when handling HD including during: . handling, preparation/mechanical manipulation, and administration . Review of the CDC's NIOSH Safety and Health document, titled Managing Hazardous Drug Exposures: Information for Healthcare Settings, dated 12/2024, last accessed on 5/22/25 via https://www.cdc.gov/niosh/docs/2023-130/default.html and https://www.cdc.gov/niosh/docs/2025-103/default.html, the documents indicated: Workplace exposure to hazardous drugs can result in negative acute and chronic health effects in healthcare workers including adverse reproductive outcomes. Efforts should be made to reduce all worker exposures to hazardous drugs. Occupational exposure to hazardous drugs merits serious consideration, as workers may be exposed daily to multiple hazardous drugs over many years. NIOSH suggests careful precautions and safeguards to protect workers, fetuses, and breastfed infants. Further review of the document indicated to use single glove for handling intact tablet form and double gloves for handling oral liquid form of the hazardous medications as directed. The NIOSH list included finasteride as HD and should have been handled with gloves during medication administration.

Based on interview and record review, the facility failed to document disposition and destruction of the non-narcotic (non-opioid) prescription medications with resident census of 35. This failed practice could contribute to the risk of drug diversion (unlawful use of prescription drug by unauthorized individuals) and unsafe disposition practices. Findings: During a concurrent inspection of the facility's medication room and interview with Licensed Vocational Nurse (LVN) 2, on 5/13/25, at 9:50 AM, LVN 2 could not locate any documentation record for prescription drug destruction and was not sure how non-narcotic prescription medications were stored and/or destroyed. LVN 2 stated the medication room did not have a storage section for resident's discontinued medications. In an interview with the Director of Nursing (DON) on 5/14/25 at 9:42 PM, the DON stated the facility allowed the nurses to destroy the discontinued prescription medications. The DON stated the facility did not have a system of documentation with a witnessed signature. The DON stated the facility did not have an option to return unused drugs to the pharmacy, so any nurse could destroy the discontinued or discharged medications without documentation. In a telephone interview with facility's Consultant Pharmacist (CP) on 5/16/25 at 11:05 AM, the CP stated she helped with destruction of narcotic drugs and was not involved with non-narcotic drug disposition. The CP stated the facility should follow their policy on discontinued drug disposition and the Nurse Consultant (a nurse that advised facility on proper policy and regulation compliance) may have addressed this with the facility. Review of the facility's policy, titled Discarding and destroying Medications, dated 1/2022, the policy indicated Medication that cannot be returned to the dispensing pharmacy . are disposed of in accordance with federal, state and local regulation governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances . Non-controlled substances . are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous medications. The policy did not address the documentation for accountability of non-narcotic medication destruction.

Based on interviews and record reviews the facility failed to address and prevent duplicate use of two similar medications used to treat severe form of stomach heartburn known as Gastro-Esophageal Reflux Disease (GERD-a condition of stomach acid flowing back into the esophagus and can contribute to stomach bleeding) in one out of five sampled residents reviewed for unnecessary drugs (Resident 28) when: Resident 28 received two drugs called pantoprazole (or Protonix) and omeprazole (or Prilosec) simultaneously, which had belonged to the same class of drug called Proton Pump Inhibitors (PPIs-medications that reduce the production of stomach acid and help relieve symptoms like heartburn or GERD). The duplicate use of two PPI could contribute to adverse drug consequences and cause further health problems. Findings: During a review of Resident 28's electronic medical record (HER), titled Diagnosis, dated 5/14/25, the record indicated Resident 28 had GERD with recent hospitalization, diabetes (blood sugar disease), kidney disease, and heart issues among others. During a concurrent interview and record review on 5/14/25 at 4:06 p.m., with Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1, Resident 28's Order Summary Report (an electronic document listed medications and nursing orders) for May 2025 was reviewed. The Order Summary Report indicated that Resident 28 had been taking Prilosec orally every day for GERD since 12/11/24 and resumed the medication after hospitalization on 4/29/25. The record indicated that the Medicator Director (MD) ordered Protonix on 4/27/25 when Resident 28 returned to the facility from the hospital. RN 1 stated the duplicate drugs were not flagged when the second drug was added to the medical record. LVN 1 stated Prilosec should have been discontinued to prevent duplicate therapy. LVN 1stated nurses should notify the MD about Resident 28 receiving two PPIs. During a phone interview with facility's Consultant Pharmacist (CP), on 5/15/25 at 11:05 a.m., the CP stated it's a hard no for Resident 28 to take both Prilosec and Protonix. The CP stated the duplicate PPI would not have provided any additional benefit to Resident 28. A phone call and message to the MD caring for Resident 28, on 5/14/25, at 3:50 p.m., were not returned during the survey. Review of the facility's Policy and Procedure (P&P), titled Drug Regimen Review, revised 9/2017, the policy indicated The physicians, all other medical practitioners, and staff will follow the approaches discussed in the policy on Medication Utilization and Prescribing to guide decisions about using medications to treat any condition or symptom. As part of everyday care, this should include extensive ongoing efforts to review medications in individual residents/ patients for indications, doses, duration, and potential or actual adverse consequences. Review of the facility's policy, titled Medical Director Roles and Functions, dated 9/2017, the policy indicated Resident/patient care will be consistent with pertinent clinical standards of practice. Review of a Centers for Medicare & Medicaid Services (CMS) Medicaid Integrity Group document, dated 10/2015, titled Proton Pump Inhibitors Use in Adults, last accessed on 5/22/25 via https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/pharmacy-education-materials/downloads/ppi-adult-factsheet11-14.pdf, the document indicated the FDA has issued several warnings regarding the long-term use of PPIs, including the risk of fractures, hypomagnesemia (low magnesium level), C. difficile infection (a type of bowel infection), and potential kidney problems. The FDA also recommends using the lowest effective dose and shortest duration of therapy.

Based on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with resident census of 35. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of three errors out of 43 opportunities which resulted in a facility wide medication error rate of 9.52% in three out of 7 residents (Resident 26, Resident 29, and Resident 31) observed for medication administration as follows: 1. Resident 26 was administered wrong cough medication called Robitussin DM (a brand name combinations liquid medicine containing Guaifenesin [an expectorant that helped loosen and thin mucus] with Dextromethorphan [a cough suppressant]) when the doctor's order indicated to give plain Robitussin (or guaifenesin, which thin and loosen mucus and made it easier to clear chest congestion). 2. Resident 29 was given a laxative drug called Senna (a natural stimulant laxative acts by creasing activity of the intestines to cause a bowel movement) when the doctor's orders asked for a combination of Senna plus Docusate (or DSS, a stool softener). 3. Resident 31 was given the wrong strength of a pain patch (also called transdermal patch, an adhesive medicated patch applied to the skin to deliver a specific dose of medication through the skin and into the bloodstream) called Lidoderm 4% (or Lidocaine patch, a product containing numbing agent applied to skin to reduce pain sensation) when the doctor's order asked for Lidoderm 5% (which was a stronger patch dosage). These failures may result in unsafe medication use affecting residents' health and well-being. Findings: 1. During a medication administration observation in facility's hallway B, accompanied by Registered Nurse 1 (RN 1), on 5/13/25, at 8:01 AM, RN 1 after giving Resident 26's routine morning medication, contacted the doctor for resident's complaint of allergy and cough symptoms. RN 1 received orders from MD for Robitussin liquid 10mL (mL is milliliter, a measure of volume) three times a day as needed for 7 days. RN 1 went into the facility's medication room to look for Robitussin and could not find it. RN 1 then went to nearby unit and used Hallway A's bottle of Robitussin DM. RN 1 administered Robitussin DM 10mL to Resident 26. During the review of Resident 26's Medication Administration Record (or MAR, a legal document that listed doctor's order and the nursing administering the drugs), dated 5/14/24, the record indicated RN 1 marked that Resident 26 received 10mL of the Robitussin. In an interview with RN 1, in hallway B, on 5/14/24, at 9:17 AM, RN 1 stated the facility did not stock the plain Robitussin liquid medication and she should have clarified Resident 26's order with the doctor. In an interview with the Director of Nursing (DON) in her office on 5/14/25 at 9:42 AM, the DON stated the nursing staff should have clarified the order with the doctor. The DON stated the house supply (a set of nonprescription medications the facility stocked) should have been reviewed for the availability of the products. 2. During a medication administration observation in facility's hallway B, accompanied by Registered Nurse 1 (RN 1), on 5/13/25 at 8:28 AM, RN 1 administered a laxative medication called Senna to Resident 29 along with 7 other morning medications. During the review of Resident 29's Medication Administration Record (MAR), dated 5/14/24, the record indicated an order for morning administration of the laxative as follows: Sennosides-Docusate Sodium Tablet 8.6-50 MG (MG is milligram, a unit of measure); Give 1 tablet by mouth two times a day for BOWEL MANAGEMENT . -Start Date 4/17/2025 (Sennosides-Docusate tablet a combination of Senna and Docusate) Further review indicated the RN 1 gave a laxative with only Senna as its ingredient and did not follow the MAR order of the doctor. In an interview with RN 1 on 5/14/24 at 9:17 AM, RN 1 stated she overlooked giving the correct pill and the two bottles looked alike in terms of bottles color and letters. 3. During a medication administration observation in hallway A, accompanied by Licensed Nurse 2 (LVN 2) on 5/13/25 at 9:04 AM, LVN 2 applied a lidocaine 4% pain patch to Resident 31's back in addition to six other oral medications. During the review of Resident 31's Medication Administration Record (MAR) dated 5/14/24, the record indicated an order for morning administration of lidocaine patch as follows: Lidocaine Patch 5 % Apply to lower back topically one time a day for pain management . -Start Date: 5/13/2025 Further MAR review indicated LVN 2 marked the MAR for administration of lidocaine 5% when a 4% strength patch, a lower dosage of the pain patch, was administered. LVN 2 was not available for interview after MAR review. In an interview with the Director of Nursing (DON) on 5/14/25 at 10:16 AM, the DON stated the nursing staff should have followed the doctor's order and should have given the right dosage of medication as noted in the MAR. The DON stated the prescription strength of the lidocaine patch could have been ordered through the provider pharmacy. Review of the facility's policy titled: Administering Medications dated 4/2019, the policy indicated Medications administered in accordance with prescriber orders . The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, . of administration before giving the medication.

Based on observation, interview, and record review the facility failed to ensure safe storage of medication and medical supplies in the active storage areas of treatment cart (a mobile cart where medication and supplies for wound and skin care are stored) and the medication room (a locked room used to store medications and supplies) with census of 35 when: 1. Facility's medication room stored expired vaccine, expired testing products, expired supplies, and co-mingled supplies for IV (Into the Vein) medication use on residents that were no longer in the facility. 2. Treatment cart stored expired supplies and opened products that were marked sterile and for one time use in the active storage areas. These failures could contribute to unsafe storage and use of spoiled medication and supplies that could affect the well-being of vulnerable elderly residents. Findings: 1. During a concurrent interview and inspection of the facility's medication room on 5/13/25 at 9:30 AM, accompanied by Licensed Vocational Nurse and Director of Staff Development (DSD), the small room stored both medications and supplies for resident care with expired items as follows: a. The open shelf stored two boxes of multiple Covid testing product (test for respiratory infection) marked as iHealth Covid-19 Antigen Rapid Test (Brand name for the covid testing product) with expiration date of 3-3-2025. DSD could not find a newer expiration date for this product. b. The refrigerator stored two syringes of Covid vaccine (a product that protected from getting Covid respiratory disease) in the refrigerator with no clear expiration date and was marked as follows: Covid-19 Vaccine mRNA, Spikevax 2024-2025 formula (a brand name for the vaccine), the pharmacy label on the Ziploc bag indicated it was a house supply (means it could be used on any resident). The labels indicated the product was issued by provider pharmacy on 1/19/25 and there was another label indicating 3/17/25. There were two labels one the Ziploc bag indicating: 1. Refrigerate and 2.Store in freezer. Thaw before using per package direction. Do not Shake, Protect from Light . The label was not clear on exact Beyond Use Date (the date after which the product should not be used). DSD used his smart phone and searched for the vaccine's stability once out of the freezer, and it showed it was stable for 60 days after thawing. The label was not clear when it was thawed or when it was the beyond use date. Review of the drug information for Spikevax vaccine, accessed via DailyMed (a website by National Library of Medicine and Food and Drug Administration or FDA, a federal government entity that provides information about approved drugs), last accessed on 5/22/25 via https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=f96b315c-fa57-4876-a7e5-a9b584d8e6e6 , the manufacturer information on safe storage indicated Store frozen between -50°C to -15°C (-58°F to 5°F) ( C stand for Celsius and F stands for Fahrenheit scale , both are scales for temperature recording). After thawing, SPIKEVAX may be stored refrigerated between 2°C to 8°C (36°F to 46°F) for up to 60 days or up to the expiration date printed on the carton, whichever comes first. After thawing, SPIKEVAX may be stored between 8°C to 25°C (46°F to 77°F) for up to 12 hours. c. A plastic drawer sitting on the counter in the medication room had a large stock of various supplies for IV use co-mingled with supplies for foley Catheter (a tube inserted into the bladder to drain urine) in addition to expired (outdated on 1-5-2025) swabs for testing for throat infection labeled as Starswab II (brand name of manufacturer). The plastic drawer stored labeled containers of supplies and saline flush (salt solution used to clean IV line) for residents that were no longer in the facility. DSD acknowledged the findings. 2. During a concurrent interview and inspection of the facility treatment cart located in the main hallway, accompanied by DSD, on 5/13/25 at 10:40 PM, the treatment cart stored multiple opened wound care products that were marked sterile and one-time use as follows: a. Multiple opened sterile Iodoform Packing strips (used as an antiseptic and disinfectant for wound healing) marked on the label as Sterile unless seal is tampered with, or jar is opened or damaged and Do Not Reuse. b. Opened packets of Non-adherent Pad by Dukal (manufacturer) marked as sterile noted on the label Sterility guaranteed unless package is damaged or opened. c. Opened packets of Calcium Alginate dressing (used to manage various types of wounds, particularly those that produce moderate to heavy exudate) marked as sterile. d. Opened packets of Comfort Foam by DermaRite (manufacturer, used for management of exuding wounds) marked with sterile and Do Not Reuse and Do not use if damaged e. Multiple expired (outdated on 1-5-2025) swabs for testing for throat infection labeled as Starswab II (brand name of manufacturer) DSD acknowledged the findings and removed the products from active storage. In an interview with Director of Nursing (DON) on 5/14/25 at 10:16 AM, the DON stated they had a small medication room, and it needed to be continuously re-organized for safer storage. The DON also stated every month the nurses and pharmacy consultant checked the storage areas, and they needed to be more detailed in checking the active storage areas. Review of the facility's policy titled: Storage of Medications dated 4/2019, the policy indicated The facility stores all drugs and biologicals in a safe, secure and orderly manner . The nursing staff is responsible for maintaining the medication storage and preparation area in a clean, safe and sanitary manner . Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . Discontinued, outdated or deteriorated drugs or biologicals are returned to dispensing pharmacy or destroyed. Review of the facility's policy titled: Medication Labeling and Storage dated 2/2023, the policy indicated medications are stored in an orderly manner in cabinets, drawers, carts, . Labeling of medications and biologicals dispensed by pharmacy is consistent with applicable federal state requirements and currently accepted pharmaceutical practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement their policy regarding food for residents brought in by family or other visitors for one of 27 sampled residents (Resident 31) when Resident 31's two bottles of outdated apple juice were stored in the facility refrigerator. This deficient practice had the potential for Resident 31 to consume drinks that were out of date which could cause avoidable gastrointestinal upset. Findings: During a review of the facility's policy and procedure (P&P) titled: Bringing in Food for a Resident, dated 3/24/25, the P&P indicated .Food or beverages that are past the manufacturer's expiration date will be thrown away. Food or beverage items without a manufacturer's expiration date will be dated upon arrival in the facility, and thrown away three days after the date marked, or if frozen in 30 days .Refrigeration can occur in the designated resident food refrigerator. Unused food will be discarded within three days, and if kept frozen, within 30 days . During a concurrent observation and interview on 5/13/25 at 3:14 p.m., with director of staff development(DSD), in the staff break room, two frozen bottles of apple juice were found in the freezer of the refrigerator designated for staff usage, with the markings A R and RM [ROOM NUMBER] written in both bottles. The first bottle of the two bottles of apple juice had an expiration of 2/13/25, and the second bottle of apple juice had no written expiration date. On interview, DSD acknowledged that the two frozen bottles of apple juice belonged to Resident 31 in room [ROOM NUMBER]. DSD confirmed that one bottle of apple juice was expired, and the other bottle of apple juice had no expiration date. DSD stated, residents' food or drinks should not be placed in the staff refrigerator. Review of Resident 31's Facesheet (information containing contact details, brief medical history at-a-glance) indicated: Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's physician's order dated 4/25/25 indicated a diet order of regular diet and thin liquids (A regular diet is a standard, unrestricted diet that allows individuals to eat a wide variety of foods without specific limitations. Thin liquids refer to liquids that are typically considered normal in consistency, like water, juice, or coffee). During an interview on 5/14/25 at 2:59 p.m., with Director of Nursing(DON), DON stated the two bottles of apple juice should have been stored in the facility's refrigerator designated to store the residents' food and drinks from home. DON further stated that Resident 31's outdated two bottles of apple juice should have been thrown, because Resident 31 could have drunk the expired juice and could have gotten sick with an upset stomach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper infection prevention and control practices when: 1. Shared Hoyer Lift used by 7 of 7 sampled residents was not maintained in the designated clean and dirty area in Utility Room. 2. The facility failed to properly clean and disinfect the glucometer (a device used to measure blood sugar) according to the manufacturer's guidelines, and facility's policies and procedures (P&P) between resident use. 3. Enhanced Barrier Precautions (EBP) protocol was not followed when providing direct care to Resident 239. These failures had the potential to result in transmission of infection to Residents and Staff throughout the facility. Findings: 1. During a concurrent observation and interview on 5/14/25 at 3:15 p.m. with Infection Preventionist (IP) in the Utility Room, there were 2 Hoyer Lifts (a mechanical device used to safely transfer individuals with limited mobility). One of the two Hoyer Lift base was within a red taped rectangular area labeled DIRTY AREA on the wall, and to the right, there was a cabinet labeled CLEAN AREA that contained various unopened residents' medical supplies. IP stated, it was unclear whether the Hoyer Lift was clean or dirty but the expectation is that after each resident use, it is supposed to be wiped down and cleaned with a disinfecting solution. Additionally, the IP also stated that the Hoyer Lift would not fit in the DIRTY AREA spot and I could see the potential for cross contamination issues with this. During a review of the electronic health records of Residents 5, 9, 19, 20, 21, 25, and 239, their electronic health records all indicated they used the Hoyer Lift. During a review of the facility's policy and procedure (P&P) titled: Cleaning and Disinfection of Resident-Care Items and Equipment dated September 2022, the P&P indicated, 5. Reusable items are cleaned and disinfected or sterilized between residents .6. Reusable resident care equipment is decontaminated and/or sterilized between residents according to manufacturer's instructions .7. Only equipment that is designated reusable is used by more than one resident .9. Durable Medical Equipment (DME-category of medical devices designed to assist individuals with disabilities, injuries, or chronic health conditions; can withstand repeated use) is cleaned and disinfected before reuse by another resident. During a review of the website https://www.cdc.gov/infection-control/media/pdfs/strive-ec102-508.pdf publication titled, Cleaning and Disinfection Strategies for Non-Critical Surfaces and Equipment, [undated], the article, indicated, Daily Cleaning and Disinfection- .Clean and Disinfect all surfaces. This includes horizontal, vertical and contact surfaces .Special Isolation Procedures- .Disinfect cleaning equipment Non-Critical Equipment-disinfect all non-critical patient care equipment before using it with another patient Assure staff responsible for device cleaning receive training on cleaning procedures and follow the equipment manufacturer's instructions 2. During a review of Resident 239's admission Record (a document used to communicate basic information about a resident) printed on 5/14/25, the record indicated Resident 239 was admitted to the facility on [DATE] with a Pressure Ulcer of the Sacral Region, Stage 4 (a wound in the lower part of the spine, just above the tailbone that extends deep into the muscle, tendon, ligament, cartilage, or even bone, caused by prolonged pressure, shear forces, and friction, often in patients with limited mobility). During a review of Resident 239's Physician order dated 5/09/25, the order indicated to start the Enhanced Barrier Precautions (EBPs, are infection control measures designed to expand the use of gowns and gloves beyond standard precautions to reduce the spread of multidrug-resistant organisms (MDROs) in long-term care facilities) during high contact time secondary to chronic wound with wound vac (A wound vac is a Vacuum-Assisted Closure device which is a type of negative pressure wound therapy that helps wounds heal by applying gentle suction to remove excess fluid, reduce swelling, and promote tissue growth). During an observation on 5/12/25 at 10:48 a.m., Resident 239 was lying in her bed. Certified Nursing Assistant 1 (CNA 1) was fixing Resident 239's blankets. CNA 1 did not have a gown on. There was a signage titled Enhanced Barrier Precautions outside Resident 239's door. The signage read as . Providers and Staff must wear gloves and a gown for the high-contact resident care activities . The Director of Nursing (DON) was standing outside Resident 239's door and asked CNA 1 to don a gown while providing care to Resident 239. During a phone interview with CNA 1 on 5/13/25 at 8:31 a.m., CNA 1 stated on 5/12/25, she plugged in Resident 239's wound vac to the electrical outlet in the wall and was tidying up Resident 239's blankets. CNA 1 stated she was aware that Resident 239 was on enhanced barrier precautions, however she did not have a gown on when she provided direct care to her. CNA 1 stated it was important to follow the precautions so the infection wouldn't spread to the other staff and residents. During an interview with DON on 5/13/25 at 8:41 a.m., the DON stated since Resident 239 had an open wound, staff were required to follow enhanced barrier precautions to decrease the risk of cross-contamination, potentially exposing other residents and staff to harmful pathogens. The DON stated since CNA 1 was in close contact with Resident 239 on 5/12/25 and did not wear a gown, she did not follow enhanced barrier precautions. During a record review of the Care Plan for Resident 239, the Care Plan, Enhanced Barrier Precautions required was initiated on 5/09/25. The Goal of the Care Plan indicated the EBPs will be followed during high contact activities through the next review date on 8/06/25. During a review of facility's Policy and Procedure (P&P) titled Enhanced Barrier Precautions dated 9/18/2024, the P&P indicated, EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents .EBPs employ targeted gown and glove use during the high contact resident care. 3. During a medication pass observation of Registered Nurse (RN) 1, on 5/13/25 at 8:28 a.m., Registered Nurse (RN) 1 brought the glucometer into Resident 29's room and placed the glucometer directly on the overbed table. RN 1, with gloved hand, poked Resident 29's left index finger to get blood to measure the blood sugar. After checking Resident 29's blood sugar, RN 1 took the glucometer out of the room, wiped it once with a Sani-Cloth wipe (disinfecting wipes used in healthcare settings to clean and sanitize surfaces) for less than 10 seconds, and then put it back in the medication cart drawer. During an interview on 5/14/25 at 9:17 a.m., in hallway B, RN 1 stated she thought using one wipe was enough to clean the glucometer. During an interview with RN 1, on 5/14/2025 at 9:20 a.m., and concurrent record review of the manufacturer's instructions for Sani-Cloth germicidal disposable wipes, the instructions indicated a two-step process for cleaning and disinfecting a glucometer after use: 1. Use one wipe to remove dirt, blood, and other bodily fluids from the (glucometer) surface. 2. Use a new wipe to disinfect the (glucometer) surface and the surface must remain wet for recommended contact time of two minutes, then let it air dry. RN 1 acknowledged she did not follow manufacturer's instructions for cleaning and disinfecting the glucometer. During an interview with the Director of Nursing's (DON) in her office on 5/14/25 at 9:42 a.m., the DON stated that cleaning the glucometer is a two-step process. Staff must use two separate wipes and ensure the glucometer stays wet for two minutes, as required by the Sani-Cloth manufacturer's specification. During an interview with the Infection Preventionist (IP) on 5/15/25 at 11:57 a.m., the IP stated he was new to the role and expected the nursing staff to follow facility's policy on the two-step process of cleaning and disinfecting the shared glucometer between resident use. During a review of facility's P&P titled Cleaning and Disinfection of Resident -Care Items and Equipment, revised on 9/2022, indicated reusable resident care equipment is decontaminated and /or sterilized between residents' use according to manufacturers' instructions. Review of the manufacturer of Assure Platinum glucometer (a brand name by ARKRAY, the manufacturer of glucometer used by the facility), titled ARKRAY Technical Brief: Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System , dated 9/2024, last accessed on 5/22/25 via https://cdn.pepperapps.io/arkray/public/6372938c5d3664788b179794?signature=eyJhbGciOiJkaXIiLCJlbmMiOiJBMTI4Q0JDLUhTMjU2In0 [NAME]-zPbrA4UpWqmrx5CWqVA.j0hN7RTIwDlhn_ddmUxUrPoDtoekFW0hVi__otLAHk7yUDrnxRNXLd0MmggoJGQKJ814RxYHBIcNJqEor8GZ-gP7kZpBsaiDxUAIWEQCTqYfcD869VyUTRP0Y4ONP3RtTRFv7d0afNJMXEsO9Yq_29iUwuhaGHpj4tdXzRleg9iyZpfkQX9hRgSJgQNnxTZ0.F__tkadrCM9BsbQuWYC29g , the documents under Cleaning and Disinfecting FAQ (Frequently Asked Questions) indicated Can cleaning and disinfecting be accomplished with one wipe? No, Each time the cleaning and disinfecting procedure is performed, two wipes are needed. One wipe to clean the meter and the second wipe to disinfect the meter. What will happen if a blood glucose meter is not cleaned and disinfected after use? . It is important that the long term care facility establish a program for infection control . Program include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces . It is also important to provide education on infection control and the proper use of products. Review of the glucometer manufacturer's, with brand name Assure Platinum Blood Glucose Monitoring System, with revision date of 9/2019, last accessed via https://medaval.ie/docs/manuals/Arkray-Assure-Platinum-Manual.pdf, the section on Cleaning and Disinfecting . indicated The meter should be cleaned and disinfected after use on each patient . The cleaning procedure is needed to clean dirt, blood, and other body fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of blood-borne pathogens (means germs in the blood). A review of the Center for Disease Control (A federal agency responsible for the health and safety of people) guideline, titled Considerations for Blood Glucose Monitoring and Insulin Administration, last accessed on 5/22/25 via https://www.cdc.gov/injection-safety/hcp/infection-control/index.html, the guideline indicated Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. The guideline further indicated Dedicated meters should be cleaned and disinfected per the manufacturer's instructions and, at a minimum, anytime the device is reassigned to a different person . If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent the spread of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, it should not be shared.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a baseline care plan within 48 hours of admission and provide three (Resident 187,185, and 188) of 12 sampled residents and their representatives with a summary of the baseline care plan. This failure did not ensure the residents or their representative were informed of the plan for the provision of care. Findings: Review of the admission Record indicated Resident 187 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) and was discharged home on 2/26/24. During a review of Resident 187's clinical records and concurrent interview on 2/29/24 at 11:57 a.m., with the Director of Nursing (DON), DON stated the baseline care plan was not developed for Resident 187 within 48 hours of admission. DON further stated Resident 187 had been discharged home without a baseline care plan. Review of the admission Record indicated Resident 185 was admitted to the facility on [DATE] with diagnoses that included streptococcal arthritis (joint inflammation following a throat infection) right ankle and foot. During an interview on 2/26/24 at 9:49 a.m., Resident 185, in the presence of family members, stated he was not offered or had received a written summary of his baseline care plan. Review of Resident 185's baseline care plan dated 2/21/24 indicated a copy of baseline care plan will be given to the resident. Review of the admission Record indicated Resident 188 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the nervous system (nervous system is the highly complex part of the body that coordinates its actions and sensory information) Review of Resident 188's baseline care plan dated 2/19/24 indicated a copy of the baseline care plan will be given to the responsible party. During an interview on 2/29/24 at 11:57 a.m., the Director of Nursing (DON), stated residents baseline care plans were not completed within 48 hours by the interdisciplinary team members (IDT). DON further stated she was aware the summaries of the baseline care plan were not provided to the residents and representatives. During a review of the facility's policy and procedures (P&P) titled, Care Plan - Baseline, revised March 2022, the P&P indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The resident and/or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand). Provision of the summary to the resident and/or resident representative is documented in the medical records.

Based on observation, interview and record review, for one (Resident 6) of two sampled resident, the facility failed to implement its Care Plans, Comprehensive Person-Centered policy and procedure when there was no care plan developed to address Resident 6's risk of aspiration with appropriate interventions This failure had the potential to result in Resident 6 develop aspiration, pneumonia and respiratory infection and for residents' not receiving appropriate care and treatment. Findings: Review of Resident 6's admission record, dated 9/1/21, indicated Resident 6 was admitted to the facility with multiple diagnoses included dysphagia orophapharryngeal phase (difficulty in swallowing). Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 12/22/23, indicated Resident 6's Basic Interview of Mental status (BIMS) score was 05 (meaning poor cognition). Resident 6 had swallowing disorder related to holding food in mouth/cheeks or residual food in mouth after meals. Resident 6 diagnoses included dysphagia and Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). During an observation on 2/26/24 at 12:56 a.m., Resident 6 was sited up at the dining table in the dining area and fed by Restorative Nursing Assistant (RNA 1). Resident 6 coughed repeatedly when fed corn bread and salad. When Resident 6 coughed RNA 1 gave Resident 6 water to drink from a plastic cup and Resident 6 coughed after the drink. During an interview on 2/27/24 at 10:01 a.m., RNA 1 stated Resident 6 coughed from time to time when fed. RNA 1 stated Resident 6 used to use a special cup but get frustrated because the special cup limited the amount of water to drink at a time. RNA 1 said Resident 6 did not like to use the specialized cup. Review of physician order dated 10/1/21 indicated the physician prescribed Resident 6 to received provale cup during meals. (The provale cup helps prevent choking and aspiration pneumonia while allowing the patient to eat and drink independently). During an interview on 2/27/24 at 10:01 a.m., Director of Nursing (DON), DON stated Resident 6 did not like the provale cup and get frustrated when drinking water so staff stopped using the special cup. DON said Resident 6 used regular plastic cup to drink water and cough frequently. DON stated Resident 6 was high risk for aspiration. DON said coughing help Resident 6 to prevent aspiration. DON said she did not inform the speech therapist or referred resident for speech evaluation. During an interview on 2/29/24 at 10:50 a.m., DON accompanied by the MDS coordinator (MDS), DON stated there no active care plans to address Resident 6 risk from aspiration and dysphagia diagnosis. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised March 2022, the P&P indicated: The comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident; The comprehensive, person-centered care plan is developed within (7) days of the completion of the required MDS assessment and no more than 21 days after admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to assess one sampled resident (Resident 16) when the resident experienced a severe weight loss. This failure had the potential to result in continuous, unplanned weight loss for one of 13 sampled residents. Findings: Review of the document titled, Weight Change Protocol dated 2023, showed Early identification of a weight problem and possible cause(s) can minimize complications. Assessment of residents experiencing weight changes should be completed in a timely manner . Residents will be weighed monthly and weekly for those newly admitted and those deemed to be at high risk for weight changes . Variances are calculated from monthly and weekly weights that are obtained by facility staff. Residents who experience significant changes in weight or insidious (continuous weight loss that does not necessarily meet the significant/severe weight loss guidelines) weight loss will be assessed by the Facility RD [Registered Dietitian]. The following criteria define significant or insidious weight changes . 5 # [pound] weight loss or gain in 1 month . 10% weight loss or gain in 6 months. The Facility RD will assess, nutritionally diagnosis, suggest interventions, monitor, and evaluate the success of interventions . A care plan is to be developed stating problems, the goal, and the approaches, interventions to accomplish the goal . The care plan must be revised as the goals and interventions change. The goals, interventions in the care plan should match the latest assessment . Review of Resident 16's admission Record showed he was [AGE] years old and admitted on [DATE]. The diagnoses included, but were not limited to, hemiplegia (paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) affecting right dominant side, dementia (a group of conditions characterized by at least two brain functions, such as memory loss and judgement), dysphagia (difficulty swallowing), depressive disorder, and acquired absence of digestive tract. A review of the document titled, Weights and Vitals Summary showed weights recorded for Resident 16 included but were not limited to: 6/5/23 191 pounds (lbs) 11/4/23 178 lbs 12/4/23 170 lbs This document showed in 6 months from 6/5/23 (191 lbs) to 12/4/23 (170 lbs), Resident 16 had a 21 lb/11 percent (%) weight loss. In addition, Resident 16 had an 8 lb weight loss in one month from 11/4/23 (178 lb) to 12/4/23 (170 lb). A record review for Resident 16 showed the last nutrition related documentation by an RD in Resident 16's Electronic Medical Record (EMR) included a Quarterly Nutrition assessment dated [DATE], and a Progress Note dated 9/14/23. A record review for Resident 16, showed the last revised Care Plan in relation to weight loss was on 10/21/23. Review of the document titled, MDS [Minimum Data Set] 3.0 Nursing Home Quarterly . dated December 8, 2023, showed Resident 16 had a BIMS (Brief Mental Status) score of 4 (a BIMS score from 0-7 suggests severe cognitive impairment). This document also showed under Section K - Swallowing/Nutritional Status, Resident 16 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a physician-prescribed weight-loss regimen. During an interview on 3/1/24 at 9:30 a.m., the licensed vocation nurse MDS Coordinator (LVN 1) stated the RD filled out section K of the MDS, and herself and the Director of Nursing (DON) reviewed the MDS when it was completed. LVN 1 stated when reviewing Section K of the MDS, she looked for weight loss or weight gain. During an interview on 3/1/24 at 9:50 a.m., DON stated when the RD marked yes in section K for unplanned weight loss/gain, the facility started the process for weight variance. DON stated the RD needed to do an assessment and brought the assessment to the Interdisciplinary Team (IDT). DON stated the IDT discussed things, such as the necessity to reweigh a resident and the interventions recommended by the RD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two (Resident 2, 16 ) of five sampled residents were free from unnecessary drug when psychotropic medications were administered without adequate clinical indication and monitoring for its use when; 1. Resident 2 was administered Ziprasidone HCL (hydrochloride), an antipsychotic medication at bedtime for dementia and depression manifested by hitting, striking out during care and mobility. Resident 2 was administered Ziprasidone without adequate monitoring of target behaviors. 2. Resident 16 was administered Zyprexa, an antipsychotic medication for altered sensorium (inability to think clearly or concentrate), throwing objects, hitting/punching staff. Resident 16 was administered Trazadone, an antidepressant for sleep without adequate monitor of hours of sleep. Resident 16 was administered PRN (as needed) Lorazepam (Ativan), an antianxiety medication without the implementation of non-pharmacological interventions first before offering PRN medication. Resident 16's PRN Ativan was extended beyond 14 days without the physician documentation of the clinical rationale for continued use. (Note: Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior). According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic conditions related to dementia. [Reference: www.[NAME].com]. These failures had the potential for residents to receive unnecessary drugs and adverse medication side effects. Findings: 1. During an observation and concurrent interview with Certified Nursing Assistant (CNA 3), on 2/27/24 at 7:42 a.m., Resident 2 laid in bed in her room awake and was nonverbal. CNA 3 stated Resident 2 had no behavior or agitation, and when care was explained, Resident 2 was cooperative, nice and sweet. CNA 3 further stated Resident 2 had a left leg contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) and may agitate when turned and reposition. Review of admission Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 12/28/23, indicated Resident 2 had short and long-term memory problems. Resident 2 had no physical, verbal or other behavioral symptoms directed towards others e.g. hitting, kicking, pushing, scratching, grabbing, rejection of care or wandering. Resident 2 had no behavioral symptoms of feeling down, depressed or hopeless, feeling tired or having little energy or pleasure in doing things. Resident 2 had diagnoses that included depression. Review of the physician order dated 1/30/24 indicated the physician prescribed Resident 2 to receive Ziprasidone HCL oral capsule 40 mg (milligram) give one capsule by mouth at bedtime for antipsychosis (prevents or minimizes hallucinations, like seeing or hearing things that are not there). Review of the Medication Administration Record (MAR), dated 1/1/24 to 1/31/24, indicated Resident 2 received Ziprasidone HCL oral capsule 60 mg, one capsule at bedtime for depression and dementia. Review of the MAR, dated 2/1/24 to 2/26/24, indicated Resident 2 received Ziprasidone 40 mg one capsule by mouth at bedtime for antipsychosis. Further review of the MAR, dated 1/1/24 through 2/25/24, indicated no documentation of target behavior monitoring for Resident 2's use of Ziprasidone. During an interview on 2/27/24 at 12:53 p.m., Licensed Vocational Nurse (LVN 2), LVN 2 stated Resident 2 used to be agitated when first admitted to facility. LVN 2 further said Resident 2 was now calm with no behavior of hitting or striking out. During an interview on 2/28/24 at 8:58 a.m., CNA 2 stated she provided care for Resident 2, two to three times a week. CNA 2 stated Resident 2 was cooperative when care was explained. Review of the Consultant Pharmacist's (CP) Medication Regimen Review (MRR), dated 1/3/24, indicated Resident 2 has been receiving the antipsychotic medication Ziprasidone that requires behavior and side effect monitoring. Please evaluate for gradual dose reduction. Review of Resident 2's Preadmission Screening and Resident Review (PASRR), dated 12/21/23, indicated a negative (no mental illness) Level 1 screening (a tool that helps identify possible serious mental illness or intellectual/developmental disability-ID/DD). If Level I is negative, no advance screening to Level II occurs. A Level II evaluation helps determine placement and specialized services. 2. Review of the Significant Change in Status-Minimum Data Set, dated [DATE], indicated Resident 16's Basic Interview of Mental status (BIMS) score was 02 (meaning poor cognition). Resident 16 was not oriented to correct year, month, and day of the week. Resident 16 had unclear speech and was usually understood and understand others. Resident 16 had no serious mental illness or exhibited other behavioral symptoms directed towards others, such as hitting or scratching and screaming. Resident 16's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Review of the impaired behavioral patterns initiated 6/19/23, indicated Resident 16 had behavior manifestation with period of aggressiveness related to dementia. Review of the order summary report, dated 6/27/2023, indicated the physician prescribed Resident 16 to receive Zyprexa 5 mg one tablet by mouth, one time daily for altered sensorium with behavioral disorder manifested by hitting, punching staff, and throwing objects. Review of the MAR, dated 1/1/24 to 1/31/24, indicated Resident 16 received Zyprexa 5 mg tablet one tablet by mouth one time a day for altered sensorium, hitting/punching staff. Review of the Consultant Pharmacist's (CP) MRR dated 1/5/24, indicated for Resident 16 to please update Zyprexa order to include indication. During an observation and concurrent interview on 2/29/24 at 11:00 a.m., Resident 16 was seated in wheelchair in the dining room playing with puzzles. Resident 16 stated he was doing well. During an interview on 2/29/24 at 11:02 a.m., CNA 1 stated he was a regular caregiver for Resident 16. CNA 1 stated Resident 16 had no behavior of hitting or punching staff. CNA 1 stated he started work at the facility eight months ago, and at that time, Resident 16 was aggressive when care was provided, but no more. CNA 1 stated Resident 16 was up in the wheelchair daily, and able to mobilize himself up and down the hallways. Review of the order summary report, dated 7/6/2023, indicated the physician prescribed Resident 16 to receive Lorazepam oral tablet 1 mg, give one tablet by mouth every 6 hours PRN for anxiety and aggressive behaviors. Review of the MAR, dated 2/1/2024 to 2/26/2024, indicated Resident 16 received PRN Lorazepam 1 mg one tablet by mouth for anxiety and aggressive behavior more than 14 days without a physician reevaluation for continued use. Further review of the MAR, dated 1/1/24 to 1/30/24, and 2/1/24 to 2/26/24, indicated Resident 16 was administered PRN Lorazepam 1 mg tablet by mouth 17 times in January 2024 and nine times in February 2024 without implementation of no- pharmacological interventions first before offering PRN medication. Review of CP's MRR, dated 1/5/24, regarding Resident 16 to please be aware there needs to be a review of PRN psychotropic medications by Medical Doctor (MD) every 14 days unless stated on the order otherwise. During a telephone interview on 3/01/24 at 9:51 a.m., Medical Doctor (MD 1), MD 1 stated she was not aware of the need to reevaluate and document Resident 16's use of PRN Ativan after 14 days. Further review of order summary report, dated 8/26/2023, indicated the physician prescribed Resident 16 to receive Trazodone HCL 100 mg, give one tablet by mouth in the evening for sleep. Review of the MAR, dated 1/1/24 to 1/30/24, and 2/1/24 to 2/26/24, indicated Resident 16 was administered Trazodone 100 mg one tablet by mouth in the evening sleep. Resident 16's hours of sleep was not monitored. During a review of Resident 16's clinical records and MRR, and concurrent interview, on 2/29/24 at 2:53 p.m., with DON, DON stated the facility's expectation was for licensed nurses to first offer non- pharmacological interventions before the administration of PRN psychotropic medications. DON said hours of sleep were not monitored for the use of Trazodone HCl, and the attending physician did not document the rationale for the extended time use of Lorazepam PRN in Resident 16's medical records. Furthermore, DON stated she was aware that hitting and striking out were not appropriate indications for use of antipsychotic medications and PRN psychotropic medications need to be reevaluated every 14 days. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated July 2022, the P&P indicated, Residents will not receive medications that are not clinically indicated to treat a specific condition. Non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical records. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are NOT antipsychotics if the prescribe or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consider alternative recommendations for the use of the provale cup assistive device (helps prevent choking by delivering a measured amount of liquid. Cups vary with different delivery amounts) while allowing the patient to eat and drink independently, for one (Resident 6) of 12 sampled residents. Resident 5 was identified at risk for aspiration (food or liquids enters the windpipe). This failure resulted in staff not using an assistive device with meals or consulting with the Speech Therapist for recommendations when Resident 5 refused using the provale cup. This had the potential to result in aspiration and the development of pneumonia. Findings: During an observation on 2/26/24 at 12:56 a.m., Resident 6 was seated at the dining table in the dining area and fed by the Restorative Nursing Assistant (RNA 1). Resident 6 coughed repeatedly when fed corn bread and salad. When Resident 6 coughed, RNA 1 gave Resident 6 water to drink from a plain plastic cup. Review of the Minimum Data Set (MDS), a resident assessment and care guide tool, dated 12/22/23, indicated Resident 6's Basic Interview of Mental status (BIMS) score was 05 (meaning poor cognition). Resident 6 also had a swallowing disorder related to holding food in the mouth/cheeks or residual food in mouth after meals. Resident 6 diagnoses included dysphagia (difficulty swallowing foods or liquids) and Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). During an interview on 2/27/24 at 10:01 a.m., RNA 1 stated Resident 6 coughed from time to time when fed. RNA 1 stated Resident 6 used to use a special cup but got frustrated because the cup limited the amount of water to drink at a time and did not like using the special cup. Review of the physician order dated 10/1/21 indicated the physician prescribed Resident 6 to receive a provale cup during meals of mechanical soft ground texture, thin liquid consistency. Review of the speech therapy (ST) Discharge summary dated [DATE] indicated Resident 6 had therapy for dysphagia. Resident 6 had excessive coughing. ST requested Resident 6 to have provale cup to restrict her sip size during meals. During an interview on 2/27/24 at 10:01 a.m., with the Director of Nursing (DON), DON stated Resident 6 did not like the provale cup and got frustrated when drinking water so staff stopped using the special cup. DON said Resident 6 used a regular plastic cup to drink water and coughs frequently. During an interview on 2/27/24 at 11:52 a.m., with the Speech Therapist ST), ST stated Resident 6 had an order to use provale cup for drinks and was not informed Resident 6 refused the use of the provale cup. During an interview on 2/29/24 at 10:12 a.m., DON stated Resident 6 has a high risk for aspiration. DON further stated she did not inform ST or referred Resident 6 for speech re-evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent falls and implement appropriate interventions for one (Resident 16) of 12 sampled residents when, Resident 16 had repeated unwitnessed falls. The facility did not implement Resident 16's need for supervision with stand-by assistance during transfers. These failures caused Resident 16 to sustain repeated falls and had the potential to result in injuries. Findings: Review of the Interdisciplinary Team (IDT, consists of staff members from different departments) progress notes, dated 2/26/24, indicated Resident 16 had an unwitnessed fall in the dining/activity room. Resident 16 called out for help and was seen sitting on the dining room floor in front of a wheelchair and facing a regular chair that he was previously sitting in. Review of the Significant Change in Status-Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/8/23, indicated Resident 16 was admitted to the facility on [DATE]. Resident 16's diagnoses included stroke and Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language). Resident 16's Basic Interview of Mental status (BIMS) score was 02 (meaning poor cognition). Resident 16 needed extensive assistance and one person physical assistance with how resident moves to and from lying position, transfers, movements between surfaces, including to or from bed, chair, wheelchair, standing position, use of toilet, transfer on/off toilet, cleanses after elimination, and personal hygiene. Resident 16 had impairment with limited range of motion to bilateral lower extremities (hip, knee, ankle and foot). Resident 16 had history of falls since admission and unsteady balance with moving from a seated to standing position, transfer between bed and chair or wheelchair, and only able to stabilize with staff assistance. During an observation on 2/29/24 at 11:21 a.m., Resident 16 was seated in a wheelchair with no cushion or device to alert staff with self transfer attempts to get up. Resident 16 could self propel the wheelchair up and down the hallways dragging his right leg along. Review of the IDT progress notes indicated Resident 16 was a high risk for falling and had the following documented falls: On 2/21/24 at 2200 (10:00 PM), Resident 16 was assisted to the floor in the hallway when he tried to stand up and lost his balance. On 1/13/24 at 10:00 AM, Resident 16 was sitting in dining/activity room, stood up, lost balance CNA (certified nursing assistant) assisted Resident 16 to sit on the floor. On 12/7/23 at 19:45 (7:45 PM), Resident 16 had an unwitnessed fall, found yelling, hey helpnext to his bed in his room. On 11/28/23 at 2020 (8:20 PM), Resident 16 was found on the floor in the hallways beside his wheelchair in front of nursing station trying to transfer from wheelchair to regular chair. On 10/28/23 at 2020 Resident 16 found on the floor inside the room by his bed. Resident tried to transfer from his wheelchair to his bed. On 10/16/23 at 18:15 (6:15 PM,) Resident 16 was found on the floor at the end of the hallway. Resident 16 seemed to try to transfer from his wheelchair to another wheelchair. On 9/13/23 at 10:05 AM, Resident 16 was found on the floor in the hallway, laid on his right side with head on the floor. Resident 16 usual function was wheeling self in entire facility; On 8/28/23 at 10:47 AM, Resident 16 had unwitnessed fall inside the activity/dining room. Resident impulsive, has no safety awareness. Review of the care plan initiated 4/17/23 indicated Resident 16 was at risk for continued falls, sub-[NAME] hemorrhage (bleeding in the brain) and injuries related to continued gradual physical weakness. The intervention included physical therapy (PT) evaluation and treatment as ordered. Review of the PT Discharge summary dated [DATE] indicated Resident 16 will safely perform functional transfers with SBA (stand-by assist) and needed supervised assistance with bed mobility in order to reduce risk of fall. {SBA : Stand-by assist. The resident still required caregiver to stand-by them for safety}. During an interview on 3/1/24 at 9:14 a.m., CNA 4 stated she was Resident 16's caregiver for at least twice a week. CNA 4 stated Resident 16 transfers himself from bed to wheelchair and chair to bed CNA 4 stated Resident 16 sometimes goes to the bathroom by himself and does not call for assistance. Further review of the care plan revised 4/20/21 indicated Resident 16 had impaired cognitive function, impaired thought processes, dementia with progressive gradual decline and does not use call light. Care plan interventions included cue, orient and supervise as needed, provide adaptive/safety equipments as needed. During an observation and concurrent interview on 3/1/24 at 11:10 a.m., Resident 16's was not in his room. Resident 16's bed was in the lowest position with landing mat on the floor. There was no device on the bed to alert staff of unassisted transfers. The Director of Nursing (DON) stated the facility is concerned about his repeated falls. During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing, revised March 2018, the P&P indicated; Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation and record review, the facility failed to ensure pureed food was the appropriate consistency for six out of 30 residents. This failure had the potential for residents on pureed diet to aspirate (draw food into the lungs) and/or negatively impact the resident's dining experience resulting in poor food intake and compromising their nutritional status. Findings: During the tray line observation, on 2/26/24 at 11:30 a.m., the pureed chili had the texture of a thickened cream soup and pureed cornbread was a thin pudding texture. Both foods did not hold their shape and spread out when placed on the resident lunch plate. During a follow up tray line observation, on 2/27/24 at 11:23 a.m., the pureed beef roast and zesty spinach were plated. Each were runny and spread out on the plate. During a review of the Diet Type Report, dated 2/28/24, the document indicated, six residents were on pureed diet order. During a review of the undated Regular Pureed Diet document from the facility's Registered Dietician (RDs) for Healthcare diet manual, the document indicated, The texture of pureed food should be of smooth and moist and able to hold its shape.

Based on observation, interview, and record review, the facility failed to: 1. Offer a substitute of equal nutritive value when milk on the planned menu was routinely not provided when milk was on the planned menu for all diets. 2. Effectively maintain a system to ensure the resident's food preferences were accurately recorded on their individual tray cards. These failures had the potential for 30 of 30 residents who received food from the kitchen to not receive the nutrients intended by the planned menu and not receive foods according to resident preferences. Findings: 1. During a review of the winter menus, dated 2/26/24 and 2/27/24, the menu indicated, milk was the beverage to be served to residents on all diets. During the tray line observation, on 2/26/24 at 12:11 p.m., meal trays were prepared, placed on a food delivery cart, and were transported to residents for lunch. One 4 oz cup of water and one 4 oz cup of cranberry juice were on 29 lunch trays. One meal tray had one 4 oz cup of water and one 4 oz cup of yellow sugar-free beverage. Over 20 trays did not include milk. During a follow up tray line observation, on 2/27/24 at 11:36 a.m., the Dietary Services Supervisor (DSS), Dietary Aide (DA) 2 and [NAME] 2 were placing one 4 oz cup of water and one 4 oz cup of cranberry juice on each lunch trays. Over 20 trays did not include milk. During an interview on 3/1/24 at 12:10 p.m., with DSS and Registered Dietitian (RD) 1, DSS stated that most residents do not like milk for lunch and for other meals. DSS further stated when residents were not getting milk on a regular basis, there was no substitution made. RD 1 stated she was not aware that most of the residents did not like milk and she did not make sure a substitution was provided when a resident preferred not to drink milk when it was on the planned menu. 2. During an interview on 02/26/24 at 11:00 a.m., with Resident 5, Resident 5 stated a lot of times she receives cold food and she is lactose intolerant (not able to digest the sugar lactose in milk or dairy products). Resident 5 indicated they (residents) do not get much in terms of variety of choices and chooses what she thinks will taste ok and not give her nausea. During an interview and concurrent document review, on 2/28/24 beginning at 11:20 a.m., DSS demonstrated the system for maintaining food preferences. It was noted the facility's administrative documents for the facility were not maintained within the licensed building of the facility, and were maintained at an affiliated, separately licensed facility. The concurrent review of the resident profile cards (document of the residents' physician ordered diet, allergies, and likes and dislikes), and also intended to provide special instructions to food production staff. The surveyor asked how food production staff would be able to accurately check resident preferences or any special instructions, since the profile cards were not accessible to them. DSS stated there was a printed diet report updated weekly and posted in the food production kitchen. DSS also indicated the profile cards were not currently updated because there continued to be resident profile cards that were no longer at the facility. A random review of the resident profile card for Unsampled Resident 3 showed she listed multiple dislikes, including zucchini, broccoli, fish, bread, or rolls, none of these dislikes were listed on her profile card. Similarly, there were greater than 15 profile cards with no likes/dislikes or preferences listed. Review of facility document titled, Diet Type Report dated 2/28/24, showed there were 32 listed residents. However the facility's current census was listed as 30. Except for Resident 6's preference for iced cold or hot beverages, there were no other listed preferences. Similarly for Resident 5 guidance was limited to nursing instructions for the nurse to check the tray every Sunday and no food preferences listed on the diet report. Resident 5's tray card listed only cheese as a dislike. During a review of the facility's policy and procedure (P&P) titled, The Dietary Profile, dated 2023, the policy indicated, The FNS [Food and Nutrition Services] Director or other designated personnel will update the profile card. The policy also indicated the profile card would include information obtained by visiting the resident and should include food and beverage preferences, food dislikes, appetite, and swallowing ability.

Based on observation, interview, and record review, the facility failed to provide the physician- prescribed therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet) when: 1. Six of six sampled residents (Residents 4, 6, 13, 15, 16,17) on a Fortified diet (a diet with added protein, fat, and/or carbohydrate to increase calories) did not receive supplemental food items as ordered. 2. Three of three sampled residents (Residents 5, 28, 21) on a Consistent Carbohydrate diet (CCHO - a diet that promotes stable blood sugar levels) received a regular diet instead of the CCHO diet. 3. One of one sampled resident (Resident 16) with a diet order for extra protein did not receive extra meat as ordered. These failures had the potential to result in weight loss and/or unstable blood sugar for the residents who did not receive their therapeutic diets as ordered. See also tag F 803. Findings: 1. During a review of the facility document, Diet Type Report, dated 2/28/24, the document indicated Residents 4, 6, 13, 15, 16, and 17 had orders for a Fortified diet. During a lunch tray line observation on 2/26/24 at 12:11 p.m., there was no margarine served on any resident lunch tray, including the lunch trays of Residents 4, 6, 13, 15, 16, and 17. The lunch trays of Residents 4, 6, 13, 15, 16, and 17 included the food items provided to residents on a Regular diet without provision of any additional food items, such as additional margarine. During a review of the facility, Winter Menus, dated 2/26/24, the Menus indicated one teaspoon (tsp) of margarine should be included on lunch trays for all diets excluding low fat/low cholesterol diets. During a lunch tray line observation on 2/27/24 at 11:23 a.m., [NAME] 1 used a two ounce (oz), red spoodle (a combination utensil used as a ladle and a spoon) to spread gravy between the mashed potatoes and beef roast on each resident meal plate, including the lunch trays of Residents 4, 6, 13, 15, 16, and 17. The lunch trays of Residents 4, 6, 13, 15, 16, and 17 included the food items provided to residents on a Regular diet without provision of any additional food items such as extra gravy. During a review of the facility, Winter Menus, dated 2/27/24, the Menus indicated regular and therapeutic diets were to receive one to two ounces of brown gravy on herb crusted beef roast during the lunch service. 2. During a review of the facility, Diet Type Report, dated 2/28/24, the Report indicated Residents 5, 28, and 21 were on a CCHO diet. During a concurrent lunch tray line observation and interview on 2/26/24 at 11:30 a.m., with [NAME] 2, all resident lunch trays received a 2 inch by 2.5-inch piece of cornbread, and a serving of Citrus Chiffon Delight Dessert, including the lunch trays of Residents 5, 28, and 21. [NAME] 2 stated the same dessert was provided to all the residents. During a review of the facility document, Winter Menus, dated 2/26/24, the Menus indicated residents on Regular diets were to receive Citrus Chiffon Delight and residents on CCHO diet were to receive Diet Citrus Chiffon Delight. The Menu also indicated residents on a Regular diet were to receive one piece of cornbread with green chilis, and residents on CCHO diets were to receive one-half piece of cornbread (a half piece of the regular 2 inch by 2.5-inch cornbread) with green chilis. During a concurrent interview and record review on 2/27/24 at 10:15 a.m., in the kitchen, with [NAME] 1 and [NAME] 2, the recipes for Citrus Chiffon Delight and Triple Fruit Crisp were reviewed. The recipes indicated changes from the Regular diet items of Citrus Chiffon Delight and Triple Fruit Crisp should be made for CCHO diets as follows: diet gelatin was to be substituted for regular gelatin for preparation of the Diet Citrus Chiffon and brown sugar should be omitted from the ingredients in the Diet Triple Fruit Crisp. [NAME] 2 stated he had prepared the Triple Fruit Crisp earlier in the day using the Regular recipe. [NAME] 1 and [NAME] 2 both stated they had used the Regular diet recipes for Citrus Chiffon Delight and Triple Fruit Crisp and had not made a separate diet dessert as indicated in the recipes. During a lunch tray line observation on 2/27/24 at 11:23 a.m., each resident lunch tray received one garlic stick, and a serving of the regular Triple Fruit Crisp, including the lunch trays of Residents 5, 28, and 21. A review of the facility document, Winter Menus, dated 2/27/24, the Menus indicated residents on a Regular diet were to receive one slice of garlic bread and a serving of Triple Fruit Crisp. The Menus indicated CCHO diets were to receive half of a garlic stick and a Diet Triple Fruit Crisp. During a review of the facility's P&P titled, Diet Orders, dated 2023, the P&P indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. 3. During a review of Resident 16's Physician's order, dated 9/18/23, the order indicated Resident 16's diet was Regular, Fortified, Extra Calorie, Extra Protein. During tray line observation on 2/27/24 at 11:40 a.m., Resident 16's lunch tray was plated with one 3-ounce slice of beef roast, mashed potatoes, zesty spinach, and a garlic stick. The lunch tray had a copy of Resident 16's meal card; the meal card indicated Resident 16 was to receive extra meat. Resident 16 did not receive any additional items to increase the nutrient/caloric content of the food served. During a review of the facility's Winter Menu, dated 2/27/24, the menu indicated residents on regular diets were to receive three ounces of Herb Crusted Beef Roast. During a review of facility's policy and procedure (P&P) titled, Fortification of Food: Increasing Calories and/or Protein in the diet, dated 2023, the P&P indicated, The goal of fortification of food is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutritional status; Adding calories by 1. Adding extra ½ oz or 1 tablespoon (Tbsp) melted margarine to one food item at breakfast, two at lunch, and one at dinner will add 100 calories per ½ oz, 2. Adding extra 2 oz of gravy to foods designated to receive gravy will add 20-50 calories per item. During a review of the facility's P&P titled, Diet Orders, dated 2023, the P&P indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accurate documentation of medication administration for three (Residents 5, 13, and 16) of five sampled residents when two nursing staff (Director of Nursing and Licensed Vocational Nurse 3) failed to document multiple medications' administration on four separate days (2/2/24, 2/11/24, 2/14/24, 2/17/24) These failures had the potential to result in unnecessary duplication of medication administration, and prevented accurate analysis of effectiveness of medication due to lack of clarity as to whether or not the medication was administered. Findings: During a review of the facility admission Record, undated, the admission Record indicated Resident 5 was admitted to the facility in 2022. During a review of Resident 5's Medication Administration Record (MAR) dated February 2024, the MAR indicated no entries for administration of the following scheduled medications: 2/11/24 at 9 a.m.: amiodarone (to treat high blood pressure), amlodipine (to treat high blood pressure); jardiance (to treat high blood sugar); fluoxetine (to treat depression); metoprolol (to treat high blood pressure). 2/11/24 at 5 p.m.: Xarelto (to prevent blood clots); metoprolol. 2/17/24 at 9 p.m.: rosuvastatin (to treat high cholesterol); vraylar (to treat depression). During a review of Resident 13's admission Record, undated, the admission Record indicated an admission date in 2021. During a review of Resident 13's MAR dated February 2024, the MAR indicated no entries for administration of the following scheduled medications: 2/2/24 at 5 p.m.: metoprolol. 2/2/24 at 9 p.m.: lantus (to treat high blood sugar). 2/11/24 at 8 a.m.: metformin (to lower blood sugar). 2/11/24 at 9 a.m.: aspirin (to prevent blood clots); Lexapro (to treat depression); valsartan (to treat high blood pressure); Eliquis (to prevent blood clots); metoprolol. 2/11/24 at 1 p.m.: metformin. 2/11/24 at 5 p.m.: Eliquis. 2/11/24 at 6 p.m.: metformin 2/11/24 at 9 p.m.: atorvastatin (to treat high cholesterol). During a review of Resident 16's admission Record, undated, the admission Record indicated an admission date in 2021. During a review of Resident 16's MAR dated February 2024, the MAR indicated no entries for administration of the following scheduled medications: 2/11/24 at 9 a.m.: aspirin; fluoxetine; furosemide (to treat high blood pressure); metolazone (to treat high blood pressure); potassium chloride (to replenish body electrolytes); senna (to prevent constipation); Zyprexa (a mood stabilizer); Depakote (a mood stabilizer and anti-seizure medication); metoprolol. 2/11/24 at 5 p.m.: atorvastatin; Depakote; trazadone (to promote sleep). 2/14/24 at 9 p.m.: metoprolol. During a concurrent interview and record review on 2/29/24 at 3:25 p.m. with Licensed Vocational Nurse (LVN) 3, the February MARs of Resident's 5, 13, and 16 were reviewed. LVN 3 stated the missing MAR entries between 5 p.m. and 9 p.m. for Residents 5, 13, and 16 had been medications she had administered to the residents. LVN 3 stated she had been too busy to document the medication administration during the shifts, and then had fallen ill and forgotten to document the medications when she returned to work. During a concurrent interview and record review on 3/1/24 at 3:11 p.m., with the Director of Nursing (DON), the February MARs of Resident's 5, 13, and 16 were reviewed. The DON stated the missing MAR entries between 8 a.m. and 1 p.m. for Residents 5, 13, and 16 had been medications she had administered to the residents, but she had been too busy to document the administration in the residents' MARs. The DON stated the expectation was for a medication to be charted when the medication was administered. A review of Fundamentals of Nursing: The Art and Science of Nursing Care, 3rd Edition, by [NAME], Lillis and Lemone; copyright 1997, p. 656, indicated, Documenting Medication Administration: The medication record is a legal document. Recording each dose of medication as soon as possible after it is given provides a documented record that can be consulted if any questions as to whether the client received the medication.

Based on observation, interview, and record review the facility failed to ensure one out of the one facility dishwashing machine was able to maintain water temperatures during the wash and rinse cycles within the manufacturer's recommended water temperature range of 120 degrees Fahrenheit (ºF) and 140 ºF. This failure had the potential for dishware used by residents to not be sanitized sufficiently to prevent food borne illness. Findings: During a continuous observation on 2/27/24 at 10:13 a.m., in the kitchen, Dietary Aide (DA) 2 placed dishes in the dishwashing machine and began the dishwashing cycle. During the wash cycle, the dishwashing machine water temperature gauge reached a maximum of 106 degrees Fahrenheit (ºF), the water temperature gauge remained at a temperature of 106 ºF during the rinse cycle. During an interview on 2/27/24 on 10:15 a.m. with DA 2, DA 2 stated she had checked and recorded the dishwashing machine water temperature earlier in the Dish Machine Temperature Log. During a concurrent interview and record review on 2/27/24 at 10:20 a.m. with DA 2, the Dish Machine Temperature Log dated February 2024 was reviewed. The Temperature Log indicated that the dishwashing machine was a low temperature dishwasher (uses chemical sanitization to wash and sanitize dishware) and indicated instructions to, Please record wash and rinse temperatures, and chlorine parts per million (ppm is a unit used to describe very small concentrations of a substance in a larger solution) before each meal. Run empty racks through machine until proper temperatures and chlorine level are reached. Wash temperature must be at least 120 ºF for the dishwashing machine. (Use manufacturers guidelines on machine for range of wash and rinse temperature.). The log further indicated that on 2/27/24, the breakfast dishwasher wash cycle water temperature was 120 ºF, and the dishwasher rinse cycle water temperature was 140 ºF. During an observation on 2/27/24 at 10:25 a.m. with DA 2, a water-proof digital holding thermometer (A holding thermometer is intended to record and demonstrate the highest water temperature during all cycles in a dish machine.) was placed inside the dishwashing machine. At the end of the dishwashing wash and rinse cycles, the thermometer indicated the maximum temperature of the water was 147.8 ºF, and the minimum water temperature was 74 ºF. During an observation on 2/27/24 at 2:29 p.m., the information plate on the dishwashing machine showed the minimum wash and rinse temperature was 120 ºF, and the maximum recommended incoming water temperature was 140 ºF. During a review of facility's policy and procedure (P&P) titled Sanitation, dated 2023, the P&P indicated, All equipment shall be maintained as necessary and kept in working order. During a review of the dishwashing machine manufacturer guidelines, dated December 5, 2007, the guidelines indicated, The minimum wash and rinse water temperature was 120 ºF and the recommended maximum wash and rinse temperature was 140 ºF.

Based on observation, interview, and record review, the facility failed to employ a qualified nutrition professional to manage the food and nutrition services when; 1. The Dietary Services Supervisor (DSS) did not work in the facility on a full-time basis and the Registered Dietitian (RD) worked part-time. 2. DSS did not know the cool down method for a leftover meat sauce and Pozole soup. 3. DSS did not ensure that time and temperature monitoring was performed by kitchen staff during thawing of frozen food items. 4. DSS did not ensure residents were served palatable food when food was served at a low temperature, tasted bland, and was a poor texture. 5. DSS did not ensure food was fortified (adding protein, fat, and/or carbohydrate to foods) for 15 out of 15 residents on fortified diet. 6. DSS did not ensure six out of six residents on Consistent Carbohydrate (CCHO - a diet that helps keep blood sugar levels stable) diet received a Regular diet instead of the CCHO diet. 7. DSS had not communicated to RD 1 that most residents did not like milk for lunch and for other meals which resulted in the facility not providing a substitute of equal nutritive value. 8. DSS did not effectively maintain a system to ensure that resident's food preferences were accurately recorded on individual tray cards. These failures had the potential for food and nutrition services staff to be inadequately trained and supervised to carry out food and nutrition services for 30 out of 30 residents in a safe and sanitary manner. Findings: 1. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m, with DSS, there were multiple unlabeled and undated food items, thawed and refrozen food items, and 10 tomatoes had areas of white fuzzy material and dark spots resembling mold was in the freezer and refrigerator. DSS stated that cooks are responsible for checking food items in the refrigerator and freezer. DSS further stated, I should be monitoring the refrigerator and freezer too, but I am not here full time. I am also working in the facility next door. During an interview on 2/26/24 at 11:20 a.m. with RD 1, RD 1 stated she worked for the facility for only a month and, I work 8 hours in this facility and once a week for the other facility next door. RD 1 further stated there was another RD (RD 2) that works for the facility. 2. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the policy indicated 1. The Food & Nutrition Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. During a review of the facility's undated DSS Job Description which indicated, The DSS duties and responsibilities included: To enforce food safety and sanitation policies by performing regular inspections of facilities and employees. According to the 2022 Federal Food Code, safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety (TCS) foods has been consistently identified as one of the leading contributing factors to foodborne illness. During slow cooling, TCS foods are subject to the growth of a variety of pathogenic microorganisms. A longer time near ideal bacterial incubation temperatures (70 ºF - 125 ºF), is to be avoided. If the food is not cooled in accordance with this Code requirement, pathogens may grow to sufficient numbers to cause foodborne illness. The Food Code provision for cooling provides for cooling from 135ºF to 41°F or 45°F in 6 hours, with cooling from 135ºF to 70°F in 2 hours. The 6-hour cooling parameter, with an initial 2-hour rapid cool, allows for greater flexibility in meeting the Code. The initial 2- hour cool is a critical element of this cooling process. During an observation on 2/26/24 at 10:12 a.m., in the kitchen refrigerator was a container lid labeled meat sauce dated 2/24/24, and another container labeled Pozole soup dated 2/23/24. During a review of the meat sauce recipe, dated Week 4 Saturday, the recipe indicated it contained ground beef. During a review of the Pozole soup recipe, dated Week 4 Friday, the recipe indicated it contained pork meat. During concurrent interview and record review on 2/27/24 at 11:02 a.m, with DSS, an undated and blank Cool Down Log was reviewed. The log indicated, the leftover meat sauce and Pozole soup temperature was not monitored during the cool down process.DSS stated, The leftover meat sauce and Pozole soup in the refrigerator doesn't necessarily need a cool down log since the meat was mixed with other ingredients. On 2/28/24 at 11:50 a.m., the surveyor requested DSS to provide the staff training related to food safety. As of 3/1/24, at the time of exit, the facility failed to provide documented staff training. 3. During a review of facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the policy indicated, 1. The Food & Nutrition Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. During a review of the facility's undated DSS Job Description, the document indicated, The DSS duties and responsibilities included: To enforce food safety and sanitation policies by performing regular inspections of facilities and employees; To monitor records of food temperatures, . cool down logs. If incomplete, identify responsible employee and enforce compliance. According to the 2022 Federal Food Code, an important duty of the Person in Charge is to make sure that any required temperatures are achieved or maintained when foods are thawed. The Person in Charge ensures that employees are monitoring food temperatures to verify the critical temperature limits, the likelihood of temperature abuse is reduced. This includes oversight of temperature monitoring to ensure that temperatures for Time/Temperature Control for Safety (TCS) foods are routinely monitored during thawing to ensure that the growth of bacterial pathogens and toxin production is prevented and that foods that require temperature control for safety are being held at temperatures that adequately prevent pathogen growth and toxin production. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with [NAME] 1, multiple thawed and refrozen food items were in the freezer. [NAME] 1 stated that received frozen food items were generally thawed by staff in the food production sink by running water over the product and that it was likely the product was thawed and refrozen. [NAME] 1 further stated there was no time and temperature monitoring of this process. During a concurrent follow up observation and interview on 2/26/24 at 3:06 p.m., with [NAME] 2, there were two frozen pieces of cooked roast beef in a cardboard box on the counter next to the food production sink. [NAME] 2 stated he recently pulled them from the freezer and would begin thawing under water shortly. [NAME] 2 further stated there was no time or temperature control monitoring of this process. During an interview on 2/27/24 at 10:45 a.m., DSS stated they (kitchen staff) thaw frozen meat under running water without time and temperature monitoring and that it was okay not to monitor since the meats are already cooked. The facility's P&P manual was requested from DSS. DSS stated the manual was kept in the facility next door. On 2/28/24 at 11:50 a.m., the surveyor requested DSS to provide staff training related to food safety. As of 3/1/24, at the time of exit, the facility failed to provide documented staff training. 4. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the policy indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperature; 3. The hot food served on tray line must be at or above minimum holding temperature of 140 ºF; 7. Temperature of the food when the resident receives it is based on palatability. The goal is to serve hot food hot. The recommended hot food temperature for an entrée, starch, and vegetable at delivery to resident was greater than or equal to (?) 120 ºF. During a review of the undated Regular Pureed Diet document from the facility's Diet Manual, the document indicated The texture of pureed food should be of smooth and moist. During a review of facility's undated DSS Job Description, the document indicated The DSS duties and responsibilities included to supervise receiving of food to ensure correct items, temperatures and amounts; When on duty, be present at each meal services, monitoring for compliance in food temperatures and texture modification; Communicate with dietitian regarding resident changes or request. During an interview on 02/26/24 at 11:00 a.m., with Resident 5, Resident 5 stated that a lot of times she receives cold food and does not get much in terms of variety of choices and chooses what she thinks will taste ok and not give her nausea. During tray line observation on 2/26/24 at 11:30 a.m., pureed chili had the texture of a thickened cream soup and pureed cornbread was a thin pudding texture. Both foods did not hold their shape and spread out when placed on the resident lunch plate. During a follow up tray line observation on 2/27/24 at 11:23 a.m., pureed beef roast and zesty spinach were plated, both were runny and spread out on the plate. During a concurrent tray line observation and interview on 2/28/24 at 12:05 p.m., with RD 1, the temperature of the food served was measured with a calibrated thermometer. A tray of regular fish Italiano was 113 degrees Fahrenheit (ºF). RD 1 stated temperature of hot foods during tray line should be at least 141 ºF. Temperature of the food on a resident's pureed tray, placed on a food service cart number 2 used to carry food to resident rooms, was also checked. Pureed fish was 121.8 ºF, pureed broccoli with garlic was 119.3º F, and pureed risotto was 106.5 ºF. Test trays with pureed and regular textured food were also placed on cart number 2. It was noted the kitchen did not have a piece of equipment to hold food hot on the tray line, which is the standard in licensed facilities for holding hot food during a tray line food service. During a concurrent observation and interview on 2/28/24 at 12:45 p.m. with Registered Dietitian (RD) 1, the regular and pureed food test tray were sampled. The temperature of the regular textured food was as follows: fish Italiano was 97 ºF, creamy risotto style rice was 118.3 ºF and broccoli with garlic was 102.1 ºF. The temperature of the pureed broccoli with garlic was 119.6 ºF. The regular risotto and broccoli tasted bland (no or very little flavor), and the pureed risotto, broccoli, and fish had a very sticky and gummy mouth texture. RD 1 stated the fish and broccoli was cold and that the risotto was at room temperature when she tasted it. RD 1 further stated she would like the food to be a little warmer to at least 120 ºF when served to the residents. She also acknowledged that the risotto tasted bland, and the pureed food was sticky. During an interview on 2/29/24 at 8:37 a.m. with the Activity Director, AD stated DSS was notified and aware of resident's cold food complaints that was discussed during the resident council meeting. During an interview on 2/29/24 at 8:42 a.m., with DSS, DSS stated he provided education to kitchen staff related to cold food complaints however did not follow up. During an interview on 2/29/24 at 8:58 a.m. with RD 1, the RD 1 stated resident's complaints of cold food was not communicated to her when she started working for the facility. 5. During a review of facility's policy and procedure (P&P) titled, Fortification of Food: Increasing Calories and/or Protein in the diet, dated 2023, indicated, The goal of fortification of food is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutritional status; Adding calories by 1. Adding extra ½ oz or 1 tablespoon (Tbsp) melted margarine to one food item at breakfast, two at lunch, and one at dinner will add 100 calories per ½ oz, 2. Adding extra 2 oz of gravy to foods designated to receive gravy will add 20-50 calories per item; Identification of the residents in need of fortification will be done by the RD or the Food and Nutrition Services Director. The physician will then order a Fortified Diet. During a review of the facility's P&P titled, Diet Orders, dated 2023, indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. During a review of facility's undated DSS Job Description, the document indicated, The DSS duties and responsibilities included to when on duty, be present at each meal service, monitoring for compliance in . therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet). During tray line observation on 2/26/24 at 12:11 p.m., margarine was not served on lunch trays for all residents including residents on a fortified diet (Cross-reference F803). Residents on a fortified diet did not receive any additional items to increase the nutrient content of the food served. A review of the Winter Menus, dated 2/26/24, indicated 1 tsp of margarine should be included at lunch tray for all diets excluding lowfat/low cholesterol. During a follow up tray line observation on 2/27/24 at 11:23 a.m., [NAME] 1 used a two ounce (oz) red, spoodle (a utensil, cross between a ladle and a spoon) to spread gravy between the mashed potatoes and beef roast for each meal plate. Extra gravy was not served for residents with fortified diet order. Residents on a fortified diet did not receive any additional items to increase the nutrient content of the food served. A review of the Winter Menus dated 2/27/24, showed regular and therapeutic diets received 1-2 oz of brown gravy on the herb crusted beef roast. During a review of the Diet Type Report, dated 2/28/24, the document indicated 15 residents were on a Fortified diet order. 6. During a review of the facility's P&P titled, Diet Orders, dated 2023, indicated Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department. During a review of the facility's undated DSS Job Description, which indicated, The DSS duties and responsibilities included: When on duty, be present at each meal service, monitoring for compliance in . therapeutic diet (a diet order as part of treatment for a disease or clinical condition to decrease or increase specific nutrients in the diet). During a concurrent tray line observation and interview on 2/26/24 at 11:30 a.m., with [NAME] 2, [NAME] 2 dished the citrus chiffon delight dessert. [NAME] 2 stated the dessert was the same for all the residents. When the desserts were placed on Resident trays, regular citrus chiffon delight was placed on Regular and CCHO diet trays. In addition, one whole piece of cornbread was served on Regular diet and CCHO diet lunch trays. A review of the Winter Menus, dated 2/26/24, indicated Regular diets should receive Citrus Chiffon Delight and CCHO diet should receive Diet Citrus Chiffon Delight. The menu also showed Regular diets should receive one piece of Cornbread with [NAME] Chilis, and CCHO diets should receive one half piece of Cornbread with [NAME] Chilis. During a concurrent observation, interview, and record review on 2/27/24 at 10:15 a.m., [NAME] 2 was dishing the Triple Fruit Crisp and stated he had prepared it earlier using the regular recipe. The Citrus chiffon delight recipe and Triple fruit crisp recipe, concurrently dated Week 1 Monday and Tuesday was reviewed with [NAME] 1 and [NAME] 2. The recipe indicated diet gelatin was to be substituted for regular gelatin for the diet Citrus chiffon and brown sugar was not an ingredient for making a diet Triple fruit crisp. [NAME] 1 and [NAME] 2 stated they used the regular recipe for desserts and did not make a separate diet dessert. During a tray line observation on 2/27/24 at 11:23 a.m., Regular and CCHO diets received one garlic stick, and regular triple fruit crisp. A review of the Winter Menus dated 2/27/24 indicated, Regular diets should receive one slice of garlic bread and Triple Fruit Crisp.In addition, CCHO diets should receive ½ slice of garlic bread and Diet Triple Fruit Crisp. During a review of Diet Type Report, dated 2/28/24, the document indicated, 6 residents were on CCHO diet. 7. During a review of the facility's undated DSS Job Description, the document indicated, The DSS duties and responsibilities included: To Communicate with dietitian regarding resident changes or request. During a review of the winter menus, dated 2/26/24 and 2/27/24, the menu indicated, milk was the beverage to be served to residents on all diets. During tray line observation on 2/26/24 at 12:11 p.m., meal trays were prepared, placed on a food delivery cart, and were transported to residents for lunch. One 4 oz cup of water and one 4 oz cup of cranberry juice were on 29 lunch trays. One meal tray had one 4 oz cup of water and one 4 oz cup of yellow sugar free beverage. Over 20 trays did not include milk. During a follow up tray line observation on 2/27/24 at 11:36 a.m., DSS, Dietary Aide (DA) 2, and [NAME] 2 were placing one 4 oz cup of water and one 4 oz cup of cranberry juice on each lunch tray. Again, over 20 trays did not include milk. During an interview on 3/1/24 at 12:10 p.m. with DSS and RD 1, DSS stated that most residents do not like milk for lunch and for other meals. The DSS further stated that when residents were not getting milk on a regular basis, there was no substitution made. RD 1 stated she was not aware that most of the residents did not like milk and she did not make sure a substitution was provided when a resident preferred not to drink milk when it was on the planned menu. 8. During a review of the facility's P&P titled The Dietary Profile, dated 2023, the policy indicated The FNS [Food and Nutrition Services] Director or other designated personnel will update the profile card. The policy also indicated the profile card would include information obtained by visiting the resident and should include food and beverage preferences, food dislikes, appetite, and swallowing ability. During a review of facility's undated DSS Job Description, the document indicated The DSS duties and responsibilities included: To maintain correct tray cards and supplement labels for correct food service; Input food preferences into computer system; When on duty, be present at each meal service, monitoring for compliance in . food preferences. During an interview on 02/26/24 at 11:00 a.m. with Resident 5, Resident 5 stated that they do not get much in terms of variety of choices so that she just choses what she thinks will taste ok and not give her nausea. During a concurrent interview and document review on 2/28/24 beginning at 11:20 a.m., the Dietary Services Supervisor (DSS) demonstrated the system for maintaining food preferences. It was noted the administrative documents for the facility were not maintained within the licensed building of the facility, rather were maintained at an affiliated separately licensed facility. Concurrent review of the resident profile cards (a document that documents the residents' physician ordered diet, allergies, as well as likes and dislikes). Resident profile cards are also intended to provide special instructions to food production staff. The surveyor asked how food production staff would be able to accurately check resident preferences or any specialized instructions, since the profile cards were not accessible to them. He stated there was a printed diet report that was updated weekly and posted in the food production kitchen. The DSS also indicated the profiles cards were currently not updated as there continued to be resident profile cards that were no longer at the facility. Random review of the resident profile card for Unsampled Resident 3 revealed while she listed multiple dislikes including zucchini, broccoli, fish, bread, or rolls, none of these dislikes were listed on her tray card. Similarly, there were greater than 15 profile cards where no likes/dislikes or preferences were listed. Review of facility document titled Diet Type Report dated 2/28/24, revealed there were 32 listed residents, however the facility's current census was listed as 30. It was also noted except for Resident 6's preference for iced cold or hot beverages there were no other listed preferences. Similarly for Resident 5 the listed the nursing instructions for the nurse to check the tray every Sunday. There were no food preferences listed on the diet report. Concurrent review of Resident 5's tray card listed only cheese as a dislike.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure food and nutrition staff had the appropriate competencies and skills set when: 1. Staff did not follow correct procedure for thawing frozen food item. 2. Staff did not appropriately demonstrate how to check the sanitizer strength used for the dish machine. 3. Staff recorded dish wash machine temperature inaccurately. These failures had the potential for inappropriate food preparation and dishwashing procedure that could result in food borne illness. Findings: 1. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with [NAME] 1, an unlabeled plastic package of tan colored frozen meat was in the freezer. It was also noted in the bottom of the plastic bag there was a frozen clear, pink tinged fluid. [NAME] 1 identified the item as frozen chicken and stated that product was received frozen and staff generally thawed meat in the food production sink by running water over the product. [NAME] 1 acknowledged it was likely the product was thawed and was refrozen and stated there was no time or temperature monitoring of this process. During a concurrent follow up observation and interview on 2/26/24 at 3:06 p.m., with [NAME] 2, there were two frozen pieces of cooked roast beef in a cardboard box on the counter next to the food production sink. [NAME] 2 stated he recently pulled them from the freezer and would begin thawing under water shortly. [NAME] 2 further stated there was no time or temperature control monitoring of this process. According to the 2022 Federal Food Code, an important duty of the Person in Charge is to make sure that any required temperatures are achieved or maintained when foods are thawed. The Person in Charge ensures that employees are monitoring food temperatures to verify the critical temperature limits, the likelihood of temperature abuse is reduced. This includes oversight of temperature monitoring to ensure that temperatures for time/temperature control for safety (TCS) foods are routinely monitored during thawing to ensure that the growth of bacterial pathogens and toxin production is prevented and that foods that require temperature control for safety are being held at temperatures that adequately prevent pathogen growth and toxin production. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. 2. During an observation on 2/27/24 on 10:13 a.m., Dietary Aide (DA) 2 was washing dishes using the dish machine. DA 2 demonstrated how to check the chlorine strength by dipping a sanitizer strip in water pooled in the dish machine. [NAME] 2 noticed that the sanitizer strip used by DA 2 was the improper strip. [NAME] 2 then handed DA 2 the correct strip which was the chlorine strip and retested the dish machine sanitizer concentration. [NAME] 2 guided DA 2 through the testing process. During a review of facility's undated Dietary Aide Job Description, the document indicated, Duties and Responsibilities: Perform dishwashing/cleaning procedures in timely fashion; Follow established safety procedures and infection control policies and procedures when performing daily task. During a review of facility's policy and procedure (P&P) titled Sanitation, dated 2023, the policy indicated No Food & Nutrition Services employee shall operate any major piece of equipment without knowing how to operate it correctly. 3. During a concurrent observation and interview on 2/27/24 at 10:13 a.m., with DA 2, DA 2 completed a dish wash cycle. DA 2 stated she checked and recorded the temperature earlier in the Dish Machine Temperature Log. During a concurrent interview and record review on 2/27/24 at 10:20 a.m., with DA 2, the Dish Machine Temperature Log, dated [DATE] was reviewed. The log indicated, 2/27/24 lunch dish wash temperature was recorded when lunch was not served yet. The log further indicated the temperatures are consistently the exact same number for multiple cycle on multiple days. During a review of the facility's undated, Dietary Aide Job Description, the document indicated. Duties and Responsibilities: Maintain accurate and timely logs of temperature, chemical level, etc. as directed; Perform dishwashing/cleaning procedures in timely fashion. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 2023, the policy indicated, 1. The Food & Nutrition Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. On 2/28/24 at 11:50 a.m., the surveyor requested the Dietary Services Supervisor (DSS) to provide staff training related to food safety. As of 3/1/24, at the time of exit, the facility failed to provide documented staff training.

Based on observation and record review, the facility failed to provide food items according to the menu when nine of 30 sampled residents receiving a regular diet order (Residents 4, 6, 13, 15, 16,17, 29, 186, and 188) were not served with one teaspoon (tsp) of margarine at lunch. This failure had the potential for residents to receive and/or consume inadequate caloric intake. See also tag F 808. Findings: During a review of the facility document, Diet Type Report, dated 2/28/24, the document indicated Residents 4, 6, 13, 15, 16,17, 29, 186, and 188 were on a regular textured diet that allowed margarine consumption. During a lunch tray line observation, on 2/26/24 at 12:11 p.m., there was no margarine served on any resident lunch tray, including the lunch trays of Residents 4, 6, 13, 15, 16,17, 29, 186, and 188. During a review of the facility document, Winter Menus, dated 2/26/24, the Menu indicated one tsp of margarine should be included on the lunch tray for all regular textured diets, excluding the low/fat, low cholesterol diet. During a review of the facility's P&P titled, Diet Orders, dated 2023, the P&P indicated, Diet orders as prescribed by the Physician will be provided by the Food & Nutrition Services Department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During a review of the facility's admission Record dated 03/01/23, Resident 5 was admitted to the facility on [DATE]. During an interview on 02/26/24 at 11:00 a.m. with Resident 5, Resident 5 stated a lot of times, she receives cold food and she is lactose intolerant. Resident 5 indicated they do not get much in terms of variety of choices and she chooses what she thinks will taste ok and not give her nausea. During a concurrent interview and record review, on 02/27/24 at 1:34 p.m., the Resident Council President stated the food is sometimes ok and sometimes not. Also, the food would be late and cold, and these issues were addressed on 11/'23 during the Resident Council Meeting. A review of the last three months of the Resident Council minutes meeting, dated 11/27/23, it was reported the food was ok, sometimes tasty, sometimes not. Further review indicated the facility will give verbal in-service on the importance of following recipes, using herbs and spices and signed by DS on 11/27/23. During a concurrent tray line observation and interview, on 2/28/24 at 12:05 p.m., with Registered Dietitian (RD) 1, temperature of the food served was measured with a calibrated thermometer. A tray of regular fish Italiano was 113 degrees Fahrenheit (ºF). RD 1 stated the temperature of hot foods during tray line should be at least 141 ºF. The temperature of the food on a resident's pureed tray placed on food service Cart # 2 used to carry food to resident rooms, was checked. The pureed fish was 121.8 ºF, pureed broccoli with garlic was 119.3ºF, and pureed risotto was 106.5 ºF. Test trays with pureed and regular textured food were also placed on Cart # 2. It was noted the kitchen did not have the equipment to hold food hot on the tray line, which is the standard in licensed facilities for holding hot food during the tray line food service. During a concurrent observation and interview, on 2/28/24 at 12:45 p.m., with RD 1, the regular and pureed food test trays were sampled. The temperature of the regular textured food were: fish Italiano was 97 ºF, creamy risotto style rice was 118.3 ºF, and broccoli with garlic was 102.1 ºF. The temperature of the pureed broccoli with garlic was 119.6 ºF. The regular risotto and broccoli tasted bland (no or very little flavor), and the pureed risotto, broccoli, and fish had a very sticky and gummy mouth texture. RD 1 stated the fish and broccoli was cold and the risotto was at room temperature when she tasted it. RD 1 further stated she would like the food to be a little warmer to at least 120 ºF when served to the residents. RD 1 also acknowledged the risotto tasted bland and pureed food was sticky. During a review of the facility's policy and procedure (P&P) titled, Meal Service, dated 2023, the policy indicated, Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperature; 3. The hot food served on tray line must be at or above minimum holding temperature of 140 ºF; 7. Temperature of the food when the resident receives it is based on palatability. The goal is to serve hot food hot. The recommended hot food temperature for an entrée, starch, and vegetable at delivery to resident was greater than or equal to 120 ºF. During a review of undated Regular Pureed Diet document from the facility's Diet Manual, the document indicated The texture of pureed food should be of smooth and moist. Based on observation, interview, and record review, the facility failed to ensure residents were served palatable food when food was served at a low temperature, tasted bland, and had poor texture. These failures had the potential for 30 of 30 residents to consume a decreased amount of nutrients leading to weight loss and/or nutrient related medical complications. Findings: During an interview on 2/26/24 at 10:28 a.m., Resident 1 stated the meals served at the facility were often cold and not palatable. Resident 1 stated the same menu was served repeatedly. Review of the Minimum Data Set (MDS), a Resident Assessment and care guide tool, dated 1/25/24, indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's Basic Interview of Mental status (BIMS) score was 13 (meaning cognitively intact). Resident 1's diagnoses included hypothyroidism (a condition in which the thyroid gland that regulates metabolism doesn't produce enough thyroid hormone). Review of the resident council meetings' minute,s dated 5/24/23 and 1/30/24, indicated residents discussed how come food was cold and the cycle of menus was discussed. During an interview on 2/27/24 at 9:58 a.m., the Activity Director (AD), AD stated residents complained of cold food, dietary issues, and (food) flavor. AD stated she reported (complaints) to the Dietary Supervisor (DS). During an interview on 2/29/24 at 8:50 a.m., the Dietary Services Supervisor (DSS) stated he was aware that residents complained of cold food. DS stated his expectation was for food to reach the residents at 120-degree temperature. DSS said he did not do a follow-up check of the food temperature.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve foods in a sanitary manner that prevents foodborne illness for the facility when: 1. Cool down method was not performed for a leftover meat sauce and Pozole soup in the refrigerator. 2. Frozen food items were incorrectly thawed and refrozen. 3. A box of cherry tomatoes in the refrigerator was covered with white fuzzy material and dark spots. 4. A bag of cooked chicken was stored together in the same compartment with frozen raw meat and poultry. 5. Multiple unlabeled and undated food items were found in the freezer. 6. Staff did not handle drinkware in a manner to protect the drinkware from contamination. 7. The ice machine evaporator plate had black build-up residue, the evaporator cover had white mineral build-up, and the cleaning and sanitizing procedures was not followed according to the manufacturer's instruction. These failures had the potential for residents to be exposed to food borne illness. Findings: 1. During an observation on 2/26/24 at 10:12 a.m., in the kitchen refrigerator, there was a covered container labeled, meat sauce dated 2/24/24, and another covered container labeled, Pozole soup, dated 2/23/24. During a review of the meat sauce recipe, dated Week 4 Saturday, the recipe indicated the meat sauce contained ground beef. During a review of the pozole soup recipe, dated Week 4 Friday, the recipe indicated the pozole soup contained pork meat. During concurrent interview and record review on 2/27/24 at 11:02 a.m., with the Dietary Services Supervisor (DSS), the Cool Down Log was reviewed. The log had columns and rows. The written instructions on the Cool Down Log indicated, log the menu or item on the first column; log the temperature upon removal from the oven on the second column; log the date, time and temperature once food drops to 140 degrees Fahrenheit (ºF) on the third column; log the temperature at two hours or less and time (If 70 ºF or less, you have four more hours to get temperature 41 ºF or less. If more than 70 ºF, take corrective action per policy) and staff signs their initials on the fourth column; log temperature at four hours or less and time (If 41 ºF or less cooling done) and staff signs their initials on the fifth column; log temperature by six hours and time, must be 41 ºF or less (If more than 41 ºF, take corrective action per policy) and staff signs their initials on the sixth column. The Cool Down Log had no entries in any of the columns or rows. The DSS stated the leftover meat sauce and pozole soup had no temperature monitoring completed during the cool down process because the meat was mixed with other ingredients. During a review of the facility's policy and procedure (P&P) titled, Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food, dated 2023, the document indicated, Cooked Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) food (food that requires time/temperature control for safety to limit the growth of pathogens [i.e., bacterial or viral organisms capable of causing a disease or toxin formation]) shall be cooled . in a method to ensure food safety. PHF or TCS food include: a food of animal origin that is raw or heat-treated. Also included would be soups and gravies made with any of the above PHF or TCS food; When cooling down food, use the Cool Down Log to document proper procedure; During the cooling process, use a clean, sanitized, and calibrated probe thermometer to measure the internal temperature of the food at the center of the product. Note menu item, date, time, temperature, and cook's initials on the cool down log used. 2. During an observation on 2/26/24 at 9:25 a.m., in the kitchen walk-in freezer, on the bottom shelf, there was an unlabeled, resealable plastic bag which contained a tan-colored frozen item with pink liquid. During a concurrent interview with [NAME] 1, [NAME] 1 stated the frozen tan-colored item was a frozen chicken part. [NAME] 1 stated the chicken had been received frozen and staff generally thawed frozen meat in the food production sink by running water over the frozen meat. [NAME] 1 stated the chicken had likely been thawed and then placed back in the freezer to refreeze. [NAME] 1 stated there was no date or time or temperature monitoring documentation of the thawing/refreezing process. During an observation on 2/26/24 at 3:06 p.m., the kitchen counter next to the food production sink had a cardboard box with two frozen pieces of cooked roast beef. During a concurrent interview with [NAME] 2, [NAME] 2 stated he had recently pulled the frozen roast beef from the freezer, and was preparing to thaw the meat under running water. [NAME] 2 indicated he did not monitor for time/temperature control during the thawing process. During an interview on 2/27/24 at 10:45 a.m., with [NAME] 2 and the DSS, [NAME] 2 stated he had thawed the two frozen pieces of cooked roast beef for about an hour yesterday under running water. The DSS stated he had thawed the two frozen pieces of cooked roast beef again for about an additional hour earlier on 2/27/24. The DSS stated the kitchen staff would thaw frozen meat under running water without time and temperature monitoring since the meats were already cooked. During a review of the facility's P&P titled, Procedure for Freezer Storage, dated 2023, the document indicated . Estimated time for thawing meat: 1 day (24 hours) for every 5 pounds (lbs) frozen meat in the refrigerator at approximately 40 degrees Fahrenheit (ºF); 8. Frozen food should be left in the refrigerator to thaw. Once thawed, uncooked meats are to be used within 2 days. During a review of the facility's P&P titled, Thawing of Meats, dated 2023, the document indicated . Submerge under running, potable water at a temperature of 70 ºF or lower, with a pressure sufficient to flush away loose particles; The food product cannot remain in the temperature danger zone (41 ºF to 140 ºF) for more than four hours, which includes the time the food is thawed. 3. During a concurrent observation and interview on 2/26/24 at 9:55 a.m. with DSS, on a shelf in the refrigerator, there was a closed lid cardboard box which contained ten cherry tomatoes, the tomatoes were covered with white fuzzy material and dark spots. The side of the cherry tomato box had a sticker which indicated a delivery date of 1/26/24; the top of the box lid had a handwritten date of 1/7/24. The DSS stated cherry tomatoes are good for one week at room temperature. The DSS stated he relied on the cooks to check food items in the refrigerator and freezer. During a review of the facility's P&P titled, Storing Produce, dated 2023, the document indicated, Check boxes of fruit and vegetables for rotten, spoiled items. One rotten tomato, . in a box can cause the rest of the produce to spoil faster. Throw away all spoiled items. 4. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with [NAME] 1, the freezer had one bag of chopped cooked chicken stored in the same compartment as frozen raw meat. During a review of the facility's P&P titled, Storage of Frozen Food, dated 2023, the P&P indicated, Store raw meat, poultry, .separately from cooked and ready-to-eat food to prevent cross contamination; Store cooked or ready-to-eat food above raw meat, poultry, . if these items are stored in the same unit. 5. During a concurrent kitchen observation and interview on 2/26/24 at 9:25 a.m., with Dietary Services Supervisor (DSS) and [NAME] 1, on a shelf in the freezer was one bag of opened, unlabeled frozen patties dated 2/24/24. The DSS stated the patties were pork sausages and used a black marker pen to label the bag, Pork Sausage. On another shelf in the freezer were the following items: one resealable plastic bag of undated and unlabeled frozen chicken; one package of undated frozen cauliflower; and a package of unlabeled brown ground meat. During a review of the facility's P&P titled, Procedure for Freezer Storage, dated 2023, the P&P indicated, .All frozen food should be labeled and dated. During a review of the facility's P&P titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, All food items in the refrigerator and freezer need to be labeled and dated. 6. During an observation on 2/28/24 at 12:05 p.m., in the kitchen, Diet Aide 3 (DA 3) filled a cup with juice and filled a second cup with water with ungloved hands. DA 3 placed both filled cups on a resident lunch tray, picked up a plastic lid while touching the side, top, and bottom surfaces of the lid, and placed the plastic lid on a filled cup. DA 3 touched the top drinking surface of the cup when the lid was placed on the cup. The process was repeated for the second cup of liquid. During a review of the P&P titled, Sanitation, dated 2023, the P&P indicated, Food and Nutrition Services employees are to employ the following methods in handling dishes and utensils. Cups and glasses are to be grasped firmly in the middle when picking up or by the handle. Hands must not contact food surface. The eating portion which comes into contact with the food must never be touched. During a review of the 2022 Federal Food Code, the Food Code indicated cleaned and sanitized utensils were to be handled so that the contamination of food-and lip-contact surfaces was prevented. 7. During a concurrent observation and interview on 2/26/24 at 2:44 p.m. with [NAME] 2, a blue ice chest cooler filled with ice was on the floor in front of the ice machine. [NAME] 2 stated the ice machine had been broken for two weeks and the facility was being provided by a near-by affiliated skilled nursing facility. During a concurrent observation and interview, and record review on 2/28/24 at 11:30 a.m., with the Maintenance staff person (Maintenance), at the affiliated skilled nursing facility, the ice machine was inspected. Maintenance stated he was the maintenance provider for both facilities, and his duties included cleaning of the ice machine. The Maintenance stated he cleaned the ice machine once a month by spraying bleach germicidal cleaner into a hot damp washcloth and wiping the inside of the ice bin (the area where formed ice is stored) and the chute (the part of the ice machine where formed ice is transferred from the top of the ice machine where the ice is made into the bin). Maintenance stated this was all he did to clean the ice machine. The Maintenance stated he did not have the manufacturer's cleaning instructions and had never opened the top of the ice machine to clean the inside of the ice machine, and had never removed the evaporator plate (a metal grid where water runs over and ice is formed) cover/curtain, or removed any parts from the machine to clean. The Maintenance opened the top of the ice machine to inspect the area where ice was made and removed the evaporator cover. The inside surface of the evaporator cover, which faced the evaporator plate and running water, had areas with rough white residue. The Maintenance stated the white residue was calcium build-up from exposure to water. The plastic frame around the evaporator plate had black residue in the upper left and right corners, and in the frame on the right-side seam. The ice sensor, upper left and right corners of the evaporator plate had black residue build up. The black residue was able to be removed when wiped with a paper towel. The Mainenance stated the spray bottle labeled, [Brand Name], Healthcare Bleach Germicidal Cleaner, was the product he used to clean the ice machine. The brand of the spray cleaner was not the same company as the ice machine manufacturer. The directions on the spray cleaner indicated for food contact surfaces, a potable water rinse was required. During a review of the ice machine's manufacturer manual titled, [Company name], [Model Name], Air/Water/Remote Condenser Ice Machines, Technician's Handbook, dated 2018, the manual indicated, You are responsible for maintaining the ice machine in accordance with the instructions in this manual. Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment . [Company Name] Ice machine Cleaner and Sanitizer are the only products approved for the use in [Company Name] ice machines (the manual provided specific information on the company's cleaner and sanitizer) . the handbook indicated, bleach germicidal cleaner was not the cleaner and sanitizer product approved for the ice machine The ice machine and bin must be disassembled, cleaned and sanitized; remove sanitized; remove mineral deposits from areas or surface that are in direct contact with water . Ice machine cleaner is used to remove lime scale and mineral deposits. Ice machine sanitizer disinfects and removes algae and slime . Step 1 Open the front door to access the evaporator compartment. The cleaning instructions included 16 detailed steps for cleaning the evaporator compartment, the dispenser, and the bin. During a review of the facility's policy and procedure titled, Sanitation, dated 2023, indicated 14. Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. During a review of the 2022 Federal Food Code, the Food code indicated equipment food-contact surfaces are to be smooth and clean to sight and touch. The Food Code indicated nonfood-contact surfaces of equipment were to be cleaned at a frequency necessary to preclude accumulation of soil residues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was provided supervision when staff were unaware of Resident 1's whereabouts for two eight-hour shifts (16 hours). This failure had the potential to result avoidable accidents while Resident 1 was not in the facility unsupervised. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] with diagnoses that included, abnormal posture, difficulty walking, anemia (when your blood produces a lower-than-normal amount of healthy red blood cells), depression (persistent feeling of sadness and loss of interest and can interfere with your daily life), anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), end stage kidney disease (kidneys are no longer able to work at a level needed for day-to-day life) and was dependent on hemodialysis (process of purifying the blood of a person whose kidneys are not working normally). During a concurrent interview and review of clinical records with Director of Nursing (DON) on 11/8/23 at 11:20 a.m., the progress notes were reviewed. DON stated Resident 1 went to the dialysis clinic on 10/25/23 for treatment and did not return to the facility. DON stated during the afternoon shift, Licensed Vocational Nurse (LVN) 1 did not document the incident and did not notify the incoming night shift that Resident 1 was not in the building. DON further stated, on the following day, after being unable to locate Resident 1, DON called Resident 1's cellphone and learned Resident 1 had gone home to the Family Member's (FM) home after dialysis treatment. DON stated FM answered DON's call and stated Resident 1 was sent to the hospital after complaining of abdominal cramps. DON stated the hospital discharged Resident 1 back to the facility on [DATE]. During a follow-up interview on 11/8/23 at 12:59 p.m., DON stated a wandering/elopement assessment should have been completed for Resident 1 upon admission to determine appropriate interventions. DON stated there was no wandering/elopement assessment done for Resident 1. During a telephone interview on 12/11/23 at 12:27 p.m., LVN 1 stated not knowing that Resident 1 was not in the building on 10/25/23. LVN 1 also stated he did not receive any calls from the facility management about Resident 1 not being inside the building during LVN 1's shift and no one from the facility called to ask Resident 1's whereabouts. During a telephone interview on 12/12/23 at 12:14 p.m. with LVN 2, LVN 2 stated, during shift report with LVN 1, LVN 1 stated everything was okay and left. LVN 2 stated she did not know Resident 1 was not in the building until about 4 a.m. when LVN 2 entered Resident 1's room to find an empty bed. LVN 2 stated she asked Certified Nursing Assistant (CNA) 1 and CNA 2, and both did not know Resident 1 was not in the room the entire time. During a review of Resident 1's Order Recap Report dated 10/25/23 to 11/8/23, that indicated an order dated 8/17/23 to check Resident 1's vital signs after dialysis and to monitor the dialysis access site on Resident 1's left upper arm every shift. During a telephone interview on 12/11/23 at 2 p.m. with CNA 3, CNA 3 stated Resident 1 eft for dialysis around 1 p.m. accompanied by the transport personnel. CNA 3 was working until the afternoon shift and assigned to care for Resident 1. CNA 3 stated Resident 1 did not return to the facility at the usual time but did not notify LVN 1 about it.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to maintain medical records on Resident 1 that were accurately documented and complete when; - Licensed Vocational Nurse (LVN) 1 did not document Resident 1's whereabouts for the entire afternoon/evening shift. - LVN 1 signed off Medication Administration Record (MAR) indicating medications were administered to Resident 1 while Resident 1 was actually not in the facility. These failures resulted in inaccurate medical records and falsification of medication administration. Findings: During a concurrent interview and review of clinical records with Director of Nursing (DON) on 11/8/23 at 11:20 a.m., Resident 1's progress notes were reviewed. DON stated Resident 1 went to dialysis clinic on 10/25/23 for treatment and did not return to the facility. DON stated Licensed Vocational Nurse (LVN) 1, during the afternoon shift, did not document the incident and did not notify the incoming night shift that Resident 1 was not in the building. On the following day after being unable to locate Resident 1, DON called Resident 1's cellphone and found out that Resident 1 went home to a Family Member's (FM) home after dialysis treatment. During a review of Resident 1's Order Recap Report dated 10/25/23-11/8/23, the Order Recap Report indicated Resident 1 was to receive the following during the afternoon shift; -Buspirone (treats anxiety) hydrochloride (HCL) 10 milligram (mg) tablet one tablet by mouth. -Cholestyramine powder (treats bile-acid diarrhea) four grams by mouth. -Cyclosporine (targets the body's immune system) oral capsule 25 mg 1 capsule by mouth. -Depakote (treats manic episodes) oral tablet delayed release 125 mg one tablet by mouth. -Florastor (probiotic, maintains body's digestive balance) oral capsule 250 mg one capsule by mouth. -Melatonin (sleep aid) oral tablet three mg one tablet by mouth. -Mycophenolate Mofetil (suppresses/targets the immune system) oral capsule 250 mg one capsule by mouth. -Assess pain level every shift. -Dialysis: check vital signs after dialysis every evening shift on Monday, Wednesday and Friday. -Dialysis: monitor AV fistula (abnormal connection or passageway between an artery and a vein often surgically created for hemodialysis) on left upper arm for presence of bruit (abnormal sound generated by turbulent flow of blood in an artery) &thrills (thrill is a vibration felt upon palpation of a blood vessel) every shift. -Monitor dressing on access site for any bleeding and reinforce dressing as needed. During a review of Resident 1's MAR for October 2023, the MAR indicated the following medications/treatments were administered/provided to Resident 1; -Vital signs that included blood pressure, temperature, pulse rate, respiration rate, oxygen saturation were checked at 3 p.m.; the MAR indicated Resident 1's blood pressure=126/77, temperature=97. 3 degrees Fahrenheit, pulse rate=76, respiration rate= 17 and oxygen saturation= 96 percent (%). - Melatonin three mg one tablet was administered at 9 p.m. - Buspirone 10 mg tablet was administered at 5 p.m. - Cholestyramine Powder four grams was administered at 5 p.m. - Cyclosporine 25 mg oral capsule was administered at 9 p.m. - Depakote 125 mg oral tablet was administered at 5 p.m. - Florastor 250 mg oral capsule was administered at 5 p.m. - Mycophenolate Mofetil 250 mg oral capsule was administered at 9 p.m. - Resident 1's pain level was assessed at 3 p.m., Resident 1's pain level was zero out of 10 (pain level 0-10, zero as no pain and 10 as the worst pain). - Resident 1's AV fistula on the left upper arm was checked for presence of bruit and thrills at 3 p.m. - Resident 1's dialysis access site on the left upper arm was monitored for signs and symptoms of infection, bleeding, redness, pain, swelling and discharge. - Novasource Renal four ounces was given to Resident 1, Resident consumed 90 percent (%). - Norco 5-325 mg oral tablet was administered to Resident 1 at 8:20 p.m. for a five out of 10 pain. During a telephone interview on 12/11/23 at 12:27 p.m. with LVN 1, LVN 1 stated not knowing Resident 1 was not in the building on 10/25/23 during LVN 1's shift at the facility or knowing Resident 1 had not returned to the facility (after dialysis). LVN 1 stated during medication administration, LVN 1 signed off on the medications as given to Resident 1 before the actual administration. During a telephone interview on 12/11/23 at 2 p.m. with CNA 3, CNA 3 stated Resident 1 left for dialysis around 1 p.m. accompanied by the transport personnel. CNA 3 was assigned to care for Resident 1 and knew Resident 1 did not return to the facility. CNA 3 did not notify LVN 1 about it.

Based on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 received care and services with reasonable accommodation when the bathroom did not have a grab bar on the left side to assist Resident 1's toileting needs. This failure had the potential to result in decreased independence to perform activities of daily living (ADLs). Findings: During a review of Resident 1's admission Record dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility in June 2022 with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis (type of arthritis when cartilage/ flexible tissue at the end of the bones wear down) and the need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 7/27/23, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 13 out of 15 indicating Resident 1 is cognitively intact. The MDS also indicated, under Section G, Resident 1 was able to transfer from bed to chair and use the toilet with staff assistance. During an interview on 8/8/23 at 1:15 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 refused to go to the bathroom despite a lot of encouragement from the staff. CNA 1 also stated Resident 1 was able to hold onto the grab bar to stand up. During a concurrent observation and joint interviews on 8/18/23 at 1 p.m. with Resident 1 and CNA 2, CNA 2 stated she did not know why Resident 1 did not want to use the bathroom. CNA 2 stated a bedside commode is provided at the bedside for Resident 1 to use for bowel movements and a urinal was at the bedside. Resident 1 stated the bathroom did not have a grab bar to hold onto during transfers from the chair to the toilet. An observation of Resident 1's bathroom was done. There was a grab bar on the right side of the toilet, while none was on the left side. Resident 1 stated not being able to use the right grab bar because of right side paralysis and only the left hand was good. Resident 1 stated not feeling safe if there was not a left side grab bar. During an interview on 8/8/23 at 1:09 p.m. with Director of Nursing (DON), DON stated Resident 1 was not able to move right side of the body because of right side paralysis but was able to hop on the left leg and use the left arm to hold onto the grab bar in the bathroom. DON stated Resident 1 needed some staff assistance on the right side. During a review of Resident 1's ADL care plan dated 9/29/22, the ADL care plan indicated for the staff to encourage Resident 1 to participate to the fullest extent possible with all ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of two sampled residents (Resident 1), the facility failed to ensure assessment accurately reflects Resident 1's status when the Minimum Data Set (MDS, an assessment tool used to direct resident care) coded a diagnosis of diabetes mellitus without supporting documentation. This failure had the potential to result in uncoordinated care. Findings: During a review of Resident 1's admission Record, dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis, and diabetes mellitus (inappropriately elevated blood sugar levels). During a telephone interview with Family Member (FM) 1 on 8/7/23 at 7:09 p.m., FM 1 stated facility staff had been saying Resident 1 was diabetic and was filling out forms for Resident 1 incorrectly despite Resident 1 not having of diabetes. During a concurrent interview and record review on 8/8/23 at 12:38 p.m. with Director of Nursing (DON), Resident 1's admission Record, dated 8/8/23 and MDS dated [DATE], were reviewed. DON stated, when Resident 1 was admitted to the facility in June 2022, a company that helped the facility enter ICD (International Classification of Diseases, a medical coding system to catalog health conditions by categories) codes in the clinical record added diabetes as one of Resident 1's diagnoses. DON stated Resident 1's clinical record from the discharging facility did not have documentation that Resident 1 had diabetes. DON stated because Resident 1 did not receive any treatment for diabetes, Resident 1's MDS should not reflect the diagnosis. Review of Resident 1's MDS dated [DATE] indicated, under Section I- Active Diagnoses, instructions included to check the diagnoses that were active the last 7 days of assessment period. The MDS indicated Resident 1 was checked off for diabetes mellitus. DON stated the MDS was coded incorrectly. During a review of Resident 1's Order Summary Report, dated 8/8/23, the Order Summary Report indicated Resident 1 did not receive any treatment for diabetes. During a review of Resident 1's care plan initiated in July 2022, the care plan indicated Resident 1 did not have any actual or potential problems related to diabetes and did not receive any interventions to address it.

Based on observation, interview, and record review, for one of two sampled residents (Resident 1), the facility failed to ensure Resident 1 received treatment in accordance with professional standards and Resident 1's choices when: 1. A long-standing skin rash was not treated in a timely manner. 2. Neurovascular Specialist's (one who has expertise in treating a variety of conditions and vascular malformations of the brain, spine, and peripheral nerves) recommendation for a 30-day heart function monitor was not followed up. This failure resulted in delayed management of care. Findings: 1. During a review of Resident 1's admission Record, dated 8/8/23, the admission Record indicated Resident 1 was admitted to the facility in June 2022 with diagnoses that included aphasia (loss of ability to understand or express speech, due to brain damage), hemiplegia (paralysis of one side of the body), muscle weakness, osteoarthritis (type of arthritis when cartilage/ flexible tissue at the end of the bones wear down) and the need for assistance with personal care. During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care). dated 7/27/23, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 13 out of 15 indicating Resident 1 is cognitively intact. During a concurrent observation and joint interviews on 8/8/23 at 11 a.m. with Director of Nursing (DON) and Resident 1, Resident 1's left upper arm had thick raised patches of scaly and pinkish brown area. Resident 1 stated the rash started since admission. A smaller area of raised pink, scaly patch was noted on Resident 1's left elbow. DON stated it was Resident 1's scar tissue but Resident 1 quickly stated it was not a scar tissue but a rash like the one in the upper arm. Resident 1 stated the rashes were itchy and kept Resident 1 up at night. Resident 1 also stated the staff had been applying cream but that had stopped four days ago. During a concurrent interview and review on 8/8/23 at 11:05 a.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Order Summary Report dated 8/8/23 was reviewed. LVN 1 stated Resident 1's rash had been treated with ketoconazole cream (antifungal, treats fungal infection of the skin) which was kept at Resident 1's bedside for the Certified Nursing Assistants (CNAs) to apply. LVN 1 stated there was no physician's order in the clinical record to apply ketoconazole cream, and no care plan that addressed it. During an interview and concurrent review on 8/8/23 at 11:15 a.m. with DON, Resident 1's clinical record was reviewed. DON stated there was no Interdisciplinary Team meeting to address Resident 1's rash. DON also stated Resident 1 has had the rashes since admission in June 2022 but there was no documentation that Resident 1's attending physician was notified about it. During a review of the facility's policy and procedure (P&P) titled Administering Medications last revised April 2019, the P&P indicated the following; - Medications may only be administered by persons licensed or as permitted by this state. - Medications are administered in accordance with prescriber's orders, including any required time frame. - Topical medications used in treatments are recorded on the resident's Treatment Administration Record (TAR). 2. During a telephone interview on 8/7/23 at 7:09 p.m. with Family Member (FM) 1, FM 1 stated Resident 1 was taken to an appointment with a specialist and came back with an order for heart monitor, but the facility refused to put it on because Resident 1 was not Skilled. During a review of Neurovascular Clinic Follow-up Visit dated 9/9/22, the Neurovascular Clinic Follow-up Visit indicated a recommendation for a 30-day cardiac event monitor to check for paroxysmal atrial fibrillation (abnormal heartbeat) which was a possible cause of Resident 1's stroke. The recommendation indicated, if Resident 1 was found to have atrial fibrillation, Resident 1 would be switched from aspirin 81 milligrams (mg) to a direct oral anticoagulant to prevent any future secondary stroke. The recommendation indicated for Resident 1 to continue taking aspirin until results of the 30-day cardiac monitor is available. During a review of Resident 1's Order Summary Report dated 8/8/23, the Order Summary Report indicated Resident 1 received aspirin 81 mg one tablet daily. During a telephone interview on 8/22/23 at 12:33 p.m. with DON, DON stated Resident 1 went to the hospital Emergency Department (ED) on 10/28/22 after experiencing chest pain. DON stated the hospital performed several tests and Resident 1 returned to the facility the same day without any new order. DON confirmed there was no documentation in the clinical record that indicated the cardiac monitor was not needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to formally notify Resident 1 and Resident 1's responsible party in writing of the changes in Resident 1's health plan, health plan coverage and non-coverage of services. This failure resulted in the interruption of Resident 1's rehabilitation services (health care services that help improve skills and functioning for daily living that have been impaired because of sickness). This delay in treatment caused Resident 1 to feel sad. Findings: During a review of Resident 1's Face Sheet dated,12/22/22, the face sheet indicated, Resident 1 was admitted to the facility on [DATE] with a Medi-Cal managed care health insurance (a public health plan for people with Medi-Cal). Medi-Cal is a public health insurance program which provides needed health care services for low-income individuals. During a review of Resident 1's Order Summary Reports (Physician's orders), dated 7/2/22, the Physician's orders indicated Resident 1's diagnoses of aphasia (a disorder that results from damage to portions of the brain that are responsible for language) and hemiplegia following cerebral infarction (loss of ability to move in one side of the body caused by brain cell death due to disrupted blood flow to the brain). The Physician's orders indicated to start rehabilitation services. Review of Resident 1's Minimum Data Set Assessment (MDS - an assessment tool used to direct resident care), dated 9/29/22, indicated Resident 1 had a Brief Interview for Mental Status (BIMS - an assessment tool to determine a resident's orientation to time and their capacity to remember) score of 15. The BIMS score range is from 0-15, with zero as the most impaired. During an interview on 12/22/22, at 11:30 a.m., with Resident 1, Resident 1 stated, he felt sad when the facility stopped his rehabilitation services because of non-coverage by his health plan. Resident 1 further stated, the facility did not inform him of the reason why his health plan stopped paying for his rehabilitation services. During an interview on 12/23/22, at 4:34 p.m., with Administrator (Adm), Adm stated, Resident 1's daughter was informed by the facility of the changes in Resident 1's health plan, coverage, and non-coverage of services verbally, but was not informed in writing. During an interview on 1/4/23, at 2:18 p.m., with Business Office Manager (BOM), BOM stated, when Resident 1's rehabilitation services stopped in 7/29/22 because of health plan non coverage, BOM did not give Resident 1 and his daughter a formal notice in writing regarding the changes in Resident 1's health plan coverage. During a review of Resident 1's Order Summary Reports (Physician's orders), dated 6/27/22, 8/3/22 ,8/8/22 ,10/7/22,11/16/22 and 12/8/22, the Physician's orders indicated active orders for Resident 1 to have rehabilitation services. During a review of the facility's policy and procedure (P&P) titled, [Notification of changes, coverage of services], indicated, . changes in our resident's coverage for their services are promptly shared with the resident and/or the resident representative. The intent of the policy is to provide appropriate and timely information about changes relevant to the resident to the parties who will make decisions about care, treatment, and preferences to address the changes. The P&P also indicated, Notification for the changes . must be shared immediately in writing within two calendar days of the end of coverage .

Based on observation, interview, and record review, the facility failed to: 1. Have a prescribed medication available for one (Resident 14) of eight residents. 2. Ensure one pill crusher and one pill cutter were cleaned after use. The failure to administer two consecutive doses of Resident 14's medication for reduction of fluid inside the eye had the potential to result in increased fluid pressure inside the eye causing nerve damage and impaired vision. The failure to remove medication residue from the pill crusher and cutter after use had the potential for administration of unordered medications or incompatible medications due to the mixing of different medications used in the pill crusher and pill cutter. Findings: 1. A review of Resident 14's admission Record indicated Resident 14 was admitted to the facility in 2017 with a diagnosis of diabetes (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs), eye disease related to diabetes, and glaucoma (a condition of increased eye pressure from excessive fluid inside the eye which can lead to nerve damage and impaired vision). A review of Resident 14's Physician's Orders, for March 2022, indicated an order with a start date of 9/9/17, to instill one drop of brimonidine tartrate solution (a medication used to reduce fluid pressure in the eye by reducing fluid production and increasing fluid drainage) in Resident 14's right eye three times a day for the diabetes related eye disease. A review of Resident 14's Medication Administration Record (MAR) dated 3/1/22 to 3/31/22, indicated the brimonidine tartrate solution was due daily at 9 a.m., 1 p.m., and 5 p.m. During concurrent observation and interview on 3/23/22, at 9:15 am, in Resident 14's room, Licensed Vocational Nurse 1 (LVN 1) administered Resident 14's morning medications. LVN 1 stated Resident 14 had not received the eye drop of brimonidine tartrate solution at 9 a.m. because the facility had run out of the medication. During an interview on 3/23/22 at 11:45 a.m., LVN 1 stated she had contacted the pharmacy and was told Resident 14's brimonidine tartrate solution would be delivered in time for the 5:00 p.m. dose. A review of Resident 14's MAR for 3/1/22 to 3/31/22, indicated nursing staff had not administered the eye drop solution brimonidine tartrate on 3/23/22 at 9 a.m. or 1 p.m. 2. During a concurrent observation and interview on 3/23/22, at 10:30 a.m., with LVN 1, the medication cart contained a pill cutter (a device for cutting pills into fractional pieces) and a pill crusher (a device for crushing pills into a powder). The pill cutter had white powder residue in all the cutter compartments. The pill crusher had a white powder residue at the tip of the blue handlebar and a dry brown spot on the right side of the base. LVN 1 stated the white powder residues could potentially result in the mixing of medications not prescribed to a resident. A review of the facility policy and procedure, Cleaning and Disinfection of Resident-Care Items, dated 2001, indicated, Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).

Based on observation, interview, and record review, the facility failed to ensure one of two kitchen staff wore a head covering while working in the kitchen. This failure had the potential to result in food contamination from hair shed by staff and cause food to be less palatable and/or spread food borne illness. Findings: During an observation and concurrent interview on 3/24/22, at 10:36 a.m., in the kitchen, [NAME] 1(CK 1) was in the kitchen with no head covering. CK 1 stated he forgot to put on a hairnet when he entered the kitchen. CK 1 stated residents could get sick from hair shed onto their food. During an interview on 3/24/22, at 10:43 a.m., with the Dietary Manager (DM), DM stated, all staff were required to wear a hairnet upon entry into the kitchen. During a telephone interview on 3/24/22, at 12:14 p.m., with Registered Dietician (RD), RD stated all staff must wear a hairnet when inside kitchen so hair does not get on food. RD stated hair in resident food was both a potential source of foodborne illness, and was very unsanitary, unappetizing, and unappealing. A review of the facility's policy and procedure (P&P) for kitchen staff titled, Dress Code for Women and Men, dated 2018, indicated, Appropriate dress in the Food & Nutrition Department .Men: .Hat for hair, if hair is short. Hair net for hair, if hair is long (over the ears or longer).

Based on interview and record review the facility failed to ensure the recommendations from the January 2022 medication regimen review (MRR, a review of all medications prescribed to each resident to check for provision of pharmaceutical services not consistent with accepted professional standards) for five (Resident 5, 6, 7, 11, 12) of 13 sampled residents were reviewed by the attending physician. This failure had the potential to result in the administration of unnecessary medications for the five residents during January 2022. Findings: A review of Resident 5's admission Record, undated, indicated he was admitted in 2021 with a diagnosis of depressive disorder (a mood disorder resulting in sadness and loss of interest in life). A review of Resident 6's admission Record, undated, indicated he was admitted in 2021 with a diagnosis of end stage renal disease. (ESRD, the stage of kidney impairment that appears irreversible and permanent and requires a regular course of dialysis or kidney transplant to maintain life.) A review of Resident 7's admission Record, undated, indicated she was admitted in 2021 with a diagnosis of major depressive disorder. A review of Resident 11's admission Record, undated, indicated she was admitted in 2018 with a diagnosis of cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area) and major depressive disorder. A review of Resident 12's admission Record, undated, indicated he was admitted in 2021 with a diagnosis of cerebral infarction and chronic pain. A review of the facility MRR binder on 3/24/22 contained no documentation for a completed MRR in January 2022. During an interview on 1/24/22 at 11:06 a.m., with the Director of Nursing (DON), the DON stated she had not ensured the MRR had been completed in January 2022; she had missed it. The DON stated the MRR was completed on 12/29/21, and the next completed MRR was dated 2/6/22. The DON stated the monthly MRR was a review of all the medications and lab work for every resident in the facility. During a concurrent interview and record review on 3/25/22 at 9:40 a.m., with the DON, the DON provided a copy of MRR documents dated 1/21/22. The MRR documents included forms titled, Note to Attending Physician/Prescriber, with Printed: 1/21/22, on the bottom right- hand corner of the form, for the following residents: A review of Resident 5's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist recommended the physician re-evaluate the order for Resident 5's prescribed antidepressant medications. A review of Resident 5's form area designated, Physician/Prescriber Response, had a handwritten note with the name of the physician and the DON, and the date of 3/22/22. A review of Resident 6's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist recommended the physician re-evaluate the order for Resident 6's continuous allergy medication. A review of Resident 6's form area designated, Physician/Prescriber Response, had no entries. A review of Resident 7's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist suggested the physician consider reducing the prescribed antidepressant medications from two medications to one medication. A review of Resident 7's form area designated, Physician/Prescriber Response, had a handwritten note with the name of the physician and the DON, and the date of 3/22/22. A review of Resident 11's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist recommended the physician re-evaluate the order for Resident 11's prescribed antidepressant medication. A review of Resident 11's form area designated, Physician/Prescriber Response, had a handwritten note with the name of the physician and the DON, and the date of 3/24/22. A review of Resident 12's Note to Attending Physician/Prescriber, dated 1/21/22, indicated the pharmacist suggested the physician consider reducing the prescribed antidepressant medications from two medications to one medication. A review of Resident 12's form area designated, Physician/Prescriber Response, had a handwritten note with the name of the physician and the DON, and the date of 3/22/22. The DON stated she had called the physician and entered the physician response on 3/22/22, for Residents 5, 7, and 12, and had called the physician and entered the physician response on 3/24/22 for Resident 11. During a review of the facility policies and procedures (P & P), titled Consultant Pharmacist Services Provider Requirements, dated 2007, the P & P indicated The Consultant Pharmacist, or designee, provides pharmaceutical care services, including but not limited to the following: .Medication Regimen Review (MRR) for each Skilled Nursing (SNF) resident at least monthly, or more frequently under certain conditions, incorporating the facility mandated standards of care in addition to other applicable professional standards. Communicate to the responsible prescriber and the director of nursing potential or actual problems detected and other findings related to medication therapy orders at least monthly.

4. During a concurrent observation and interview on 3/23/22, at 8:10 a.m., Licensed Vocational Nurse 1 (LVN 1) placed a wrist blood pressure monitor and a pulse oximeter on a medication tray and entered Resident 234's room. When LVN 1 left the room, LVN 1 wiped the blood pressure monitor and pulse oximeter using a sanitizing wipe but did not thoroughly wet the surface or ensure it remained wet for two minutes, per manufacturers specifications to adequately disinfect. LVN 1 stated the blood pressure monitor and oximeter should be cleaned for two minutes since the equipment was shared between residents and could spread germs. During a review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, indicated, Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. A review of the [brand name] sanitizing wipe directions for use, To disinfect and deodorize: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry. Based on observation, interview, and record review, the facility failed to ensure infection control policies and procedures were followed when: 1. Two scheduled nursing staff (Licensed Vocational Nurse 1, Certified Nursing Assistant 1), had no documented completion of pre-entry screening for symptoms of COVID-19 (COVID-19, a respiratory infection which can result in breathing difficulty and other complications, including death. Symptoms include fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea). Licensed Vocational Nurse 1 had no documented screening for 3/15/22, 3/16/22, 3/17/22, or 3/20/22. Certified Nursing Assistant 1 had no documented screening for 3/17/22. 2. Certified Nursing Assistant 3 (CNA 3) failed to perform hand hygiene after doffing gloves, and properly dispose of the soiled gloves, for one of 14 sampled residents (Resident 14). 3. For two of 14 sampled residents (Resident 10, Resident 14), nursing staff moved an open bag of bathing supplies (disposable towelettes) from Resident 10's bed and used the towelettes for Resident 14's bath. 4. Nursing staff failed to disinfect a wrist blood pressure cuff (a cloth or plastic band which is wrapped around the wrist and inflated to obtain a measurement of blood pressure) and a pulse oximeter (a device, usually secured or taped around a finger, used to measure the percentage of oxygen dissolved in the blood) between use by different residents. These failures had the potential to result in infection or spread of infection, including COVID-19 infection. Findings: 1. A review of the facility document titled, [facility name] Nursing Schedule March 1-31, 2022, indicated Certified Nursing Assistant 1 (CNA 1) was scheduled to work 3/17/22 and Licensed Vocational Nurse 1 (LVN 1) was scheduled to work 3/15/22, 3/16/22, 3/17/22, and 3/20/22. A review of the facility document titled, COVID-19 Screening Vaccinated Employees, revised 8/18/21, indicated a line for the date, and instructions at the top of the page, All employees must be screened and wear a mask before entering the facility. The form had lines for individual names, and columns for each name to indicate temperature, proof of vaccination, whether or not the individual had travelled outside the country in the last two weeks, whether or not the individual had been in contact with a COVID positive person in the last two weeks, presence or absence of cough/fever/chills/shortness of breath/loss of smell or taste/diarrhea/nausea or vomiting/sneezing or cold-like symptoms, and verification of use of hand sanitizer before entry to the facility. A review of the screening forms dated 3/15/22 through 3/20/22 indicated no entries to document completion of the screening process for COVID-19 by Certified Nursing Assistant 1 (CNA 1) on 3/17/22, or by Licensed Vocational Nurse 1 (LVN 1) on 3/15/22, 3/16/22, 3/17/22, or 3/20/22. During an interview on 3/23/22 at 11:14 a.m., with the Director of Nursing (DON), the DON stated staff were required to document completion of a daily screening for symptoms of COVID-19 on the COVID-19 Screening Vaccinated Employees form. The DON stated CNA 1 had worked on 3/17/22, and LVN 1 had worked on 3/15/22, 3/16/22, 3/17/22, or 3/20/22. The DON was unable to provide documentation CNA 1 had completed the screening process on 3/17/22, or that LVN 1 had completed the screening process on 3/15/22, 3/16/22, 3/17/22, or 3/20/22. The DON stated it was important the screening process be completed daily to help prevent staff from exposing residents to COVID-19. 2. A review of Resident 14's admission Record indicated she was admitted in 2017 with a diagnosis of diabetes mellitus (the body's inadequate production of the hormone insulin results in high blood sugar levels causing excessive urination and damage to body organs). A review of Resident 14's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 12/9/21, indicated Resident 14 was totally dependent on one person for assistance with personal hygiene and bathing. A review of Resident 10's admission Record indicated she was admitted in 2018 with a diagnosis of Parkinson's disease (a disease of progressive deterioration of the brain and muscular systems). A review of Resident 10's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 1/20/22, indicated Resident 10 was totally dependent on one person for assistance with personal hygiene and bathing. During an observation on 3/21/22 at 10:25 a.m., in the shared room of Resident 10 and Resident 14, Certified Nursing Assistant 3 (CNA 3) wore gloves while she gave a bed bath to Resident 14, while Resident 14 lay in her bed. CNA 3 doffed her soiled gloves and placed them on Resident 14's bedside table. CNA 3 did not perform hand hygiene after she removed the used gloves and left Resident 14's bedside to get supplies. A review of facility's policy and procedure (P & P), titled Bed Bath, revised February 2018, indicated when staff completed the bath, gloves should be removed and discarded in the designated container, immediately followed by wash and dry your hands thoroughly. 3. During an observation and concurrent interview on 3/21/22 at 10:27 a.m., in the shared room of Resident 10 and Resident 14, CNA 3 went to Resident 10's bedside and picked up an open packet of bathing towelettes which were on top of the blanket covering Resident 10's feet. CNA 3 carried the towelettes to Resident 14's bedside, placed the towelettes on top of Resident 14's bedside table, wet the packet with a rinse-less wash solution (a cleansing solution that does not require rinsing), and stated she was going to complete Resident 14's bed bath. During an interview on 3/21/22 at 11:01 a.m., with the Director of Nursing (DON), the DON stated each resident had their own bathing supplies, and there was no reason wipes should be moved from one resident to another. The DON stated sharing bathing supplies could lead to the spread of infection between residents.