**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review the facility's staff failed to: 1. Ensure one out of two sampled residents (Resident 13) rights were not violated by not explaining medications that were given. This deficient practice had the potential of the resident lower the resident self-esteem. Findings: During a review of Resident 13's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 13 was admitted to the facility on [DATE]. Resident 13's diagnosed was dysfunctional uterine bleeding (a condition heavy or prolonged vaginal bleeding from the uterus). During a review of Resident 13's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 8/19/2024 the MDS indicated, Resident 13's cognition (ability to learn, reason, remember, understand, and make decisions) was severely impaired. The MDS indicated Resident 13's had a gastronomy (a surgical procedure that creates an opening in the stomach to help with feeding and administering medication) for nutrition. The MDS indicated Resident 13's active diagnoses were respiratory failure (a condition when the lungs are unable to provide enough oxygen to the blood or remove carbon dioxide from the body) and anoxic brain injury (occurs when the brain is deprived of oxygen). During an observation on 11/9/2024 at 9:43 a.m. in Resident 13's room, Resident 13 was wiping her mouth with a towel to wipe away secretions (fluids produced by the glands that line the nose, mouth, and throat) after coughing. During an observation on 11/9/2024 at 9:55 a.m. in Resident 13's room, Licensed Vocational Nurse (LVN) 1, LVN 1 gave Resident 13's medications via gastrotomy tube and did not explain the medications to the resident. Resident 13 was alert and awake looking in the direction of LVN 2 while medications were being administered. During an interview on 11/10/2024 at 12:09 p.m. with Registered Nurse (RN) 2, RN 2 stated when giving medications the process is to introduce ourselves to the resident and explain to the resident what medications they are receiving. RN 2 state it was important to explain the medications so the resident will know the risk and benefits of the medication. RN 2 stated the medications were to be explained before giving to maintain dignity. RN 2 stated if the medications are not explained it takes away the residents right to refuse and it could make the resident feel uninformed. During an interview on 11/10/2024 at 1:04 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated during the mediation pass she had missed that step to explain the mediations to Resident 13 before administering. LVN 1 stated was important to explain the medications, so the resident knows what's going into their bodies. LVN 1 stated Resident 13 was alert and had the right to refuse the medications. LVN 1 stated not explaining the medications to the resident would take away her rights as a resident. During a review of the facility's policy and procedure (P&P) titled, Residents and Family Education, dated 2/2021, the P&P indicated the resident and family members will be given sufficient information to make decision. The P&P indicated to educate to improve outcomes by promoting healthy behavior and appropriately involving residents in their care, treatment, and service decision. The P&P indicated to educate on how to use medications safely and effectively. During a review of the facility's policy and procedure (P&P) titled, Residents Rights, dated 2/2021, the P&P indicated to ensure that the subacute will provide the necessary care and treatment of the residents within the boundaries of their rights. The P&P indicated residents will be treated with consideration, respect and full recognition of dignity and individuality, treatment, and care of personal needs. The P&P indicated the right of the resident to refuse treatment to the extent permitted by law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had a revised care plan for outside food. This deficient practice of not revising the care plan for outside food had the potential to place Resident 12 at risk for aspiration (the act of breathing in a foreign object). Findings: During a review of Resident 12's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnosed was respiratory failure (a condition when the lungs are unable to get enough oxygen into the blood or remove carbon dioxide from the body). During a review of Resident 12's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 10/26/2024 the MDS indicated, Resident 12's cognition (ability to learn, reason, remember, understand, and make decisions) was moderate impairment. The MDS indicated Resident 12's nutritional approaches were to be mechanical altered diet (a diet that consist of food that are easy to swallow and chew). had a gastronomy (a surgical procedure that creates an opening in the stomach to help with feeding and administering medication) for nutrition. During an interview on 11/10/2024 at 9:17 a.m. with Resident 12, Resident 12 stated my family brings me food from home. Resident 12 stated his family has been bringing him food for the last few weeks. During a review of Resident12's Nutrition Care Plan, dated 10/26/2024, the Nutrition Care Plan Indicated Resident 12's problem had the potential for altered nutrition related to weight loss/gain and mechanically altered/therapeutic diet. The Nutrition Care Plan goals indicated Resident 12 would be free from signs and symptoms of aspiration. The Nutrition Care Plan indicated the approaches were to provide the diet as ordered. During a concurrent interview and record review on 11/10/2024 at 10:42 a.m. with Registered Nurse (RN) 1, Resident 12's Nutrition Care Plan, dated 10/26/2024 was reviewed. The Nutrition Care Plan Indicated Resident 12's problem had the potential for altered nutrition related to weight loss/gain and mechanically altered/therapeutic diet. The Nutrition Care Plan goals indicated Resident 12 will be free from signs and symptoms of aspiration. The Nutrition Care Plan indicated the approaches were to provide diet as ordered. RN 1 stated Resident 12 is on a regular diet with small size bites. RN 1 stated the care plan needed to be revised so the staff will know the resident is receiving food from home. RN 1 stated the process was to update the care plan after there was a change such as family bringing in food from home. RN 1 stated if the care plan is not revised it would increase the risk of the resident aspirating. During a concurrent interview and record review on 11/10/2024 at 12:55 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 12's Nutrition Care Plan, dated 10/26/2024 was reviewed. The Nutrition Care Plan Indicated Resident 12's problem had the potential for altered nutrition related to weight loss/gain and mechanically altered/therapeutic diet. The Nutrition Care Plan goals indicated Resident 12 will be free from signs and symptoms of aspiration. LVN 2 stated the care plan is revised by the charge nurse. LVN 2 stated the revised care plan needed to be revised to adapt (to create a balance between a person and their environment) to the patient needs. During a review of the facility's policy and procedure (P&P) titled, Care Plan, Multidisciplinary, dated 8/2014, the P&P indicated to communicate information for continuity of care, to develop long and short-term goals for the patient, and to identify the problem needs, concerns of the patient. The P&P indicated care needs shall be prioritized when planning the patient's care including necessary to assure the patient's care that is left unaddressed are likely to become emergent or necessary to assure the safety of the patient. During a review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team Conference (IDT), dated 2/2021, the P&P indicated the IDT will collaborate in developing the plan of care and assessment on an ongoing basis in response to resident's condition. The P&P indicated to develop, review, and update the resident's care plan of care. During a review of the facility's policy and procedure

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had physician orders that were not updated for the diet plan. This deficient practice of not updating physician orders for Resident 12's diet had the potential to cause a delay in care. Findings: During a review of Resident 12's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnosed was respiratory failure (a condition when the lungs are unable to get enough oxygen into the blood or remove carbon dioxide from the body). During a review of Resident 12's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 10/26/2024 the MDS indicated, Resident 12's cognition (ability to learn, reason, remember, understand, and make decisions) was moderate impairment. The MDS indicated Resident 12's nutritional approaches were to be mechanical altered diet (a diet that consist of food that are easy to swallow and chew). had a gastronomy (a surgical procedure that creates an opening in the stomach to help with feeding and administering medication) for nutrition. During an observation on 11/9/2024 at 5:45 p.m. a regular soft and bite size diet with thin liquid from the kitchen was brought to Resident 12's room. During a review of Resident 12's Physician Orders, dated 11/6/2024, the Physician Orders indicated Resident 12 was to have enteral feeding (a method of delivering nutrition to the body through the digestive system) During a concurrent interview and record review on 11/10/2024 at 10:42 a.m. with Registered Nurse (RN) 1, Resident 12's Physician Orders, dated 11/6/2024, was reviewed. The Physician Orders indicated Resident 12 was to have enteral feeding (a method of delivering nutrition to the body through the digestive system) Jevity 1.5 (a liquid nutritional supplement that is used for tube feeding in patients) at 55 milliliters (a unit measuring length in the metric system) per hour via gastronomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). RN 1 stated the physician orders should have been changed to the regular diet with small bite size. RN 1 stated it was important to know what type of diet the resident is on to prevent the risk of choking and aspiration (the act of breathing in a foreign object). During a concurrent interview and record review on 11/10/2024 at 11:57 a.m. with Registered Nurse (RN) 2, Resident 12's Physician Orders, dated 11/6/2024, was reviewed. The Physician Orders indicated Resident 12 was to have enteral feeding (a method of delivering nutrition to the body through the digestive system) Jevity 1.5 at 55 milliliters per hour via gastronomy. RN 2 stated Resident 12 is on a regular soft with small bite size diet. RN 2 stated the night shift nurses were to reconciliate (a process of comparing a patient's current medications to their medical records and medication orders to identify and resolve discrepancies) the orders once a month. RN 2 stated the orders should have been transcribed and updated to reflect the regular soft diet. RN 2 stated it was important to have the correct physician orders, so the staff members know what diet Resident 12 is on. RN 2 stated not having the correct diet order could cause a delay in care. During a review of the facility's policy and procedure (P&P) titled, Order Clarification, dated 7/2023, the P&P indicated to describe standard procedure for clarification of orders that are incomplete, illegible, or unclear. The P&P indicated a clarification message will be placed in the patient profile documenting what type of clarification in the external comments section of the order. The P&P indicated clarification message will be discontinued when the order is clarified. During a review of the facility's policy and procedure (P&P) titled, Medication Reconciliation, dated 4/2023, the P&P indicated patients are at risk during transition of care (hand-offs) across settings, providers, or levels of care. The P&P indicated accurate and complete reconciliation of orders across the continuum of care is essential in the reduction of errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that involves testing a sample of blood, urine, or other substance from the body) of phenobarbital level (a test that measures the amount of phenobarbital-a medicine used to treat seizure, in the blood) for the month of October 2024, was completed for one of one sampled resident (Resident 20). This deficient practice had the potential for Resident 20's to have abnormal values or drug toxicity (accumulation of an excessive amount of any medication in the bloodstream) that would result in delay of treatment and services. Findings: During a review of Resident 20's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 20 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 20's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 20's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 7/7/2024, the MDS indicated, Resident 20's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 20 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 20's Physician Orders (a document containing active physician order), dated 11/10/2024, indicated Resident 20 had an active order of phenobarbital 97.2 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) in the morning and 129.6 mg at night for seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) prophylaxis (to prevent disease or the spread of illness). The Physician Orders also indicated, Resident 20 had an active order to monitor phenobarbital level every month. During a review of Resident 20's care plan titled, Potential for injury related to seizure disorder, dated 10/5/2024, the care plan indicated the goal will be free from falls and injury daily in the next 3 months. The care plan intervention included laboratory as ordered and medical doctor for abnormal results. During a concurrent interview and record review on 11/10/2024 at 9:24 a.m., with the Director of Nursing (DON), Resident 20's clinical records were reviewed. The DON stated the laboratory test result of phenobarbital level for the month of October 2024 for Resident 20 as ordered by the physician was not available and completed. The DON stated there was no documentation indicating the facility staff communicated with the physician of Resident 20 that phenobarbital level for the month of October 2024 was reported and there was no documented evidence of follow-up of what happened with the phenobarbital level that should had been drawn. The DON stated the phenobarbital level blood test was important to manage Resident 20's seizure making sure he is getting the right dose and to avoid drug toxicity. During a review of the facility's policy and procedure (P&P) titled, Drug Therapy Monitoring, dated 4/2023, the P&P indicated, Drug therapy monitoring shall be an ongoing, prospective or concurrent process to assure effective, appropriate, and safe drug therapy and shall be a collaborative assessment by physicians, nurses, pharmacists, and other practitioners responsible for the patient. During a review of the facility's P&P titled, Physician's Orders, Acceptance and Implementation, dated 3/2018, the P&P indicated, Orders shall be processed in accordance with applicable local, state and federal law, hospital policies and other medical staff documents. During a review of the facility's P&P titled, Monitoring Medication Administration, dated 4/2023, the P&P indicated, Each patient's medication shall be monitored on an ongoing basis for the effectiveness and actual or potential adverse effects of toxicity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure one out of two sampled residents (Resident 12) had accurate documentation to have food from home. This deficient practice of not accurately documenting food brought in by Resident 12's family and friends which had the potential for Resident 12 to aspirate (the act of inhaling food, liquids, or other material into the lungs). Findings: During an observation on 11/9/2024 at 5:45 p.m., Resident 12 refused to eat his meal. During a review of Resident 12's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 12 was admitted to the facility on [DATE]. Resident 12's diagnosed was respiratory failure (a condition when the lungs are unable to get enough oxygen into the blood or remove carbon dioxide from the body). During a review of Resident 12's Minimum Data Set ([MDS] a federally mandated assessment tool), dated 10/26/2024 the MDS indicated, Resident 12's cognition (ability to learn, reason, remember, understand, and make decisions) was moderate impairment. The MDS indicated Resident 12's nutritional approaches were to be mechanical altered diet (a diet that consist of food that are easy to swallow and chew). had a gastronomy (a surgical procedure that creates an opening in the stomach to help with feeding and administering medication) for nutrition. During an interview on 11/10/2024 at 9:17 a.m. with Resident 12, Resident 12 stated my family brings me food from home. Resident 12 stated his family has been bringing him food for the last few weeks. During a concurrent interview and record review on 11/10/2024 at 9:25 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the family for Resident 12 brought food from home. LVN 2 stated she had told the Charge Nurse about the family bringing in food. LVN 2 reviewed the progress notes (a crucial part of a patient's medical record and are used to document a patient's care and recovery) there were no documentation addressing family bringing food to Resident 12. LVN 2 stated there should have been a note written in the progress notes about the food brought in by family. LVN 2 stated it was important to document and keep track of what the resident is doing just in case Resident 12 had an allergic reaction and in case he was to choke. During an interview on 11/10/2024 at 11:14 a.m. with Registered Nurse (RN) 1, RN 1 stated the progress notes should have been updated when the family had brought food from home. RN 1 stated the progress notes should have explained to the family type of diet and education to the resident to prevent choking. RN 1 stated it was important to communicate to the next shift through the progress notes to make sure the staff is aware of the choking risk that outside food would pose. During a review of facility's policy and procedure (P&P), Charting, Guidelines, dated 2/2021, the P&P indicated to provide for appropriate documentation in the health record. The P&P indicated all documentation will be completed as required for each shift. The P&P indicated all charting should be done as soon as possible after a given event. The P&P indicated document normal findings as well as abnormal findings as this shows that the resident was being assessed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Complete the Revised McGeer Criteria (minimum set of signs and symptoms which when met, indicate that a resident likely has an infection and that an antibiotic (a drug used to treat infections caused by bacteria) might be needed) for Infection Surveillance Checklist for two out of two sampled residents (Resident 17 and 20). This deficient practice had the potential to result in the development of multi-drug resistant organisms ([MDRO] - microorganisms, predominantly bacteria that are resistant to one or more classes of antimicrobial agents) from inappropriate antibiotic use. Findings: During a review of Resident 17's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 17 was admitted to the facility on [DATE]. Resident 17's diagnoses included pneumonia (an infection/inflammation in the lungs) and respiratory failure (a serious condition that makes it difficult to breathe on your own). During a review of Resident 17's Minimum Data Set ([MDS] - a federally mandated resident assessment tool), dated 10/30/2024, the MDS indicated, Resident 17's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 17 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 17's Physician Order, dated 10/9/2024, the Physician Order indicated, Resident 17 had an order to give erythromycin ethyl succinate (an antibiotic used to treat many different types of infection caused by bacteria) every 12 hours for 14 days for treatment of high gastric residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding). During a review of Resident 20's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated, Resident 20 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 20's diagnoses included chronic respiratory failure (a serious condition that makes it difficult to breathe on your own) with tracheostomy (a surgical procedure that creates an opening in the neck into the windpipe to help a person breathe) and gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 20's Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 7/7/2024, the MDS indicated, Resident 20's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 20 was dependent (helper does all of the effort) on staff with oral hygiene, toileting hygiene, and personal hygiene. During a review of Resident 20's Physician Orders (a document containing active physician order), dated 11/10/2024, indicated Resident 20 had an active order of Zosyn (a combination of two antibiotics used to treat many different infections caused by bacteria) 3.375 grams ([gm] - metric unit of measurement, used for medication dosage and/or amount) intravenously ([IV] into or within a vein) every 6 hours and vancomycin 1 gm IV every 8 hours for treatment of leukocytosis (a condition where there is an abnormally high number of white blood cells in the body). During a concurrent interview and record review on 11/9/2024 at 5:30 p.m., with the Infection Preventionist Nurse (IPN), Resident 17 and Resident 20's clinical records were reviewed. The IPN stated she did not complete and fill out Resident 17 and Resident 20's Revised McGeer Criteria for Infection Surveillance Checklist form within 3 days after the antibiotic was ordered. The IPN stated the Revised McGeer Criteria for Infection Surveillance Checklist form was a guide to determine if the resident meets the criteria for the use of antibiotic as prescribed by a physician. The IPN stated she could not validate Resident 17 and Resident 20's antibiotics were appropriate since she did not complete the Revised McGeer Criteria for Infection Surveillance Checklist form. The IPN stated one of her functions being in charge of the antibiotic stewardship (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse event s associated with antibiotic use) was to review the antibiotic order, the duration and the laboratory results. During an interview on 11/9/2024 at 5:42 p.m., with the Director of Pharmacy (DOP), the DOP stated it was a standard of practice for all licensed nurses to complete the Revised Mcgeer Criteria for Infection Surveillance Checklist Form when the physician prescribed antibiotic for residents. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 9/2024, the P&P indicated, Facility wide surveillance will be performed to identify opportunities to prevent and/or reduce the rate in infection in our residents, employees and visitors. During a review of the facility's P&P titled, Antimicrobial Stewardship, dated 6/2023, the P&P indicated, To optimize safe and appropriate use of antibiotics, enhance clinical outcomes while minimizing unintended consequences of antimicrobial and reduce healthcare costs without adversely affecting quality of care. The P&P also indicated the antibiotic stewardship program implements at least two evidence-based guidelines to improve antibiotic use for the most common indications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure RNA services were performed daily for five out of six sampled residents (Resident 5, Resident 8, Resident 21, Resident 22 and Resident 23). This deficient practice had the potential to decline in functional mobility and contractures. Findings: a. During a review of Resident 5's face sheet, the face sheet indicated Resident 5 was admitted to the facility on [DATE]. The face sheet indicated Resident 5 had diagnoses that included chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly), hypocapnia (a decrease of carbon dioxide in the blood) and hypercapnia (a increase of carbon dioxide in the blood). During a review of the Resident's 5 Minimum Date Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 5's cognitive skills were severely impaired. The MDS also indicated Resident 5 was dependent on staff member with toileting hygiene, showering and upper/lower body dressing. b. During a review of Resident 8's face sheet, the face sheet indicated Resident 8 was admitted to the facility on [DATE]. The face sheet indicated Resident 8 had diagnoses that included cellulitis (a bacterial infection that affects the deep layers of the skin and underlying tissues), multi-compartment hemorrhage (an intracranial hemorrhage that affects multiple compartments of the brain) and acute respiratory failure (results from inadequate gas exchange by the respiratory system). During a review of the Resident 8's Minimum Date Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 8's cognitive skills were severely impaired. The MDS also indicated Resident 8 was dependent on staff member with toileting hygiene, showering and upper/lower body dressing. c. During a review of Resident 21's face sheet, the face sheet indicated Resident 21 was admitted to the facility on [DATE]. The face sheet indicated Resident 21 had diagnoses that included acute hypoxic respiratory failure (the lungs are not adequately exchanging oxygen into the bloodstream). During a review of the Resident 21's Minimum Date Set (MDS-?), the MDS indicated Resident 21's cognitive skills were severely impaired. The MDS also indicated Resident 21 was dependent on staff member with toileting hygiene, showering and upper/lower body dressing. d. During a review of Resident 22's face sheet, the face sheet indicated Resident 22 was admitted to the facility on [DATE]. The face sheet indicated Resident 22 had diagnoses that included pneumonia (an infection that inflames the air sacs in one or both lungs), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), respiratory distress (a condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen), and congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs). During a review of the Resident's 22 Minimum Date Set (MDS-?), the MDS indicated Resident 22's cognitive skills were severely impaired. The MDS also indicated Resident 22 was dependent on staff member with toileting hygiene, showering and upper/lower body dressing. e. During a review of Resident 23's face sheet, the face sheet indicated Resident 23 was admitted to the facility on [DATE] The face sheet indicated Resident 2 had diagnoses that included acute chronic respiratory failure (results from inadequate gas exchange by the respiratory system). During a review of the Resident's 23 Minimum Date Set (MDS-?), the MDS indicated Resident 23's cognitive skills were severely impaired. The MDS also indicated Resident 23 was dependent on staff member with toileting hygiene, showering and upper/lower body dressing. During a review of Resident 5's Restorative Nurse Assistant (RNA- assists the patient in performing tasks that restore or maintain physical function as directed by the established care plan) treatment record, dated October 2024, Resident 5's treatment record indicated to Apply bilateral hand rolls, right elbow and bilateral knee splints, 2 hours on, 2 hours off daily. The treatment record indicated treatment was completed 5 times a week instead of daily. During a review of Resident 8 and 21's RNA treatment record, dated October 2024, Resident 8's treatment record indicated to Apply bilateral PRAFOS, 2 hours on, 2 hours off daily. and Apply bilateral resting and splints 2 hours on, 2 hours off daily. The treatment record indicated treatment was completed 5 times a week instead of daily. During a review of Resident 22's RNA physician order, the physician order indicated, RNA to do PROM exercises to bilateral upper and lower extremities and AROM right upper extremities daily. There was no treatment record of RNA services for Resident 22. During a review of Resident 23's RNA treatment record, dated November 2024, indicated, Apply bilateral hand rolls, 2 hours on, 2 hours off daily and apply bilateral knee splints and bilateral PRAFO, 2 hours on, 2 hours off daily. During a concurrent interview and record review, on 11/10/2024 at 11:30 a.m., with the Director of Nursing (DON), the DON stated residents received RNA services five days a week. The DON stated all RNA services were to be followed per physician orders. The DON stated there were no RNA services on the weekends. The DON acknowledged Resident 5, Resident 8, Resident 21, Resident 22 and Resident 23's RNA physician order and stated all orders indicated RNA services were to be performed daily. The DON stated the risk of not providing RNA services per physician orders could result in wrist/foot drop and further contractures. A review of the facility's policy and procedures, titled Restorative Nursing Program (RNA), revised 8/2024, indicated, The RNA will carry out the treatment programs according to the written plan of care and documents daily in the Restorative Nursing Documentation record.

Based on observation, interview and record review, the facility failed to ensure that food items were labeled and expired food was not stored in the kitchen accessible to be used in preparing foods for one of 22 sampled residents (Resident 17) on the Sub-Acute unit. This practice had the potential to result in the residents ingesting expired food and can result in foodborne illnesses. Findings: During the initial tour of the kitchen, on 11/18/23 at 10:15 a.m., with Dietary Staff A, Refrigerator 9 was observed to have mandarin oranges in a clear storage container with a use by date of 11/17/23, two turkey sandwiches with a used by date of 11/17/23. Also, noted in Refrigerator 9, jalapenos were stored in a small, black storage container with a use-by date of 11/15/23, feta cheese and shredded carrots was separated in two clear storage containers with no labels noted. The technician proceeded to throw away the expired and unlabeled food. During an observation of walk-in refrigerator # 4, on 11/18/23 at 10:30 a.m. with Dietary Staff A, refrigerator 4 was noted to have expired Romaine lettuce with a use-by date of 11/17/23. DT stated romaine lettuce should have been discarded on 11/17/23 by the evening shift dietary staff. DT proceeded to discard romaine lettuce. During an observation of walk-in refrigerator 2, on 11/18/23 at 10:35 a.m. with Dietary Staff A, refrigerator 2 was noted to have a thickened unflavored water for residents with dysphagia (difficulty swallowing foods or liquids). The 18 sealed, individual cups of thickened unflavored water were noted to have a use-by date of 11/13/23. During a concurrent observation and interview, on 11/17/23 at 10:50 a.m., with Dietary Staff A, in the dry storage area, 5 large cans of spinach artichoke indicated a use-by date of 9/27/23. DT stated the risk of having expired food can cause residents to become sick from possibly spoiled food. During concurrent observation and interview, on 11/17/23 at 11:00 a.m., with Dietary Staff A, walk in refrigerator 3 was noted to have white shredded cheese in a clear storage container with a use by date of 11/17/23. Observation also included no label on an opened heavy cream carton. Dietary Staff A stated the heavy cream carton should be labeled. Dietary Staff A further stated the risk of not having items labeled can cause confusion on knowing when the carton was open or whether the contents are expired or not. A review of the facility policy and procedures, titled Infection Control-Food Storage, dated on 11/2019, indicated the following: 1. All containers of open food in the refrigerator are labeled with product name, dated and covered or wrapped. 2. Supplies are rotated so that food placed in storage first is used before new supplies are used. This practice is termed First In, First Out (FIFO). All dated items are pulled if not used before the pull dates. 3. Daily checks are made by the Chef/Food Production Manager or designee of the inventory of leftover foods to ensure that these foods can either be incorporated into the menu or discarded.

Based on interview and record review, the facility failed to follow facility's policies and patient's care plan to prevent further damage to Patient 1's wounds at bilateral buttocks. This deficient practice had the potential to result in Patient 1's bilateral buttocks wounds progressing to unstageable wound. Findings: On May 2, 2023, at 8:05 AM, during initial tour of the facility with Wound Care Nurse (WCN), Patient 1 was observed lying in bed with ventilator (breathing machine) connected to tracheostomy (a hole in the windpipe make to relieve obstruction to breathing) in patient's neck. Patient 1 was observed with a wound to his right ear. Concurrently, WNC stated Patient 1's bilateral buttocks wounds were identified since March 7, 2023, as moisture-related-skin damage and progressed to unstageable with the treatment changed from barrier ointment to calcium alginate with honey. On May 2, 2023, at 8:21 AM, during concurrent interview with Quality Assurance Nurse (QA) and record review of Patient 1's face sheet, dated August 19, 2022, Patiewnt 1's Facesheet indicated patient was admitted to the facility with a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own) and pneumonia (lung infection). A review of Patient 1's history and physical (H&P), dated August 19, 2022, the H&P indicated patient was transferred from another facility with a history of COVID-19 infection. The H&P further indicated Patient 1 was dependent on a breathing machine and had a tracheostomy placed for breathing and a gastrostomy tube (G-tube - a tube inserted through the belly that brings nutrition directly into the stomach) for feedings. A review of Patient 1's initial assessment, dated August 19, 2022, indicated the following: 1. Activities of daily living - patient required extensive assistance for all cares. 2. Level of consciousness - patient was awake, but cannot understand others, is unable to make self-understood, and was severely impaired for decision-making, and was non-verbal. 3. Gastrointestinal - patient had a g-tube on abdomen, for tube feedings. 4. Genitourinary - patient was incontinent. 5. Musculoskeletal - patient was non-ambulatory. 6. Integumentary - Braden score was 12 and was a risk for skin injury. On May 2, 2023, at 9:14 AM, during concurrent interview with WCN and review of Patient 1's Care Plan for patient's bilateral buttocks, dated March 7, 2023, interventions included to turn and reposition every 2 hours for comfort and circulation. On May 2, 2023, at 8:50 AM, during concurrent interview with WCN and record review of Patient 1's turning documentation, dated April 8, 2023, WCN stated patient was not repositioned every 2 hours, per facility policy and per patient's care plan, from 4 PM to 8 PM, because patient was on right side for four hours. Concurrently, during record review of Patient 1's turning documentation, dated April 15, 2023, WCN stated patient was not repositioned every 2 hours, per facility policy and per patient's care plan, from 2 PM to 6 PM, because patient was on left side from 2 PM to 6 PM. A review of Patient 1's Treatments, dated April 19, 2023 and April 20, 2023, indicated there was no documentation of daily skin treatment done for patient's sacral area to cleanse with normal saline, pat dry, apply Thera-honey with calcium alginate, and cover with dry dressing. A review of Patient 1's Surgical Consult, dated April 11, 2022, indicated the following: 1. Reason for visit - to manage patient's wounds at the bilateral buttocks. 2. Etiology - moisture-associated skin damage (MASD - caused by prolonged exposure to various sources of moisture, including urine or stool, and characterized by inflammation of the skin without erosion). 3. Lesion description - redness with areas of denuded skin and dead tissue is very concerning for a Kennedy terminal ulcer. 4. Treatment - continue protective barrier cream twice daily and after each incontinence, turn per facility protocol, and offloading. A review of Patient 1's Surgical Consult, dated April 18, 2023, indicated the following: 1. Reason for visit - to manage patient's wounds at the sacro-coccyx area extending to the right buttocks. 2. Etiology - pressure injury, unstageable. 3. Lesion description - serous exudate, wound edge with redness and dead tissue. 4. Treatment - dry dressing with calcium alginate with honey and protective skin barrier to peri-wound daily and after each incontinence, off-loading, and turn per facility protocol. A review of facility's Pressure Injury Assessment, Management, Preventions and Treatment Protocol, dated April 2023, indicated the following: 1. All patients will have skin integrity assessed during admission, tranfer from another department or unit, and every shift. 2. A risk assessment will be done using the Braden Scale for patients greater than eight years old. 3. Braden protocols included frequent turning - every two hours, and maximal remobilization. 4. Upon discovery of a pressure injury, the nurse will notify provider, wound care nurse, immediate supervisor, patient and/or family, initiate incident event report, and complete the EHR/photographic wound documentation. 5. Initiate a care plan specific to patient. 6. Implement Braden protocol and repositioning every two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 12) Preadmission Screening and Resident Review ([PASRR] a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes for long term care) Level 1 screening was completed after Resident 12's mental disorder was identified on 9/18/2022. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 12. Findings: During a review of Resident 12's admission Record, the admission record indicated Resident 12 was admitted to the facility on [DATE]. During a review of Resident 12's History and Physical (H&P) dated 3/25/2022, the H&P indicated Resident 12's chief complaint was acute respiratory failure (serious condition that makes it difficult to breath). During a review of Resident 12's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 7/6/2023, the MDS indicated Resident 12's cognitive (the ability to understand or to be understood by others) skills for daily decision making was moderately impaired. The MDS indicated the resident was totally dependent on staff with activities of daily living (eating, dressing, bed mobility, toilet use, and personal hygiene). During a review of Resident 12's PASRR Level 1 Screening, dated 3/24/2022, the PASRR indicated Resident 12 did not have a diagnosed mental disorder. This document was the only PASRR screening completed for Resident 12. During a review of Resident 12's Psychiatric (specialist for mental conditions) Consultation Note, dated 9/18/2022, the note indicated Resident 12 had paranoid schizophrenia (mental health condition that makes it difficult to interpret reality). The note indicated Resident 12 was to continue receiving Zyprexa 2.5 milligrams (medication to treat mental/ mood conditions). During an interview with the Director of Case Management (DCM) on 1/25/2023 at 3:01 p.m. the DCM stated if Resident 12 had a newly identified diagnosis of mental disorder, then the resident should have had a repeat PASRR Level 1 screening. The DCM stated a repeat screening for Resident 12 was not completed. During an interview with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) on 1/26/2023 on 2:37 p.m., the MDSC stated the PASRR should be done correctly to identify proper management. The DON stated moving forward, the DON would be completing the PASRR for the residents to ensure accuracy and timely submission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to remove an intravenous (IV, within the vein) catheter saline lock (a thin plastic tube that is threaded into a vein, flushed with saline, and then capped off for later use) that was inserted more than 72 hours for one of six sampled residents (Resident 10). This deficient practice increased Resident 10's potential for developing an infection. Findings: During a record review of Resident 10's face sheet, the face sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (occurs when the respiratory system cannot adequately provide oxygen to the body), anoxic brain damage (harm to the brain due to lack of oxygen), and dependence on respirator ventilator (the need for a machine to breathe for the person). During a record review of Resident 10's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/11/2023, the MDS indicated Resident 10 was rarely able to be understood and rarely understood others. The MDS indicated Resident 10 was completely dependent on staff for ADLs. During a record review of Resident 10's IV Inquiry, dated 6/22/2021 through 1/16/2023, the record indicated Resident 10 had a 20-gauge venous saline lock started on the left wrist on 1/16/2023. During a record review of Resident 10's Progress Note Inquiry, dated 1/16/2023, the record indicated a new order per Medical Doctor for type and screen (blood test to determine the appropriate blood for a blood transfusion) and one unit of packed red blood cells (PRBC). The record indicated the order was noted and carried out. During an observation on 1/24/2023, at 1:01 p.m., in the resident's room, Resident 10 had a saline lock on the left wrist. The IV site was not labeled with the insertion date. During an interview on 1/24/2023, at 1:06 p.m., with Registered Nurse (RN) 1, RN 1 stated a saline lock was changed every three days. RN 1 stated Resident 10 had a saline lock inserted on 1/16/2023 for a blood transfusion. RN 1 went to Resident 10's room and verified that there was no insertion date on the saline lock. RN 1 stated Resident 10 did not need the saline lock for anything else and it should have been removed after the blood transfusion was completed. RN 1 stated the saline lock should have been removed at least by 1/19/2023, because it may lead to the resident developing an infection. During an interview on 1/26/23, at 2:25 p.m., with the Director of Nursing (DON), the DON stated if a resident had a saline lock for the purpose of receiving a blood transfusion, the saline lock should be removed after the blood transfusion was completed. The DON stated a saline lock was changed every 72 hours to prevent an infection from happening. The DON stated a saline lock that was inserted on 1/16/2023, should have been removed on 1/19/2023. During a record review of the facility's policy and procedure (P&P), titled Intravenous Therapy Management, dated 5/2/2019, the P&P indicated, An IV site must be replaced every 72 hours, unless the patient has no other available sites for IVs. In this case an order from that physician must be obtained to leave the IV site intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide tracheal (windpipe) suctioning (method of removing mucus from the lungs) for one of three sampled residents (Resident 17), consistent with facility policy and procedures (P&P) and physician orders. This deficient practice had the potential to result in chest infections from secretions left in the tracheal tube. Findings: During a record review of Resident 17's admission Record (face sheet), the face sheet indicated Resident 17 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (serious condition that makes it difficult to breath). During a record review of Resident 17's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/27/2022, the MDS indicated Resident 17 was rarely able to be understood and rarely understood others. The MDS indicated Resident 17 was totally dependent on staff with activities of daily living (eating, dressing, bed mobility, toilet use, and personal hygiene). During a record review of Resident 17's physician orders for the month of January 2023, the orders indicated Resident 17 had a tracheostomy (a surgically made hole through the front of the neck into the trachea, in which a small tube is placed into the hole to keep it open for breathing). The orders indicated starting on 11/14/2021, to suction Resident 17's tracheal secretions every two hours and as needed. During a record review of Resident 17's record titled Treatments, dated January 2023, the record indicated starting on 11/14/2021, to suction Resident 17's tracheal secretions every two hours and as needed. The record indicated no suctioning was documented by the licensed nurses for Resident 17 from 1/1/2023 to 1/26/2023. During a record review of Resident 17's Respiratory Therapist document titled, Daily Assessment Inquiry, dated from 1/1/2023 to 1/26/2023, the document indicated Resident 17 was not suctioned every two hours. During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 1 on 1/24/2023 at 9:25 a.m., Resident 17 was observed with a productive cough (cough that brings up mucus or another fluid from the respiratory tract). Resident 17's face was red and the resident appeared uncomfortable. Resident 17 had thick whitish secretions accumulating in the tracheal tube connected to the resident's tracheostomy. Resident 17's coughing was audible from the hallway outside the resident's room. LVN 1 stated Resident 17's tracheostomy tube should not be filled with secretions. LVN 1 stated the tracheostomy tube should be kept clean and clear, and that the resident needed suctioning. LVN 1 stated Resident 17 could aspirate (to breath in) and LVN 1 stated he would suction the resident himself. During an interview with the Respiratory Therapist (RT) and concurrent record review of Resident 17's medical records on 1/26/2023 at 2:13 p.m., the RT stated Resident 17's physician ordered suctioning every two hours and as needed. The RT stated suctioning for Resident 17 was not documented every two hours. The RT stated if it was not documented then it was not done. The RT stated suctioning was to prevent accumulation of secretions. During an interview with the Minimum Data Set Coordinator (MDSC) on 1/26/2023 on at 2:37 p.m., the MDSC stated the residents should be suctioned as ordered by the physician. The MDSC stated if suctioning Resident 17 was not documented in the flowsheet then it was not completed. During a record review of the facility's policy and procedure (P&P) titled, Tracheostomy suctioning using a single use catheter, effective 5/5/2021, the P&P indicated all residents with tracheostomies will be suctioned every two hours and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two resident's (Resident 72) medication was discarded appropriately after the resident was discharged from the facility. This deficient practice had the potential to result in a medication error by inadvertent use of the wrong resident's medication. Findings: During a record review of Resident 72's admission record (face sheet), the face sheet indicated Resident 72 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes (an impairment in the way the body regulates and uses sugar [glucose] as a fuel). The face sheet indicated Resident 72 was discharged from the facility on 8/7/2022. During a record review of Resident 72's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 5/21/2022, the MDS indicated Resident 72's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired. The MDS indicated Resident 72 was totally dependent on staff with activities of daily living (eating, dressing, bed mobility, toilet use, and personal hygiene). During a review of Resident 72's Orders Report, dated 5/9/2022, the report indicated an order for Dextrose 50 percent (%) (medication given for low blood glucose [sugar]) 50 milliliters (ml, unit of measurement) as needed. During an observation and inspection of Medication Cart 1 with Licensed Vocational Nurse (LVN) 1 on 1/24/2023 at 11:01 a.m., Resident 72's Dextrose 50% was observed in the medication cart. LVN 1 stated Resident 72's medication should not have been stored in the medication cart because the resident was discharged from the facility. LVN 1 stated Resident 72's medication should have been returned to the pharmacy so the licensed nurses could not use it for another resident. During an interview with the Director of Nursing (DON) on 1/26/2023 at 2:27 p.m. the DON stated discontinued medication of discharged residents were stored in a bin and sent to the pharmacy to prevent medication errors. During a record review of the facility's policies and procedure (P&P) titled, Drugs returned to Pharmacy, dated 2/2021, the P&P indicated all discontinued medications were to be returned to the pharmacy as soon as possible. The P&P indicated upon discharge, all remaining medications were to be returned. The P&P indicated all discontinued medications must be placed in the Discontinued Medications bin in the medication room immediately. The P&P indicated the following steps: l. Registered Nurse (RN) shall place medication(s) in a plastic bag (provided by the pharmacy) with the patient label (provide in every cassette). 2. This baggy, then shall be placed in the bin marked Discontinued Medications. 3. Pharmacy personnel shall make hourly rounds and pick up any items in this bin for recycling or destruction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents' (Resident 16 and 17) informed consents were complete and accurate in accordance with acceptable professional standards. This deficient practice resulted in incomplete legal documents that could render the consent void. Findings: a. During a record review of Resident 16's admission record (face sheet), the face sheet indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (serious condition that makes it difficult to breath). During a record review of Resident 16's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/17/2022, the MDS indicated Resident 16's cognitive (the ability to understand or to be understood by others) skills for daily decision making was severely impaired. The MDS indicated the resident was totally dependent on staff with activities of daily living (eating, dressing, bed mobility, toilet use, and personal hygiene). b. During a record review of Resident 17's face sheet, the face sheet indicated Resident 17 was admitted to the facility on [DATE] with diagnoses that included respiratory failure. During a record review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 was rarely able to be understood and rarely understood others. The MDS indicated Resident 17 was totally dependent on staff with activities of daily living. During a record review of Resident 16 and 17's COVID-19 (a very contagious respiratory illness) vaccination (medication to prevent severe illness) vaccination consent forms, the consent forms indicated the reviewer's (person obtaining the consent from the resident representatives) name and signature and had no signature from the resident's and/or their responsible parties. During an interview with the Infection Preventionist (IP) Nurse on 1/24/2023 at 3:16 p.m., the IP stated Resident 16 and 17's COVID-19 vaccination consent forms were incomplete and it was not acceptable. The IP stated the facility did not know who obtained the consent from Residents 16 and 17's family. During an interview with the Medical records Director (MRD) on 1/24/2023 at 3:16 p.m., the MRD stated Resident 16 and 17's COVID-19 vaccination consent forms were incomplete and it was not acceptable. The MRD stated currently there was no process of identifying and resolving problematic documents because the department just scans the documents in order to upload to the electronic form. During a record review of the facility's policies and procedure (P&P) titled, Informed Consent, effective 9/2021, the P&P indicated: a. The witness (verifier) should legibly print his or her name, sign the document and note the date and time the witness signed the document. b. Witnesses to a patient's (or representative's) signature must always sign the form in the space allocated. Admitting clerks, registered nurses; nurse's aides, unit secretaries, or others of similar responsibility may act as witnesses. During a record review of the facility's P&P titled, Entries in the Medical Record, effective 7/2019, the P&P indicated entries in the medical record needed to be made only by authorized individuals and were signed, dated and timed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their policy and procedure for Antibiotic Stewardship Program for one of 12 sampled residents (Resident 15). This deficient practice had the potential for residents to develop antibiotic resistance (happens when germs like bacteria develop the ability to defeat the drugs designed to kill them, rendering the treatment ineffective) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 15's History and Physical (H&P), the H&P indicated Resident 15 was admitted to the facility on [DATE] for severe anemia (lack of healthy blood cells) and gastrointestinal (GI) bleeding (a symptom of many digestive system disorders, including reflux, ulcers and cancer) with a medical history of ventilator dependent, respiratory failure, status post tracheostomy (a surgically created hole [stoma] in your windpipe [trachea] that provides an alternative airway for breathing), and percutaneous endoscopic gastrostomy (PEG, placement of a feeding tube through the skin and the stomach wall), and infected decubitus ulcers (break in the skin caused by pressure, regardless of the cause, can become infected). During a review of Resident 15's Physician Progress Note, dated 1/22/2023, the note indicated Resident 15 had right lower lobe aspiration pneumonia (infection of the lungs). The note indicated Resident 15 received Sulfamethoxazole-Trimethoprim (antibiotic used to treat bacterial infections) from 12/24/2022 to 12/31/2022. During a review of Resident 15's Physician Progress Note, dated 1/23/2023, the note indicated Resident 15 was prescribed Ceftriaxone (used to treat bacterial infections in many different parts of the body) 1 gram (g, unit of measurement), at a rate of 100 milliliters per hour (ml/hr), every 24 hours, starting on 1/23/23 at 2 p.m. The note also indicated Resident 15 had a history of frequent pneumonia. During an interview with the Infection Preventionist (IP) Nurse on 1/25/2023 at 8:23 a.m., the IP stated, There is no antibiotic stewardship program at this time. The IP stated she was recently hired in November 2022, and was still receiving training in her infection prevention and control (IPC) duties. During a record review of the IP's certificates for infection control and prevention, the IP completed an Education for the Prevention of Infection (EPI) Intensive course organized by the Association for Professionals in Infection Control and Epidemiology (APIC) on 11/28/2021. The IP also completed the Centers for Disease Control and Prevention (CDC): Nursing Home Infection Preventionist Training Course on 1/21/2023. During an interview with the Director of Pharmacy (DP) on 1/25/2023 at 10:10 a.m., the DP stated, The facility does not have an antibiotic stewardship program at this time. The DP further stated, There is a Subject Matter Expert (SME) from corporate assisting me with implementing and adjusting the pharmacy review processes. I will be presenting pharmacy performance indicator data to the Quality Council this Friday (1/27/2023). During an interview with the Pharmacist (DOP) on 1/25/2023 at 12:32 p.m., the DOP stated she completed a monthly medication regimen on all the residents once every 4 weeks. The DOP stated if the practitioner orders antibiotics, the DOP checked the renal function protocol to see the frequency and allergies. The DOP stated she followed up on if labs and empiric therapy (treatment given based on experience, without precise knowledge of the cause or nature of a disorder) were ordered. The DOP stated no McGeer's criteria (guidelines used to retrospectively assess antibiotic initiation appropriateness) was used for infections in collaboration with Nursing or the IP at this time. During a review of the facility's policy and procedure (P&P) titled, Antimicrobial Stewardship, approved 3/2021,the indicated the purpose was to optimize safe and appropriate use of antibiotics, enhance clinical outcomes while minimizing unintended consequences of antimicrobial (e.g. toxicity, resistance), and reduce healthcare costs without adversely affecting quality of care. The P&P indicated, Prospective audit of antimicrobial use with direct interaction and feedback to prescriber, performed by Infectious Diseases Physician or Clinical Pharmacist, can result in reduced inappropriate use of antimicrobials. During a review of the facility's Subacute Infection Prevention Plan, approved 5/2021, the plan indicated the purpose was to ensure policies and procedures follow current infection prevention and control guidelines and recommendations. The plan indicated reducing healthcare onset of multi-drug-resistant organisms (MDROs) by identifying infections through a review of cultures screenings, clinical records, antibiotics and readmissions using the McGeer/CDC definitions of healthcare onset.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a resident care plan titled, Range of Motion(ROM)/ Joint Mobility (how far and in what direction a person can move a joint or muscle), for four of four sampled residents (Resident's 21, 19, 16, and 10). This deficient practice had the potential to result in decreased ROM which could adversely affect Resident 21, 19, 16, and 10's quality of life. Findings: a. During a record review of Resident 21's admission Record (face sheet), the face sheet indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (serious condition that makes it difficult to breath). During a record review of Resident 21's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/14/2022, the MDS indicated Resident 21's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated Resident 21 was completely dependent on staff for activities of daily living ([ADLs] eating, dressing, bed mobility, toilet use, and personal hygiene). During a record review of Resident 21's Physician Order, dated 9/1/2022, the order to provide ROM to extremities daily by restorative nurse assistant (RNA). During a record review of Resident 21's care plan titled, ROM/ Joint Mobility, last revised on 12/13/2022, the care plan indicated RNA to do ROM exercises to left upper extremity (LUE), right upper extremity (RUE), left lower extremity (LLE), and right lower extremity (RLE) five times a week. During a record review of Resident 21's Restorative Care Flow Sheet, dated 1/2023, the flow sheet indicated Resident 21 received passive ROM (achieved when an outside force such as the RNA exclusively causes movement of a joint) a total of 8 times in 21 days. b. During a record review of Resident 19's face sheet, the face sheet indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included respiratory failure. During a record review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was rarely able to be understood and rarely understood others. The MDS indicated the resident was completely dependent on staff for ADLs. During a record review of Resident 19's Physician's Order, the order indicated starting on 5/27/2022, to provide ROM to Resident 19's extremities daily by RNA. During a record review of Resident 19's care plan titled, ROM/ Joint Mobility, last revised on 12/4/2022, the care plan indicated RNA to provide ROM exercises to the resident's LUE, RUE, LLE, and RLE five times a week. During a record review of Resident 19's Restorative Care Flow Sheet, dated 1/2023, the flow sheet indicated Resident 19 received passive and active-assistive (occurs when resident able to move injured body part but may require some help to move to ensure further injury or damage does not occur) ROM a total of seven times in 21 days. c. During a record review of Resident 16's face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included intracranial hemorrhage (bleeding within the skull) and respiratory failure. During a record review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 was rarely able to be understood and sometimes understood others. The MDS indicated the resident was completely dependent on staff for ADLs. During a record review of Resident 16's Physician's Order, the order indicated starting on 10/3/2021, RNA to provide ROM to extremities daily. During a record review of Resident 16's care plan titled, ROM/ Joint Mobility, last revised on 1/17/2023, the care plan indicated RNA to provide ROM to the resident's LUE, RUE, LLE, and RLE. During a record review of Resident 16's Restorative Care Flow Sheet, dated 1/2023, the flow sheet indicated Resident 16 received passive and active-assistive ROM (occurs when resident able to move injured body part but may require some help to move to ensure further injury or damage does not occur) a total of seven times in 21 days. The flow sheet indicated eight missed opportunities of RNA exercises. d. During a record review of Resident 10's face sheet, the face sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included respiratory failure, anoxic brain damage (harm to the brain due to lack of oxygen), and dependence on respirator ventilator (the need for a machine to breathe for the person). During a record review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was rarely able to be understood and rarely understood others. The MDS indicated the resident was completely dependent on staff for ADLs. During a record review of Resident 10's Physician's Order, the order indicated starting on 6/23/2015, RNA to provide passive ROM to all extremities daily. The order indicated starting on 4/1/2021, to apply bilateral hand splints two hours on, two hours off daily. During a record review of Resident 10's care plan titled, ROM/ Joint Mobility, last revised on 1/11/2023, the care plan indicated RNA to provide ROM exercises to the resident's LUE, RUE, LLE, and RLE five times a week. The care plan indicated RNA to don (apply) on/off a left and right handroll splint(s) no more than six hours/day as tolerated. During a record review of Resident 10's Restorative Care Flow Sheet, dated 1/2023, the flowsheet indicated Resident 10 received passive ROM for a total of seven times in 21 days. The flowsheet indicated eight missed opportunities of RNA exercises. During a record review of Resident 10's Treatments flowsheet, dated 1/2023, the flowsheet indicated Resident 10 had the elbow splint/hand rolls to bilateral hands applied for a total of seven times in 21 days. The flowsheet indicated 14 missed opportunities of applying the splint/hand rolls to the resident. During an interview with the Physical therapist (PT) on 1/25/2023 at 2:41 p.m., the PT stated following the physician's orders for RNA treatment was very important for residents to maintain or improve ROM. During an interview with the Minimum Data Set Coordinator (MDSC) on 1/26/2023 on 2:37 p.m., the MDSC stated the residents' ROM and mobility care plans implemented by the RNA should have been followed as written. The MDSC stated after reviewing the RNA flow sheets (1/2023) for all the residents on the unit, from 1/1/2023 to 1/21/2023, none of the residents received ROM exercises five times a week for three weeks from the RNA as instructed in the residents' care plans. The MDSC stated if it was not documented in the flowsheet then it was not completed. During a record review of the facility's policy and procedure (P&P) titled, Assessment and Care Planning, effective 5/2021, the P&P indicated a comprehensive resident care plan will be formulated to allow the resident to reach his/her highest practicable level of physical, mental, and psychosocial functioning. During a review of P&P titled, Restorative Nursing Program (RNA), effective 5/2021, the P&P indicated the following: 1. The registered nurse (RN) will develop a written plan of care that includes problems, measurable goals, and approaches, for any resident on Restorative Nursing Program. 2. The RNA will carry out the treatment programs according to the care plan and documents daily on the Restorative Nursing Documentation Record. 3. The Director of Nursing (DON) or RN Designee will oversee the implementation of the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement the physician orders and care plans addressing range of motion (ROM, how far and in what direction a person can move a joint or muscle) for four of four sampled residents (Resident's 21, 19, 16, and 10). These deficient practices had the potential to result in a decrease of range of motion which could adversely affect Residents 21, 18, 16, and 10's quality of life. Findings: a. During a record review of Resident 21's admission Record (face sheet), the face sheet indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure (serious condition that makes it difficult to breath). During a record review of Resident 21's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/14/2022, the MDS indicated Resident 21's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated the resident was completely dependent on staff for activities of daily living ([ADLs] eating, dressing, bed mobility, toilet use, and personal hygiene). During a record review of Resident 21's Physician's Order, the order indicated on 9/1/2022, Restorative Nurse Assistant (RNA) to provide ROM to the resident's extremities daily. During a record review of Resident 21's care plan titled, ROM/ Joint Mobility, last revised on 12/13/2022, the care plan indicated RNA to provide ROM exercises to Resident 21's left upper extremity (LUE), right upper extremity (RUE), left lower extremity (LLE), and right lower extremity (RLE) five times a week. During a record review of Resident 21's Restorative Care Flow Sheet, for the month of January 2023, the flow sheet indicated Resident 21 received passive ROM (achieved when an outside force such as the RNA exclusively causes movement of a joint) to the total body for a total of 8 times in 21 days. The flow sheet indicated 7 missed opportunities of RNA exercises. b. During a record review of Resident 19's admission record (face sheet), the face sheet indicated Resident 19 was admitted to the facility on [DATE] with diagnoses that included respiratory failure. During a record review of Resident 19's MDS, dated [DATE], the MDS indicated Resident 19 was rarely able to be understood and rarely understood others. The MDS indicated Resident 19 was completely dependent on staff for ADLs. During a record review of Resident 19's Physician's Order, the orders indicated starting on 5/27/2022, RNA to provide ROM to Resident 19's extremities daily. During a record review of Resident 19's care plan titled, ROM/ Joint Mobility, last revised on 12/4/2022, the care plan indicated RNA to provide ROM exercises to the resident's LUE, RUE, LLE, and RLE five times a week. During a record review of Resident 19's Restorative Care Flow Sheet, for the month of January 2023, the flow sheet indicated Resident 19 received passive and active-assistive (occurs when resident able to move injured body part but may require some help to move to ensure further injury or damage does not occur) ROM to the total body a total of seven times in 21 days. The flow sheet indicated eight missed opportunities of RNA exercises. c. During a record review of Resident 16's face sheet, the face sheet indicated Resident 16 was admitted to the facility on [DATE] with diagnoses that included intracranial hemorrhage (bleeding within the skull) and respiratory failure. During a record review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 was rarely able to be understood and sometimes understood others. The MDS indicated Resident 16 was completely dependent on staff for ADLs. During a record review of Resident 16's Physician's Order, the order indicated starting on 10/3/2021, RNA to provide ROM to the resident's extremities daily. During a record review of Resident 16's care plan titled, ROM/ Joint Mobility, last revised on 1/17/2023, the care plan indicated RNA to provide ROM exercises to Resident 16's LUE, RUE, LLE, and RLE five times a week. During a record review of Resident 16's Restorative Care Flow Sheet, for the month of January 2023, the flow sheet indicated Resident 16 received passive and active-assistive ROM to the total body a total of seven times in 21 days. The flow sheet indicated eight missed opportunities of RNA exercises. d. During a record review of Resident 10's face sheet, the face sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included respiratory failure, anoxic brain damage (harm to the brain due to lack of oxygen), and dependence on respirator ventilator (the need for a machine to breathe for the person). During a record review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10 was rarely able to be understood and rarely understood others. The MDS indicated Resident 10 was completely dependent on staff for ADLs. During a record review of Resident 10's Physician's Order, the order indicated starting on 6/23/2015, RNA to provide passive ROM to all extremities daily. The order indicated starting on 4/1/2021, to apply bilateral hand splints two hours on, two hours off daily. During a record review of Resident 10's care plan titled, ROM/ Joint Mobility, last revised on 1/11/2023, the care plan indicated RNA to provide ROM exercises to the resident's LUE, RUE, LLE, and RLE five times a week. The care plan indicated RNA to don (apply) on/off a left and right handroll splint(s) no more than six hours/day as tolerated. During a record review of Resident 10's Restorative Care Flow Sheet, for the month of January 2023, the flowsheet indicated Resident 10 received passive ROM to the total body a total of seven times in 21 days. The flowsheet indicated eight missed opportunities of RNA exercises. During a record review of Resident 10's Treatments flowsheet, for the month of January 2023, the flowsheet indicated Resident 10 had elbow splint/hand rolls to the bilateral hands applied a total of seven times in 21 days. The flowsheet indicated 14 missed opportunities of applying the splint/hand rolls to the resident. During an interview with the Physical Therapist (PT) on 1/25/2023 at 2:41 p.m., the PT stated following physician orders for RNA treatment was very important in assisting residents to maintain or improve their ROM. During an interview with the Minimum Data Set Coordinator (MDSC) on 1/26/2023 on 2:37 p.m., the MDSC stated the residents' ROM and mobility care plans implemented by the RNA should have been followed as written and as ordered. The MDSC stated after reviewing the RNA flow sheets (for the month of January 2023) for all the residents on the unit, from 1/1/2023 to 1/21/2023, none of the residents received ROM exercises five times a week for three weeks from the RNA as per the residents' care plans. The MDSC stated if it was not documented in the flowsheet then it was not completed. During a record review of the facility's policies and procedure (P&P) titled, Assessment and Care Planning, effective 5/2021, the P&P indicated a comprehensive resident care plan will be formulated to allow the resident to reach his/her highest practicable level of physical, mental, and psychosocial functioning. During a review of the facility's P&P titled, Restorative Nursing Program (RNA), effective 5/2021, the P&P indicated the following: 1. The registered nurse (RN) will develop a written plan of care that includes problems, measurable goals, and approaches, for any resident on Restorative Nursing Program. 2. The RNA will carry out the treatment programs according to the care plan and documents daily on the Restorative Nursing Documentation Record. 3. The Director of Nursing (DON) or RN Designee will oversee the implementation of the program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview and record review, the facility failed to provide adequate Restorative Nursing Assistant (RNA) staff to provide range of motion and splint application to one of 12 sampled residents (Resident 10) on the RNA program. This deficient practice had the potential to decrease Resident 10's range of motion, which could affect Resident 10's overall function. Findings: During a record review of Resident 10's face sheet, the face sheet indicated Resident 10 was admitted to the facility on [DATE] with diagnoses that included respiratory failure (occurs when the respiratory system cannot adequately provide oxygen to the body), anoxic brain damage (harm to the brain due to lack of oxygen), and dependence on a respirator ventilator (the need for a machine to breathe for the person). During a record review of Resident 10's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 1/11/2023, the MDS indicated Resident 10 was rarely able to be understood and rarely understood others. The MDS indicated Resident 10 was completely dependent on staff for activities of daily living (ADLs, self-care activities performed daily such as dressing, personal hygiene, and toileting). During a record review of Resident 10's Physician's Orders, the orders indicated starting on 6/23/2015, RNA to provide passive ROM to all extremities daily. The orders indicated starting on 4/1/2021, RNA to apply bilateral hand splints two hours on, two hours off daily. During a record review of Resident 10's care plan titled, ROM/ Joint Mobility, last revised on 1/11/2023, the care plan indicated RNA to provide ROM exercises to the left upper extremity (LUE), right upper extremity (RUE), left lower extremity (LLE), and right lower extremity (RLE) five times a week. The care plan indicated RNA to don (apply) on/off a left and right handroll splint(s) no more than six hours/day as tolerated. During a record review of Resident 10's Restorative Care Flow Sheet, for the month of January 2023, the flowsheet indicated Resident 10 received passive ROM to the total body a total of seven times in 21 days. The flowsheet indicated eight missed opportunities of RNA exercises. During a record review of Resident 10's Treatments flowsheet, for the month of January 2023, the flowsheet indicated Resident 10 had elbow splint/hand rolls to bilateral hands applied a total of seven times in 21 days. The flowsheet indicated 14 missed opportunities of applying the splint/hand rolls to the resident. During an interview with RNA 1 on 1/25/2023 at 2:28 p.m., RNA 1 stated she was the only RNA for the entire facility and worked Monday through Friday. RNA 1 stated she was often reassigned from her RNA duties to work as a certified nursing assistant (CNA) one to three times a week and sometimes worked in another unit as a CNA. RNA 1 stated she was assigned to be a sitter for a resident or when someone called in sick, she was assigned as a CNA. RNA 1 stated there were many reasons why she was often reassigned from her duties as a RNA. During an interview with the Physical therapist (PT) on 1/25/2023 at 2:41 p.m., the PT stated following physician orders for RNA treatment was very important for residents to maintain or improve their ROM. During an interview with the Minimum Data Set Coordinator (MDSC) on 1/26/2023 on 2:37 p.m., the MDSC stated the residents' ROM and mobility care plans implemented by the RNA should have been followed as written. The MDSC stated, after reviewing the RNA flow sheets (for the month of January 2023) for all the residents on the unit, from 1/1/2023 to 1/21/2023, none of the residents received ROM exercises five times a week for three weeks from the RNA as instructed in the residents' care plans. The MDSC stated if it was not documented in the flowsheet then it was not performed. During a record review of the facility's Sub-Acute Daily Nursing Assignment Sheet, dated 1/19/2023, the assignment sheet indicated RNA 1 was assigned as a CNA during the 7 a.m. to 7 p.m. shift. During a record review of the facility's Time Clock Report for RNA 1's work hours on 1/19/2023, the report indicated RNA 1 worked from 6:51 a.m. to 3:22 p.m. During a record review of the facility's Sub-Acute Daily Nursing Assignment Sheet, dated 1/23/2023, the assignment sheet indicated RNA 1 was assigned as an emergency room (ER)/Sitter from 6:45 a.m. to 7:30 a.m. During a record review of the facility's Time Clock Report for RNA 1's work hours on 1/23/2023, the report indicated RNA 1 worked from 6:44 a.m. to 3:28 p.m. During a record review of the facility's policies and procedure (P&P) titled, Assessment and Care Planning, effective 5/2021, the P&P indicated a comprehensive resident care plan will be formulated to allow the resident to reach his/her highest practicable level of physical, mental, and psychosocial functioning. During a review of the facility's P&P titled, Restorative Nursing Program (RNA), effective 5/2021, the P&P indicated the following: 1. The registered nurse (RN) will develop a written plan of care that includes problems, measurable goals, and approaches, for any resident on Restorative Nursing Program. 2. The RNA will carry out the treatment programs according to the care plan and documents daily on the Restorative Nursing Documentation Record. 3. The Director of Nursing (DON) or RN Designee will oversee the implementation of the program.

Based on observation, interview, and record review, the facility failed to follow guidelines to prevent food contamination and the spread of foodborne illness for one of one kitchen when: 1. [NAME] 1's hairnet was not covering all her hair. 2. [NAME] 2 handled a food item with dirty gloves. 3. Dry and refrigerated food items were not labeled with a received and use by date. 4. A bag of egg rolls was not properly stored in the freezer but was stored in the refrigerator. 5. Moldy vegetables were not disposed of and expired bread and carrots were stored in the refrigerator. 6. Dry fruit was stored in a blue plastic bag without a label and without a received and use by date and expired dry storage items were not disposed of. These deficient practices increased the risk of food contamination and the spread of foodborne illness to the residents. Findings: 1. During a concurrent observation and interview on 1/24/2023, at 8:25 a.m., in the kitchen, with [NAME] (CK) 1, CK 1 was observed not wearing a hair net. CK 1 stated she was wearing a hairnet, but it had fallen off. CK 1 proceeded to get the hairnet from her pocket and put the hairnet on. Observed CK 1's hair in the front of her face was not tucked into the hairnet. CK 1 stated she should have all her hair tucked into the hairnet to prevent from hair getting onto the food. During an interview on 1/25/2023, at 11:06 a.m., with the DS, the DS stated the kitchen staff must wear a face mask and a hairnet while working in the kitchen. The DS stated hair must be completely tucked into the hairnet, so no hair falls in the food. During a review of the facility's policy and procedure (P&P) titled, Dress Code for Dietary Personnel, dated 3/2022, the P&P indicated, Hair must be contained in a hairnet or in the case of production staff, in cook hats .Hair that exceeds shoulder length must be pulled back in a hair tie (ponytail) or pinned up. 2. During an observation on 1/24/2023, at 10:10 a.m., in the kitchen, CK 2 was observed wearing gloves and walked to the refrigerator and removed an onion. CK 2 proceeded to chop the onion with a knife wearing the same dirty gloves he handled the refrigerator door with. CK 2 placed the chopped onion on the grill to cook wearing the same dirty gloves. During an interview on 1/25/2023, at 10:22 a.m., with CK 2, CK 2 stated he should wash his hands before handling food. CK 2 stated he was in hurry the day prior (1/24/2023) and forgot to remove his gloves and wash his hands after he removed an onion from the refrigerator and proceeded to chop the onion with the same gloves. CK 2 stated it was important to change his gloves, wash his hands and put on clean gloves to prevent cross contamination of food which could lead to illness if food got contaminated and was served to the residents. During an interview on 1/25/2023, at 11:06 a.m., with the DS, the DS stated the kitchen staff should wash their hands and change gloves between tasks to prevent food contamination which may lead to a foodborne illness in the residents. During a review of the facility's P&P titled, Sanitation and Safety. dated 3/2020, the P&P indicated, Single-service gloves are used when it is necessary to handle food. Workers must wash hands before putting on a new pair of gloves. Staff must change gloves before switching to a different task. 3. During an inspection of the kitchen on 1/24/2023, at 8:24 a.m., observed there was no date on a container with oatmeal. During an interview on 1/24/2023, at 8:27 a.m., with CK 1, CK 1 stated the oatmeal should be labeled with a use by date and verified the oatmeal was not dated. CK 1 stated it was important for food items to be labeled with a use by date so that staff knows how long the food item was good for and to prevent using expired food. During an inspection of the refrigerator on 1/24/2023, at 8:48 a.m., observed seven bags of sesame seed hamburger buns, a cardboard box with tomatoes, four packages of red seedless grapes and two packages of green seedless, two bags of green onions, and an open cardboard box of bread rolls that were not labeled with a use by date. 4. During an inspection of the refrigerator and concurrent interview with CK 2 on 1/24/2023, at 8:36 a.m., observed a bag of egg rolls not labeled with a date. CK 2 verified the egg rolls were not labeled with a date. CK 2 stated the egg rolls should be kept frozen until cooked according to the package instructions. CK 2 confirmed the egg rolls should not be stored in the refrigerator. CK 2 stated if the egg rolls were served to a resident, it could potentially cause an illness to the resident because the egg rolls were not properly stored, and the package was not labeled with a use by date, so he did not know if the food item was expired. CK 2 stated all food items should be labeled with an opened date and a use by date. 5. During an inspection of the refrigerator on 1/24/2023, at 8:50 a.m., observed the following: a. Five moldy cucumbers in a plastic bin and a second plastic container with moldy cucumbers dated with a use by date of 1/27/2023. b. A bag of expired greens dated 1/10/2023. c. A bag of expired cilantro dated 1/12/2023. d. Five bags of expired brown bread with a use by date of 1/16/2023. e. Two bags of expired carrots dated with a use by date of 1/13/2023. 6. During the inspection of the dry storage room, on 1/24/2023, at 9:30 a.m., observed the following: a. Two blue plastic bags with dried fruit not labeled with a description of the item, and no open and use by date. b. 40-ounce bag of croutons not labeled with a use by date nor expiration date c. Large bin with lemon gelatin, lemon drink mix, and orange gelatin with no use by date. d. Three bags of expired couscous. e. Six bags of undated tortilla strips. f. 13 boxes of expired powdered sugar. g. An undated box of pancake mix. h. Two large undated mayonnaise containers i. Seven cans of carrots and pea puree not labeled with a use by date and no expiration date j. Three bags of dry pasta not labeled with a use by date and no expiration date. During a concurrent observation and interview on 1/24/2023, at 10:07 a.m., with CK 2, in the dry storage room, CK 2 stated the blue plastic bags had raisins. CK 2 stated the raisins should be labeled and should not be stored in a plastic bag but should have been stored in a container where the salads were prepared. During a concurrent observation and interview on 1/25/2023, at 10:24 a.m., with the Dietary Supervisor (DS), in the kitchen, the DS stated all food items must be labeled with an open date and a use by date. The DS verified the dried fruit in the blue plastic bags was not labeled with a date and stated the dry fruit should have been stored in a container with a lid. The DS stated the blue plastic bag was not labeled with a description and could tell what the item was and stated it was not safe to use because it was not properly stored and labeled. During a concurrent observation and interview on 1/25/2023, at 10:30 a.m., with the DS, in the kitchen, the DS stated she and the staff had not been keeping up with checking the perishable items and dry storage items for expired items. The DS verified and confirmed all identified items were expired in the refrigerator and the dry storage room. The DS verified and confirmed the cucumbers were moldy in the refrigerator. The DS stated perishable food items were good for seven days. The DS stated perishable items were supposed to be disposed of according to the use by date and if the perishable item did not appear good, it was disposed of. The DS stated it was important for all dry goods, condiments, and perishables to have a received date and a use by date to determine how long the item was good for. The DS stated there were kitchen staff assigned to check food items weekly and another kitchen staff assigned to double check behind the first person, but he was on vacation and the kitchen had been short staffed. The DS stated it was her responsibility to make sure it got done. During a review of the facility's P&P titled, Infection Control- Food Storage, dated 3/2022, the P&P indicated, All containers of open food in the dry storeroom are resealed to preserve freshness and to prevent contamination .Supplies are rotated so that food placed in storage first is used before new supplies are used .All dated items are pulled if not used before the pull dates. Food and nutrition products are stored and prepared under proper conditions of sanitation, temperature, light, moisture, ventilation, and security .Frozen foods are kept frozen at all times until they are removed from the freezer for preparation. During a review of the facility's P&P titled, Receiving Storage and Issuing, dated 3/2022, the P&P indicated, All foods will be dated for freshness and food safety .Upon delivery of food items, if not already dated, it is the responsibility of the purchasing agent (or individual checking the delivery foods) to date the items with the current date .Potentially hazardous, ready-to-eat foods that have been frozen will be discarded if not consumed within 24 hours of being thawed .Keep all goods in clean, undamaged wrappers, packages, or containers that are labeled.

Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to meet the minimum requirements for committee members. This deficient practice had the potential to result in a lack of oversight by: 1. The QAA Committee for overall medical care provided by the facility; 2. The QAA Committee for ensuring that resident care policies are implemented appropriately; 3. The QAA Committee for the infection prevention and control program, which placed residents, staff, and visitors at risk of communicable diseases and infections. Findings: During a concurrent interview and record review on 1/26/2023 at 3:18 p.m. with the Chief Nursing Officer (CNO) and Quality Coordinator (QAR), the facility's Subacute Quality Council Meeting Minutes, dated 9/23/2022, 10/27/2022 and 12/14/2022, were reviewed. The CNO and QAR stated and confirmed the Medical Director (MD) did not attend the Quality Assessment and Assurance (QAA) Committee meetings nor did the MD sign the meeting minutes as acknowledgement the meeting minutes were reviewed. During a concurrent interview and record review on 1/26/2023 at 3:18 p.m. with the CNO and QAR, the facility's Subacute Quality Council Meeting Minutes, dated 9/23/2022, and 10/27/2022, were reviewed. The CNO stated the Infection Preventionist (IP) Nurse did not attend the QAA Committee meetings because the facility was in the process of hiring a new IP. The meeting minutes indicated no other qualified IP attended the QAA Committee meetings for September and October 2022. During a review of the facility's Performance Improvement (PI) Plan, reviewed 5/2021, the PI Plan indicated, Program Scope: The PI program shall include but not limited to an ongoing program that shows measurable improvement indicators or which there is evidence that it will improve health outcomes and reduce medical error. The PI Plan further indicated, The Quality Council (QC) chairperson is a physician who has knowledge of PI programs. The QC has been empowered to develop and oversee the organization wide PI Program. The QC provides recommendations for improvement. The QC ensures organization-wide communication of PI activities and accomplishments.