**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to adhere to its safety and supervision of resident ' s policy when one of the three sampled residents (Resident 1) left the facility without the staff ' s knowledge. This failure resulted in Resident 1 eloping for a duration of approximately 6 hours and traveling a distance of about 17 miles away from the facility, posing a potential safety risk to the clinically compromised resident (Resident 1). Findings: During a review of Resident 1's clinical record, the face sheet (contains demographic and medical information), indicated Resident 1 was admitted on [DATE] with a diagnosis that included unspecified dementia (a general term for a group of symptoms that affect a person ' s ability to think, remember, and reason, and can interfere with their daily life), Alzheimer ' s disease (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life). During a review of the clinical record for Resident 1 ' s the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated 7/05/2024, indicated, Resident 1 ' s score was a 4 which indicated Resident 1 had severe cognitive impairment. During an interview on 9/25/2024, at 11:00 a.m. with Assistant Director of Nursing (ADON) 1, ADON 1 mentioned that Resident 1 left the facility unnoticed by the staff around lunchtime and was located approximately 17 miles away at 4:30 PM on the same day. During a review of the facility documented titled 5 Day Look Back/Follow-up, dated 9/16/2024, the document indicated Resident 1 was reported missing from the facility around lunchtime and was later found at an acute general hospital at 4:30 PM. Upon further review, it was revealed that Resident 1 was interviewed regarding the incident. According to Resident 1, she travelled to her previous residence by taking the bus. During a telephone interview on 10/03/2024, at 9:59 a.m. with the Director of Nursing (DON) 1, DON 1 indicated Resident 1 went missing on 9/16/2024, approximately around lunch time, without any of the staff noticing. Upon expressing concern that the facility ' s safety and supervision policy for residents was not followed, DON 1 did not provide a specific response. During a review of the undated facility provided policy and procedure (P&P) titled, Safety and Supervision of Residents, the P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment.

2. An admission Record revealed the facility admitted Resident #45 on 11/03/2022. According to the admission Record the resident had a medical history that included a diagnosis of dementia. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2024, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #45 did not take an antidepressant medication. Resident #45's Order Summary Report, with active orders as of 05/04/2024, revealed an order dated 04/02/2024, for escitalopram (an antidepressant medication) 10 milligrams, give one tablet by mouth one time a day for episode of self-isolation manifested by reduced social interaction. Resident #45's Medication Administration Record, for the timeframe 05/01/2024 to 05/31/2024, revealed staff documented they administered escitalopram to Resident #45 at 9:00 AM on 05/01/2024 to 05/03/2024 and 05/08/2024 to 05/31/2024. During an interview on 07/26/2024 at 8:28 AM, the MDS Coordinator stated the antidepressant medication for Resident #45 should have been coded on the resident's MDS. During an interview on 07/26/2024 at 8:54 AM, the Director of Nursing stated it was her expectation that the MDS be coded correctly. During an interview on 07/26/2024 at 9:04 AM, the Administrator stated he did not have anything to do with the MDS process, but expected the MDS to be coded correctly. Based on interview, record review, and facility policy review, the facility failed ensure the accuracy of the Minimum Data Set (MDS) assessment for 2 (Resident 41 and Resident #45) of 13 sampled residents. Specifically, the facility failed to code Resident #41 received hospice care and Resident #45 received an antidepressant medication. Findings included: An undated facility policy titled, Certifying Accuracy of the Resident Assessment, indicated, 2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. 1. An admission Record indicated the facility admitted Resident #41 on 12/10/2021. According to the admission Record, the resident had a medical history that included a diagnosis of senile degeneration of the brain. Resident #41's Order Summary Report, for active orders as of 07/01/2024, indicated an order dated 05/23/2024, to admit the resident to hospice services. A significant change in status assessment Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #41 had a Staff Assessment for Mental Status (SAMS) that indicated the resident was severely impaired in cognitive skills for daily decision making. The MDS did not indicate the resident received hospice care. Resident #41's care plan, included a focus area initiated 05/24/2024, that indicated the resident was on hospice care for the diagnosis of senile degeneration of the brain. During an interview on 07/26/2024 at 8:28 AM, the MDS Coordinator stated the MDS reflected a resident's baseline status, their function and mobility to track if the resident improved and/or declined. The MDS Coordinator stated the information came from the nurse's documentation, certified nursing assistant charting for activities of daily living function, physician notes during the look-back period, physician orders and medications including psychotropic medications. The MDS Coordinator stated the significant change in status assessment MDS was completed for Resident #41 because the resident was not at their baseline and was placed on hospice services. The MDS Coordinator stated she coded that the resident's life expectancy was less than six months; however, she confirmed that hospice was not coded, but it should have been. During an interview on 07/26/2024 at 8:54 AM, the Director of Nursing (DON) stated the MDS was a resident assessment that was developed for the improvement of residents and should be coded correctly to accurately reflect the resident. The DON stated the information for the MDS came from interviews, observations, and chart review. The DON stated Resident #41 was placed on hospice and when the significant change in status assessment was completed, hospice care should have been coded. The DON stated it was her expectation that the MDS be coded correctly. During an interview on 07/26/2024 at 9:04 AM, the Administrator stated he did not have anything to do with the MDS process, but expected the MDS to be coded correctly.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed when a resident received a new mental diagnosis for 1 (Resident #18) of 3 sampled residents reviewed for PASARRs. Findings included: A typed document from the California Department of Health Care Services, dated 09/09/2023, specified Per Title 42 of the Code of Federal Regulations sections 483.100 through 483.138, individuals identified with a SMI [serious mental illness] and/or ID/DD/RD [intellectual disability/developmentally disability/related condition] must be screened and evaluated to determine whether SNF [skilled nursing facility] level of care and specialized services in the least restrictive setting that best meets their needs are required. An admission Record revealed the facility admitted Resident #18 on 03/18/2022. According to the admission Record, on 04/06/2022, the resident received diagnoses of anxiety disorder, depression, and schizoaffective disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2024, revealed Resident #18 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #18 had active diagnoses to include anxiety disorder, depression, and schizophrenia. Resident #18's care plan included a focus area updated 02/08/2024, that indicated the resident took psychotropic medications due to schizoaffective disorder manifested by auditory hallucinations secondary to hearing non-existent voices. Resident #18's care plan included a focus area updated 02/08/2024, that indicated the resident used valproic acid for mood disorder manifested by mood swings which caused angry outbursts. Resident #18's medical record revealed no evidence to indicate a PASARR evaluation was completed after the resident was diagnosed with anxiety disorder, depression, and schizophrenia. During an interview on 07/26/2024 at 8:50 AM, the Assistant Director of Nursing stated she submitted Resident #18's Level I PASARR; however, the resident received new diagnoses after they were assessed by physician and she did not know a new one PASARR needed to be completed. During an interview on 07/26/2024 at 8:55 AM, the Director of Nursing stated Resident #18's PASARR should have been resubmitted with the resident's new serious mental illness diagnoses.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) evaluation was completed for 1 (Resident #6) of 3 sampled residents reviewed for PASARRs. Findings included: A typed document from the California Department of Health Care Services, dated 09/09/2023, specified Per Title 42 of the Code of Federal Regulations sections 483.100 through 483.138, individuals identified with a SMI [serious mental illness] and/or ID/DD/RD [intellectual disability/developmentally disability/related condition] must be screened and evaluated to determine whether SNF [skilled nursing facility] level of care and specialized services in the least restrictive setting that best meets their needs are required. An admission Record revealed the facility admitted Resident #6 on 10/18/2023. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder, schizoaffective disorder, unspecified psychosis, and suicidal ideation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/01/2024, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #6 had active diagnoses to include anxiety disorder, psychotic disorder, and schizophrenia. Resident #6's care plan included a focus area initiated 10/18/2023, that revealed Resident #6 was at risk for being resistive to care related to anxiety, dementia, schizoaffective disorder, psychosis and suicidal ideation. A care plan, initiated 10/19/2023, revealed Resident #6 used antipsychotic medication for schizoaffective disorder manifested by delusions that led to aggressive behaviors. A care plan, updated 02/08/2024, revealed Resident #6 used antidepressant medication for depression manifested by an inability to sleep and diagnoses of depression, anxiety disorder, schizoaffective disorder and psychosis. Resident #6's Preadmission Screening and Resident Review Level I Screening, dated 10/18/2023, revealed a negative Level I outcome due to a 30-day Exempted Hospital Discharge. Resident #6's medical record revealed no evidence to indicate a PASARR evaluation was completed after the resident remained in the facility 30 days after admission. During an interview on 07/26/2024 at 8:50 AM, the Assistant Director of Nursing (ADON) stated she was the one that reviewed the PASARRs. The ADON stated Resident #6's PASARR was missed because she was not familiar with the 30-day exemption/resubmission. During an interview on 07/26/2024 at 8:55 AM, the Director of Nursing stated Resident #6's PASARR should have been resubmitted when the 30 day period was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an individualized comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated, for one resident reviewed for mood/behavior (Resident 5) when a care plan was not initiated for Resident 5's diagnosis of depression and use of anti-depressant medication in accordance with the facility's policy and procedure. This failure had the potential to cause inadequate management of Resident 5's medical condition, affecting Resident 5's health and safety. Findings: A review of Resident 5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Resident 5's Progress Notes, dated January 6, 2022, indicated one of her active diagnoses included depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 5's Physician Order Sheet, dated November 5, 2021, indicated Resident 5 was prescribed Celexa (anti-depressant medication) 10 milligram (mg- unit of measurement) by mouth once a day for depression. A concurrent interview and review of Resident 5's clinical record was conducted with the Assistant Director of Nursing (ADON) on January 20, 2022 at 8:59 AM. The ADON was unable to find documentation of a care plan addressing Resident 5's diagnosis of depression and her use of anti-depressant medication. She stated it is important that care plan is developed so the facility can identify, set realistic goals, implement, and re-evaluate the needs of the resident. A concurrent interview and record review was conducted with the Director of Nursing (DON) on January 20, 2022 at 9:44 AM. He reviewed the facility's undated policy and procedure titled Using the Care Plan which indicated Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . and stated it was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plans were updated and revised in a timely manner when there was a change in anti-anxiety medication for one of five residents (Resident 8). This failure had the potential to result in inadequate treatment and management of resident's overall clinical condition. Findings: During a concurrent observation and interview with Resident 8, on January 19, 2022 at 8:22 AM, in the dining room, Resident 8 was sitting up on her wheelchair. She was alert and oriented to self. She was calm and not in any acute distress. She stated she was fine. A review of Resident 8's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Resident 8's Physician Order Sheet, dated December 6, 2021, indicated Resident 8 was prescribed Buspar (anti-anxiety medication) 10 milligram (mg- unit of measurement) by mouth every eight hours for anxiety. A concurrent interview and review of Resident 8's clinical record was conducted with the Assistant Director of Nursing (ADON) on January 20, 2022 at 2:05 PM. The ADON reviewed Resident 8's Care Plan for Anti-Anxiety medications, revised August 5, 2021, and stated it was for her use of Ativan (anti-anxiety medication). She further stated it was not revised after her anti-anxiety medication was changed to Buspar (more than a month ago). A concurrent interview and record review was conducted with the Director of Nursing (DON) on January 20, 2022 at 2:20 PM. He reviewed the facility's undated policy and procedure titled Using the Care Plan which indicated Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made . and stated it was not followed. He further stated the care plan should have been revised so the facility can provide the appropriate care for their residents current medical condition.

Based on observation, interview, and record review, the facility failed to ensure an opened emergency drug kit (eKIT) containing Schedule II (two) controlled substances (drugs stored and handled with additional restrictions to prevent abuse, addictions, and unauthorized use) in the Medication/Supply Room was replaced in a timely manner in accordance with the facility's policy. This failure had the potential to result in increased risk of drug diversion (illegal distribution) and/or medication availability issues for a universe of 43 residents. Findings: During a concurrent observation and interview on January 18, 2022, at 9:43 AM, an inspection of the Medication/Supply Room was conducted with the Assistant Director of Nursing/Director of Staff Development (ADON/DSD). An opened eKIT was observed with a quantity of three (3) tablets of Norco (Schedule II combination of two drugs - hydrocodone and acetaminophen) 5 milligrams (mg - a unit of measurement for dose)/325 mg. The list of contents indicated the eKIT should contain a quantity of four (4) tablets of Norco 5 mg/325 mg. The Emergency Drug Kit Slip in the opened eKIT indicated one tablet of Norco 5 mg/325 mg was removed on January 13, 2022 at 7 PM (time period appropriately 110 hours from the time of opening to the time of discovery). During a concurrent interview, the ADON/DSD acknowledged the eKIT slip indicated the eKIT was opened on January 13, 2022, at 7 PM, three (3) tablets of Norco 5 mg/325 mg were observed, and the list of contents indicated four (4) tablets of Norco 5/335 mg. The ADON/DSD stated the eKIT should have been replaced. During a concurrent interview and record review on January 18, 2022, at 10:25 AM, the policy was reviewed with the Director of Nursing (DON) and the ADON/DSD. The policy titled Policy and Procedure Manual - Section M. EMERGENCY KIT (E-KIT) USE reviewed October 1, 2021, indicated The pharmacy is to be notified as soon as possible that the E-Kit has been opened so it can be replaced within 72 hours. The DON and the ADON/DSD acknowledged the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5%. Two medication errors for Resident 3 occurred out of a total 34 medication pass opportunities. The medication administration error rate was 5.88%. This failure had the potential to expose residents to preventable medication errors which could adversely affect their health and safety. Findings: During a concurrent observation and interview on January 20, 2022, from 8:41 to 8:56 AM, a medication pass observation for Resident 3 was conducted with Licensed Vocational Nurse 1 (LVN 1). During a concurrent observation and interview on January 20, 2022, at 8:43 AM, LVN 1 was preparing Resident 3's medications which are as follows: 1. One tablet of Abilify (antipsychotic) 20 mg (milligrams - a unit of measurement for dose) and one tablet of Abilify 5 mg for a total dose of Abilify 25 mg 2. One tablet of chewable aspirin (drug to prevent heart attack and stroke) 81 mg 3. One tablet of Buspirone (drug to treat anxiety) 5 mg 4. One tablet of Calcium (mineral supplement) 600 mg combined with Vitamin D 3 10 micrograms (mcg- a unit of measurement for dose) (400 International Units- IU- a unit of measurement for dose) 5. One tablet of docusate sodium (stool softener) 100 mg 6. One tablet of magnesium oxide (mineral supplement) 400 mg 7. Two tablets of sennosides (drug to treat constipation) 8.6 mg 8. One tablet of lorazepam (drug to treat anxiety) 1 mg. During a concurrent observation and interview on January 20, 2022, at 8:53 AM with LVN 1, ten pills were observed. LVN 1 stated she counted ten pills. The multivitamin/mineral tablet was not observed during the count. During an observation on January 20, 2022, at 8:54 AM, LVN 1 was observed administering 10 pills to Resident 3. During an observation on January 20, 2022, at 8:56 AM, LVN 1 stated she was done administering all the scheduled medications for Resident 3. During a concurrent observation, interview, and record review on January 20, 2022, at 9:42 AM, LVN 1 inspected the bottle of Calcium 600 mg/Vitamin D 3 10 mcg (400 IU) and compared it to the prescriber's order for Calcium-Vitamin D Tablet 600-200 MG-UNIT Give 1 tablet by mouth one time a day for supplement. LVN 1 acknowledged the prescriber's order for Resident 3, and stated she administered a different dose of Vitamin D than what was ordered. During a concurrent interview and record review on January 20, 2022, at 9:43 AM, LVN 1 reviewed the prescriber's order for Multi Vitamins/Mineral Tablet (Multiple Vitamins-Minerals) Give 1 tablet by mouth one time a day for Supplement. LVN 1 acknowledged the prescriber's order for Resident 3. During a review of the facility's Medication Administration Schedule, the document indicated the medication administration time for Once a Day (OD) - 0900. During a concurrent interview and record review on January 21, 2022, at 8:45 AM, the policy was reviewed with the Director of Nursing (DON). The policy titled Policy and Procedures for Med Pass -VII. PREPARATION FOR MEDICATION ADMINISTRATION . MEDICATION ADMINISTRATION - GENERAL GUIDELINES reviewed October 1, 2021, indicated Medications are administered in accordance with the written orders of the attending physician. The DON acknowledged the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a safe infection control program when outdated supplies were available for resident use in the Medication/Supply Room. This failure had the potential for a universe of 43 residents to be treated with ineffective or deteriorated (reduced quality) supplies which could negatively impact wound healing. Findings: During an observation and concurrent interview on [DATE], at 9:50 AM, an inspection of the Medication/Supply Room was conducted with the Assistant Director of Nursing/Director of Staff Development (ADON/DSD). 1. During an observation and concurrent interview on [DATE], at 9:50 AM, the ADON/DSD acknowledged the following supplies in the First Aid Kit in the Medication/Supply Room were expired. a. Three (3) Roller Gauze Bandages (used to secure wound dressings) supplies were observed expired: 2017 11 01 [supply expired [DATE]], 2018 01 03 [supply expired [DATE]], and 2018 01 03 [supply expired [DATE]]. The supplies were approximately 48 months outdated. b. Four (4) Sterile (germ-free) Non-Woven Sponges (used for wound cleaning) supplies were observed expired: 2018 03 15 [supply expired [DATE]], 2018 03 15 [supply expired [DATE]], 2017 12 10 [supply expired [DATE]], and 2017 12 10 [supply expired [DATE]]. The supplies were approximately 48 months outdated. c. One (1) Combine Pad (used to absorb heavy draining wounds) was observed expired 2018 03 01 [supply expired [DATE]]. The supplies were approximately 46 months outdated. d. One (1) Eye Pad (used to cover and protect the eye wound) was observed expired 2017 12 [supply expired [DATE]]. The supplies were approximately 48 months outdated. 2. During an observation and concurrent interview on [DATE], at 9:50 AM, the ADON/DSD acknowledged the following supplies in the Medication/Supply Room were expired: multiple individual packets in the five (5) cartons of Universal Removal Wipes (used to clean and prepare the resident's skin) indicated an imprint of [DATE] [supply expired [DATE]. The supplies were approximately 17 months outdated. During an interview with the Director of Nursing (DON) on [DATE], at 3:10 PM, the DON stated the facility had no policies regarding outdated supplies when facility see expired supplies the staff removes it from stock. During an interview with the Infection Preventionist (IP) on [DATE], at 8:08 AM, the IP acknowledged the Infection Preventionist is involved in training staff. The IP stated that if licensed nurses found outdated medical supplies, such as sterile bandages or sponges, she would tell them to discard the supply because don't know the effectiveness or if safe to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 18's clinical record, the face sheet indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses that included dementia (a group of conditions affecting memory and judgement), cerebral infarction (damage to the brain from reduced/interrupted blood supply), and hypertension (elevated blood pressure). A review of Resident 18's Order Summary Report, dated January 19, 2022, indicated Resident 18 was prescribed, Clopidogrel 75 milligram (mg- unit of measurement) by mouth once a day for atherosclerosis (deposition of fatty materials) of the aorta (blood vessel) starting September 29, 2020. A concurrent interview and record review of Resident 18's MDS, dated [DATE], was conducted with MDS-LVN on January 19, 2022, at 2:11 PM. Section N indicated Resident 18 received anticoagulant for seven days. He stated Resident 18 was taking Clopidogrel but should not be coded as anticoagulant. He further stated he coded it incorrectly. 3. During a review of Resident 27's clinical record, the face sheet indicated Resident 27 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (a disease that results in high blood sugar), cerebral infarction, and hypertension. A review of Resident 27's Order Summary Report, dated January 19, 2022, indicated Resident 27 was prescribed by her physician Clopidogrel 75 milligram (mg- unit of measurement) by mouth once a day for stroke prevention starting May 8, 2021. A concurrent interview and record review of Resident 27's MDS, dated [DATE], was conducted with MDS-LVN on January 19, 2022, at 2:19 PM. Section N indicated Resident 27 received anticoagulant for 7 days. He stated Resident 27 was also taking Clopidogrel and made a mistake in coding these two assessments for Resident 18 and 27. A review of CMS's (Centers for Medicare and Medical Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, revised October 2019, N041E, Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin), indicated Record the number of days an anticoagulant medication was received at any time during the 7-day look back period (or since admission, entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyrimadole, or clopidogrel here. Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - facility assessment tool), for three of three residents reviewed for resident assessment (Resident 5, 18, and 27) when: 1. One of Resident 5's active diagnoses was not coded. 2. Resident 18's Clopidogrel, an antiplatelet (medication that prevents blood cells from sticking together forming a clot) was coded as an anticoagulant (medication that prevents the formation of blood clots) in Resident 18's MDS, dated [DATE]. 3. Resident 27's Clopidogrel, an antiplatelet was coded as anticoagulant in Resident 27's MDS, dated [DATE]. These failures had the potential to result in unmet care needs for Resident 5, 18, and 27 which can negatively affect their health and safety. Findings: 1. A review of Resident 5's clinical record indicated she was admitted to the facility on [DATE], with diagnoses that included anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). A review of Resident 5's Progress Notes, dated January 6, 2022, indicated one of her active diagnoses included depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 5's Physician Order Sheet, dated November 5, 2021, indicated Resident 5 was prescribed Celexa (anti-depressant medication) 10 milligram (mg- unit of measurement) by mouth once a day for depression. A concurrent interview and review of Resident 5's clinical record was conducted with the Director of Nursing (DON) on January 20, 2022 at 9:10 AM. The DON reviewed Resident 5's MDS dated [DATE] and stated Resident 5's depression was not coded under Section I Active Diagnoses. He stated the MDS-LVN should have coded it. He stated, providing accurate assessment of the resident's status will help different health care disiplines be able to provide care dependent upon resident's status and needs. During a concurrent interview and record review with the DON, on January 20, 2020 at 9:39 AM, the DON reviewed Centers for Medicare and Medicaid Services' (CMS) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, under Section I, page I-1, which indicated Steps for Assessment 1. Indicate the resident's primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available . Include the primary medical condition coded in this item in Section I: Active Diagnoses in the last 7 days . He stated the manual was not followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) were re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for three of three residents reviewed for PASRR (Residents 9, 18, and 33). These failures had the potential for Residents 9, 18, and 33 not to receive the care and services most appropriate for their needs. Findings: 1. During a review of Resident 9's clinical record, the face sheet (contains demographic and medical information) indicated Resident 9 was admitted to the facility on [DATE], with diagnoses that included dementia (a group of conditions affecting memory and judgement), schizophrenia (a mental disorder which affects how a person thinks, feels and acts), and bipolar disorder (disorder associated with episodes of mood swings). A concurrent interview and record review of Resident 9's MDS dated [DATE] was conducted with the MDS Coordinator (MDS-LVN) on January 20, 2022, at 2:05 PM. He stated Resident 9's SCSA was done because of a decline in Activities of Daily Living (ADLs). During an interview and review of Resident 9's clinical record with MDS-LVN, he stated Resident 9's most current PASRR was completed on January 12, 2021, and he was not re-evaluated for a new PASRR after the completion of this SCSA. 2. During a review of Resident 18's clinical record, the face sheet indicated Resident 18 was readmitted to the facility on [DATE], with diagnoses that included dementia (a group of conditions affecting memory and judgement), major depressive disorder (mental disorder characterized by depressed mood or loss of interest in activities), and schizoaffective disorder (mental illness that affects thoughts, mood and behavior). A concurrent interview and review of Resident 18's MDS, dated [DATE], was conducted with MDS-LVN on January 20, 2022, at 1:54 PM. He stated Resident 18's SCSA was done because of a decline in ADLs and multiple elevated blood sugar levels and blood pressure readings. He further stated the latest PASSR on file was completed on September 28, 2020, and her PASRR was also not re-evaluated after the completion of the SCSA. 3. During a review of Resident 33's clinical record, the face sheet indicated Resident 33 was admitted to the facility on [DATE], with diagnoses that included Alzheimer's dementia (a progressive disease that destroys memory and other important mental functions), anxiety (intense, excessive, and persistent worry and fear about everyday situations), and impulse disorder (a condition in which a person has trouble controlling emotions and behaviors). A concurrent interview and record review of Resident 33's MDS, dated [DATE], was conducted with MDS-LVN on January 20, 2022, at 2:00 PM. He stated Resident 33's SCSA was done because of a change in the hospice (providing care for the sick and terminally ill) provider. He further stated the latest PASSR on file was completed on June 02, 2021, and her PASRR was not re-evaluated as well after the completion of the SCSA. During a follow up interview with MDS-LVN, on January 20, 2022 at 2:15 PM, he stated he did not know that PASRR had to be done after SCSA and the facility did not follow the PASRR Guidelines for Residents 9, 18 and 33. A review of the Department of Health Care Services Guide to Completing the PASRR Level I Screening, dated May 2018, indicated Select Resident Review (RR) (Status Change) if the individual has already been admitted to your facility and you are updating the existing PASRR on file for either of the following reasons .B. There is a significant change in an individual's physical or mental condition. According to the MDS 3.0 manual a significant change is a decline or improvement in an individual's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting (for declines only) and 2. Impacts more than one area of the individual's health status and 3. Requires interdisciplinary review and/or revision of the care plan.

Based on observation, interview, and record review, the facility failed to ensure a sanitary kitchen, when there where dead insects and cobwebs under the shelves in the dry storage and behind the stove. This had the potential to contaminate the food and food contact surfaces in a highly susceptible population of 43 residents. Findings: During an observation and interview on January 18, 2022, at 8:05 AM, under the shelf in the dry storage room on the east wall, there was cobwebs. Under the shelf on the west wall, there were dead insects on the floor under the shelf. The Dietary Supervisor stated the floors should be clean. During an observation on January 18, 2022, at 8:16 AM, there were cobwebs behind the stove and some debris on the floor under the stove. During a review of the FDA Federal Food Code 2017, 6-501.111 Controlling Pests, states: Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. And 6-501.112 Removing Dead or Trapped Birds, Insects, Rodents, and Other Pests, states Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to issue a discharged resident's Resident Trust Account (RTA- a legal arrangement through which funds are held by the facility for the benefit of the residents) refund, in accordance to the facility's policy and procedure, for one of five residents reviewed for personal funds (Resident 609). This failure had the potential to compromise the safeguarding of Resident 609's money in his RTA. Findings: During a review of Resident 609's closed clinical record, the face sheet (contains demographic information) indicated Resident 609 was initially admitted to the facility on [DATE], with the diagnoses of dementia (memory loss) and bipolar disorder (unstable behavior). Resident 609 was discharged to an assisted living facility on August 1, 2018. A review of Resident 609's RTA final check balance, dated October 19, 2018, (79 days after Resident 609 was discharged ) indicated a refund of two hundred thirty-two dollars and twenty-seven cents was paid to the order of Resident 609's representative. During a concurrent interview and record review of Resident 609's RTA final check balance with the Business Office Manager (BOM), on March 27, 2019, at 7:34 AM, he stated he was unable to mail Resident 609's refund in accordance to the facility policy and procedure. The BOM further stated Resident 609's RTA refund should have been issued within three business days (August 6, 2018) after his discharge according to the facility's policy and procedure. Review of the facility's undated policy and procedure titled, Accounts Receivable- Resident Trust, indicated .B. The trust account will be reconciled on the first working day of each month .N. Upon discharge of a resident, a refund will be issued within three normal business days .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident care and personal hygiene of the fingernails was provided for one of two sampled residents (Resident 14) reviewed for assistance of activities of daily living (ADLs- routine activities people do every day without assistance), when Resident 14 was observed with a blackish substance underneath his fingernails for three consecutive days. This failed practice had the potential for Resident 14 to develop skin problems and injuries. Findings: During a review of Resident 14's clinical record, the face sheet (contains demographic information) indicated Resident 14 was admitted to the facility on [DATE], with diagnoses of dementia (decline in memory and other mental abilities) and Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior). During a review of Resident 14's Minimum Data Set (MDS- a facility assessment tool), dated January 10, 2019, indicated the Brief Interview for Mental Status (BIMS) assessment was not conducted due to resident is rarely/never understood. Resident 14 required extensive assistance with one-person physical assist (resident involved in activity, staff provide weight-bearing support) for personal hygiene (how the resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands). During a review of Resident 14's ADL Self-Care Performance Deficit Care Plan, revised March 22, 2018, indicated The resident [Resident 14] requires extensive assistance by one staff with personal hygiene and oral care. During an observation on March 24, 2019, at 10:25 AM, in Resident 14's room, Resident 14 was sitting on a geri-chair in a semi-upright position. Resident 14's fingernails on both hands were observed with blackish substance underneath his fingernails. During a follow-up observation on March 25, 2019, at 1:07 PM, in Resident 14's room, Resident 14 was lying flat in bed. Resident 14's fingernails on both hands were observed with blackish substance underneath his fingernails. During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 1), on March 26, 2019, at 3:47 PM, in Resident 14's room, Resident 14 was in bed, lying on his right side. Resident 14's fingernails on both hands were observed with a blackish substance underneath his fingernails. LVN 1 confirmed Resident 14's fingernails on both hands were dirty. A concurrent observation and interview with the Director of Staff Development (DSD), on March 26, 2019, at 5:10 PM, (an hour after LVN 1 stated Resident 14's fingernails were dirty), was conducted in Resident 14's room. Resident 14 was lying flat in bed. Resident 14's fingernails on both hands were observed with blackish substance underneath his fingernails. The DSD stated Resident 14's fingernails needed to be cleaned. The DSD further stated, The expectation is for CNAs [Certified Nurse Assistants] to render nail care daily and as needed. Review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting revised March 2018, indicated Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Review of a facility document titled, Fingernails/Toenails, undated, indicated Nail care includes daily cleaning and regular trimming. Review of a facility document titled, Certified Nursing Assistant, dated March 1, 2019, indicated Attends to the individual needs of residents, which may include assistance with grooming, bathing, oral hygiene, feeding, incontinent care, toileting, colostomy care, prosthetic appliances transferring, ambulation, range of motion, communicating or other needs in keeping with the individuals' care requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a psychotropic medication (medication used to treat mental disorders) had an appropriate indication of use for one of five sampled residents (Resident 26), reviewed for psychotropic medications. This failed practice had the potential to conceal the effectiveness of treatment for Resident 26's mental disorder, which may potentially jeopardize Resident 26's health, safety and welfare. Findings: During a review of Resident 26's clinical record, the face sheet (contains demographic information) indicated Resident 26 was admitted to the facility on [DATE], with diagnoses of dementia (decline in memory and other mental abilities) and schizoaffective disorder (a mood disorder). A review of Resident 26's Physician Order Sheet, dated October 18, 2018, at 11:20 AM, indicated an order for Risperdal (psychotropic medication) 0.5 milligram (mg- unit of measurement) tablet by mouth one time a day for psychosis (mental disorder) manifested by striking out. The medication was administered to Resident 26 once a day after it was ordered on October 18, 2018. During a concurrent interview and record review with the Minimum Data Set Nurse (MDS Nurse), on March 27, 2019, at 9:51 AM, the MDS Nurse reviewed Resident 26's clinical record and was unable to find any documented evidence indicating Resident 26 was diagnosed with psychosis. During a concurrent interview and record review with the Director of Nursing (DON), on March 27, 2019, at 1:21 PM, the DON reviewed Resident 26's clinical record and was unable to find documented evidence indicating Resident 26 was diagnosed with psychosis. The DON stated the indication should have been schizoaffective disorder, and not psychosis. During a follow up interview with the DON, on March 27, 2019, at 1:40 PM, the DON reviewed the facility's policy and procedure titled Antipsychotic Medication Use revised December 2016. The DON stated the facility was not able to follow its own policy and procedure for for appropriate use of psychotropic medication. Review of the facility's policy and procedure titled, Antipsychotic Medication Use, revised December 2016, indicated Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record, consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): a. Schizophrenia; b. Schizo-affective disorder; c. Schiziphreniform disorder; d. Delusional disorder; e. Mood disorders (e.g. bipolar disorder, depression with psychotic features, and treatment refractory major depression); f. Psychosis in the absence of dementia; g. Mental illness with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high-dose steroids); h. Tourette's Disorder; i. Huntington Disease; j. Hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy.

Based on observation, interview, and record review, the facility failed to ensure the medication storage refrigerator was locked in the medication room. This failure had the potential to cause unauthorized access to narcotics (controlled substances used as opiates or painkillers, are commonly abused) which could result in diversion and misappropriation of narcotic medication in a highly susceptible population of 36. Findings: During an observation of the medication room with two Licensed Vocational Nurses (LVNs 1 and 2), on March 26, 2019, at 2:37 PM, the medication storage refrigerator was unlocked. The medication storage refrigerator contained one emergency kit (contains medications available during emergency) which had four vials (small glass container) of Ativan injections (narcotic medication used for anxiety). During a concurrent interview with LVN 1 and LVN 2, LVN 1 stated the medication storage refrigerator should be kept locked at all times. LVN 2 stated, she did not lock the medication refrigerator. LVN 2 acknowledged she was supposed to lock the refrigerator after use to ensure there was no unauthorized access to narcotic medications. During an interview with the Director of Nursing (DON), on March 26, 2019, at 3:33 PM, he verified the findings and stated the medication storage refrigerator should be locked at all times to promote safe and secure storage of narcotics. Review of the facility's policy and procedure titled, Storage of Medications/Narcotics, revised April 2007, indicated 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the manufacturer's direction for food products was followed in preparing a honey thickened (as thick as honey) cranberry juice for one of two sampled residents (Resident 29). This failed practice had the potential to place Resident 29 at risk for aspiration (inhales food and liquid into the lungs), which could affect Resident 29's health and safety. Findings: During a review of Resident 29's clinical record, the face sheet (contains demographic information) indicated Resident 29 was initially admitted to the facility on [DATE], with diagnoses of hypothyroidism (low thyroid hormone), dementia (memory loss), and muscle contracture (stiffness). A review of Resident 29's Physician Order Sheet, dated March 18, 2019, indicated Resident 29 had a diet order of fortified (food that has extra nutrients added) pureed (mashed cook food) texture with honey thickened liquids with all meals. During an observation on March 24, 2019, at 12:59 PM, in the dining room, a Certified Nursing Assistant (CNA 1) was assisting Resident 29 to drink cranberry juice with a straw. The cranberry juice had a label which read HT (HT- honey thickened). The cranberry juice was observed to be of nectar consistency (nectar-thick liquids are easily pourable), and not honey consistency. During a concurrent interview with CNA 1, she stated the cranberry juice had a nectar consistency and did not have a honey thickened consistency. CNA 1 stated thickened liquids are prepared by the dietary staff in the kitchen. She stated that nectar consistency could cause aspiration during meals for Resident 29. A review of the manufacturer's direction titled, Dysphagia, dated September 2008, indicated to make honey thickened consistency, mix eight ounces (oz- unit of measurement) of cranberry juice with two tablespoons (tbsp- unit of measurement) of thickener plus one teaspoon (tsp- a unit of measurement) of thickener (used to thicken water and juice) [2 tbsp+ 1 tsp of thickener]. During a concurrent observation and interview with a Dietary Aide (DA 1), on March 25, 2019, at 8:55 AM, while in the kitchen, DA 1 demonstrated how to prepare honey thickened cranberry juice. DA 1 mixed three tbsp of thickener into an eight ounces (oz) of cranberry juice. The cranberry juice was observed to be in a pudding consistency. DA 1 stated that is how he prepares honey thickened cranberry juice. During an interview with the Director of Dietary Services (DDS), on March 25, 2019, at 2:49 PM, the DDS stated DA 1 did not follow the manufacturer's direction in preparing honey thickened cranberry juice. DDS stated DA 1 should have not used three tbsp of thickener, but use 2 tbsp+1 tsp of thickener in to 8 oz of cranberry juice as per manufacturer's direction. During an interview with the Registered Dietician (RD), on March 25, 2019, at 4:41 PM, she acknowledged the facility did not follow the manufacturer's guidance in preparing honey thickened liquids. The RD stated adding more than the required amount of thickener into the juice will cause a decrease in fluid intake. She stated adding less than the required amount of thickener would cause aspiration. Review of the facility's policy and procedure titled, Thickened Liquids, dated January 1, 2017, indicated 6. Thickened liquids will be prepared according to manufacturer's directions on the commercial product being used . 7. Thin liquids will be thickened according to Physicians order in the Food & Nutrition Services Department. 8. This applies to all liquids being served to residents including milk, juice, water, coffee, tea, etc .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow physician's orders when an adaptive device (sippy cup-used to assist residents who has uncontrollable hand shaking [tremors] and/or hand weakness to drink from a cup independently) was not provided to maximize independence with eating and drinking for one of 33 sampled residents (Resident 25). This failure resulted in Resident 25 not receiving the adaptive device and causing Resident 25 to have soiled clothing, meal interruptions, and frustration. Findings: During a review of the clinical record for Resident 25, the Face Sheet (demographic information), indicated Resident 25 was admitted to the facility on [DATE], with diagnoses of dementia (brain disorder), depression (mood disorder), and hypertension (high blood pressure). During an observation on March 24, 2019, at 12:28 PM, Resident 25 was sitting in the dining room eating lunch. Resident 25's meal card indicated Resident 25 would receive a sippy cup and weighted utensils (adaptive eating flatware to help with the hand tremors) with meals. Resident 25 asked the Licensed Vocational Nurse (LVN 4) for assistance with opening his milk carton. LVN 4 opened the milk carton and placed the carton onto Resident 25's tray. Resident 25 attempted to drink from the milk carton with his unsteady hand and was not successful. Resident 25 placed the carton back onto the tray. Resident 25 picked the carton up again and the milk spilled on the table and onto Resident 25's gray sweat shirt. Resident 25 wiped the milk from the table with a napkin and immediately went to the sink located in the dining room. Resident 25 cleaned the milk from his soiled shirt with a wet paper towel and returned to the table to complete his meal. Resident 25 did not request another milk and the facility did not offer Resident 25 a replacement beverage. During an interview with Resident 25, on March 24, 2019, at 1:05 PM, Resident 25 stated milk was one of his favorite beverages. Resident 25 further stated, Drinking milk from the carton is just too hard sometimes because my hands shake. It's frustrating. Resident 25 stated the facility had placed an empty sippy cup onto his meal tray on several occasions. Resident 25 stated he did not use the sippy cup because there was never nothing in the cup. Resident 25 pointed to another resident's tray who had a sippy cup on their tray and stated, See, there is nothing in the cup. Resident 25 stated due to his hand tremors and weakness, It is impossible to twist the lid off the cup. Resident 25 stated he may have used the sippy cup if there had been something in the cup. During a follow up interview with Resident 25, on March 27, 2019, at 6:53 AM, Resident 25 stated, I spill my drinks a lot because my hands shake really bad. I cannot stop the shaking. Resident 25 stated he would stop eating when he spilled his drink because he did not like to be wet and dirty. Resident 25 further stated if there was a big spillage he would leave the dining room to change his soiled clothing. A review of Resident 25's care plan titled, Nutrition dated February 27, 2018, indicated, Focus: The resident has nutritional problems. Interventions/Tasks: Weighted utensils with every meal. A review of the Physician Order for Resident 25, dated September 7, 2018, indicated, Weighted utensils with every meal. A review of Resident 25's Dietary Quarterly Assessment dated October 6, 2018, indicated, Resident Information: resident is on a fortified (no added salt) NAS mechanical soft ground diet with thin liquids. Needs assistance at time with meals due to shaking. Is assisted when (Resident 25) can't control shaking. Receives sippy cup and weighted utensils. A review of the Physician Order for Resident 25, dated March 11, 2019, indicated Sippy cup with all meals. During an interview with LVN 4, on March 24, 2019, at 1:15 PM, LVN 4 stated she did not know if Resident 25's meal service included an adaptive drinking device. LVN 4 viewed Resident 25's meal card and stated Resident 25 should have had a sippy cup on his tray. LVN 4 further stated the staff are responsible for assisting residents with their meal set-up as needed. During an interview with the Director of Nursing (DON), on March 24, 2019, at 1:20 PM, the DON stated Resident 25 did not receive a sippy cup with lunch service. The DON stated Resident 25 should have received a sippy cup. The DON further stated if Resident 25 received milk, juice, and a milk shake during meal time, Resident 25 needed more than one sippy cup. The DON stated there was room for education on adaptive devices (sippy cups). During an interview with the Registered Dietitian (RD), on March 25, 2019, at 4:20 PM, the RD stated Resident 25 struggles with holding a drinking cup and using eating utensils. The RD stated Resident 25's physician had ordered an adaptive cup to assist with the meals. The RD further stated the facility should have provided an adaptive cup for Resident 25. The RD stated one of the facility's goal is to prevent avoidable dehydration and weight loss. Review of the facility's policy and procedure titled, Assistance with Meals, revised July 2017, indicated Policy Statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Residents Who May Benefit from Assistive Devices: 1. Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. These may include devices such as silverware with enlarged/paddled handles, plate guards and/or specialized cups. 2. Assistance will be provided to ensure the residents can use and benefit from special eating equipment and utensils.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure in maintaining copies of medication regimen review (MRR- review of resident's medications to identify irregularities or adverse effects) reports, including physician responses, as part of the permanent medical record for two of five sampled residents reviewed for Medication Regimen Review (Residents 26 and 14). This failed practice had the potential for inconsistent care coordination and unmet care needs for Residents 26 and 14. Findings: 1. During a review of Resident 26's medical record, the face sheet (contains demographic information) indicated Resident 26 was admitted to the facility on [DATE], with diagnoses of dementia (decline in memory and other mental abilities) and schizoaffective disorder (a mood disorder). During a review of the Consultant Pharmacist's MRR from September 1, 2018 to September 10, 2018, it indicated the pharmacist wrote a report to Resident 26's physician regarding an irregularity for Resident 26's Risperdal (medication used for mental disorders) and Aricept (medication for dementia). During a concurrent interview and record review with the Director of Nursing (DON), on March 28, 2019, at 10:31 AM, the DON reviewed Resident 26's medical record and was unable to locate Resident 26's physician's MRR response. 2. During a review of Resident 14's medical record, the face sheet indicated Resident 14 was admitted to the facility on [DATE], with diagnoses of dementia and Alzheimer's disease (brain disorder that causes problems with memory, thinking and behavior). A review of the Consultant Pharmacist's MRR, from August 1, 2018 to August 14, 2018, indicated the pharmacist wrote a report Resident 14's physician regarding an irregularity for Resident 14's Nuedexta (medication used for Pseudobulbar affect (PBA- neurologic disorder). During a concurrent interview and record review with the Director of Nursing (DON), on March 28, 2019, at 10:40 AM, the DON reviewed Resident 14's medical record and was unable to locate Resident 14's physician's MRR response. The DON stated there is a system breakdown with how the facility addresses the MRR. He further stated all of the resident's MRR reports including the physician's MRR response are not being kept as a part of the resident's medical record. The DON stated the facility has not been following their policy and procedure. During an interview with the Medical Records Director (MRD), on March 28, 2019, at 10:42 AM, the MRD verified the MRR reports including the physician's MRR response were not maintained on the resident's medical record. Review of the facility's policy and procedure titled, Medication Regimen Review, revised April 2007, indicated Copies of drug/medication regimen review reports, including physician responses will be maintained as part of the permanent medical record.

Based on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to implement and evaluate systemic measures to ensure oversight of the following: 1. Food and Nutrition Services (Refer to F812 Food Procurement, Store/Prepare/Serve/ Sanitary) 2. Infection Control (Refer to F880 Infection Prevention and Control) This failed practice had the potential to negatively affect the improvement of the residents' quality of care, quality of life and safety in a highly susceptible population of 36 residents. Findings: During an interview with the Administrator (ADM) and Director of Staff Development/Infection Control Nurse (DSD/ICN), on March 28, 2019, at 2:08 PM, the systemic issues identified during the survey process were discussed. The issues included sanitary practices by the dietary department, and infection control practices regarding tuberculosis screening. The DSD/ICN stated the issues were not evaluated for quality improvement monitoring. The DSD/ICN further stated The QAPI was not able to identify these issues [in food and nutritional services and infection control] before you [California Department of Public Health] arrive here [facility]. The facility's policy and procedure titled Quality Assurance and Performance Improvement (QAPI) Program revised April 2014, indicated The QAPI program has been developed with five strategic elements in mind .1. Design and scope: a. The program is ongoing and comprehensive. B. It involves the full range or services and departments in the facility. C. It covers all systems of care and management practices with priority given to quality care, quality of life and resident choice. Further review indicated The following steps are employed or will be employed to support and enhance the facility QAPI program: .Recognizing patterns in systems of care that can be associated with quality problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive assessment done on Minimum Data Set (MDS- a facility assessment tool) for a resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for two of five sampled residents reviewed for PASRR (Residents 4 and 19), when: 1. For Resident 4, Resident 4's PASRR was not re-evaluated after a SCSA was completed on December 10, 2018. 2. For Resident 19, Resident 19's PASRR was not re-evaluated after a SCSA was completed on January 19, 2019. These failed practices had the potential for unmet care needs for Residents 4 and 19. Findings: 1. During an observation on March 24, 2019, at 10:33 AM, in Resident 4's room, Resident 4 was lying flat in bed, resting. During a review of Resident 4's clinical record, the face sheet (contains demographic information) indicated Resident 4 was admitted to the facility on [DATE], with diagnoses of dementia (decline in memory and other mental abilities) and major depressive disorder (a mood disorder). During a review of Resident 4's MDS, it indicated a SCSA was completed for Resident 4 on December 10, 2018. During a concurrent interview and review of Resident 4's clinical record with the MDS Nurse, on March 26, 2019 at 1:50 PM, the MDS Nurse stated Resident 4's most current PASRR was dated September 11, 2018. During a subsequent interview and record review of Resident 4's MDS dated [DATE], with the MDS Nurse, on March 26, 2019, at 1:53 PM, the MDS Nurse stated a SCSA was completed for Resident 4 on December 20, 2018 because she had a new order for an antidepressant and was recently diagnosed of depression. The MDS Nurse stated Resident 4's PASRR should have been re-evaluated after the completion her SCSA. The MDS Nurse further stated I was unaware we [facility] were supposed to do it (Re-evaluation of PASRR after a SCSA). During a follow up interview and concurrent record review with the MDS Nurse, on March 26, 2019, at 2:37 PM, the MDS Nurse reviewed the facility's policy and procedure titled Antipsychotic Medication Use PASSR. The MDS Nurse stated the policy and procedure was not followed. The facility's policy and procedure titled Antipsychotic Medication Use PASRR dated December 2016, indicated Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. The interdisciplinary team will: a. Complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals). If appropriate; or b. Re-evaluate PASRR yearly and when a COC is completed. 2. During an observation on March 25, 2019, at 11:19 AM, in Resident 19's room, Resident 19 was lying in a semi-upright position, sleeping. During a review of Resident 19's clinical record, the face sheet indicated Resident 19 was admitted to the facility on [DATE], with diagnoses of dementia and major depressive disorder. During a review of Resident 19's MDS, it indicated a SCSA was completed for Resident 19 on January 19, 2019. During a concurrent interview and review of Resident 19's clinical record, with the MDS Nurse, on March 26, 2019 at 1:56 PM, the MDS Nurse stated Resident 19's most current PASRR was dated March 3, 2018. During a subsequent interview and record review of Resident 19's MDS, dated [DATE], with the MDS Nurse, on March 26, 2019, at 1:58 PM, the MDS Nurse stated a SCSA was completed for Resident 19 on January 19, 2019, because of a decline in her Activities of Daily Living (ADLs-routine activities people do every day without assistance) and ambulation. The MDS Nurse stated Resident 19's PASRR should have been re-evaluated after the completion her SCSA. The MDS Nurse further stated she just recently learned the PASRR needed to be re-evaluated after a SCSA during the recertification survey. During a follow up interview and concurrent record review with the MDS Nurse, on March 26, 2019, at 2:55 PM, the MDS Nurse reviewed the facility's policy and procedure titled Change of Condition/PASRR. The MDS Nurse stated the policy and procedure was not followed. Review of the facility's policy and procedure titled, Change of condition/ PASSR, revised December 2016, indicated Resident PASSR will be re-evaluated when a Significant Change of condition is warranted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their policy and procedure on infection control and prevention when: 1. Tuberculosis infection and disease (lung disease) screening was not done on admission or readmission to the facility for six of 35 eligible sampled residents (Resident 3, 4, 7, 13, 21, and 27). 2. Tuberculosis infection and disease screening was not done annually for twelve of 35 eligible sampled residents (Resident 5, 9, 10, 11, 14, 17, 18, 20, 23, 25, 30, and 36). 3. A soiled lunch tray with food waste was stored on the lunch cart with food trays that were being served to other residents. These failures placed the facility's residents at a greater risk for exposure to germs and had the potential to result in a preventable infection. Findings: 1. A review of Resident 3's clinical records indicated, Resident 3 was readmitted to the facility on [DATE]. The facility discovered TBS was not administered for five months after readmission. TBS was administered on March 27, 2019. 1a. A review of Resident 4's clinical records indicated, Resident 4 was admitted to the facility on [DATE]. The facility discovered TBS was not administered for six months after admission. TBS was administered on March 27, 2019. 1b. A review of Resident 7's clinical records indicated, Resident 7 was readmitted to the facility on [DATE]. The facility discovered TBS was not administered for five months after readmission. TBS was administered on March 25, 2019. 1c. A review of Resident 13's clinical records indicated, Resident 13 was readmitted to the facility on [DATE]. The facility discovered TBS was not administered for five months after readmission. TBS was administered on March 27, 2019. 1d. A review of Resident 21's clinical records indicated, Resident 21 was admitted to the facility on [DATE]. The facility discovered TBS was not administered for two months after admission. TBS was administered on March 27, 2019. 1e. A review of Resident 27's clinical records indicated, Resident 27 was readmitted to the facility on [DATE]. The facility discovered TBS was not administered for five months after readmission. TBS was administered on March 27, 2019. An interview and review of the Immunization Report for the facility's residents, with the Infection Control Nurse (ICN), on March 26, 2019, at 1:30 PM, the ICN stated tuberculosis screening (TBS) was not done on admission to the facility for Resident 4 and Resident 21. The ICN further stated TBS was not done on readmission to the facility for Resident 3, 7, 13, and 27. The ICN stated if staff did not document the TBS administration information or the TBS results in the resident's clinical record, then the resident did not have a TBS on admission or readmission to the facility. During a follow up interview with ICN, on March 28, 2019, at 7:51 AM, the ICN stated the facility should have performed TBS for all residents on admission and readmission to the facility. The ICN stated Resident 4 and Resident 7 did not have documentation in their clinical record for TBS on admission to the facility. The ICN further stated Resident 3, 7, 13, and 27 did not have documentation in their clinical record for TBS on admission to the facility. The ICN stated TBS should have been done on admission to the facility for Resident 4 and Resident 7. The ICN further stated TBS should have been done on readmission to the facility for Resident 3, 7, 13, and 27. The ICN stated the policy and procedure had not been followed for TBS. 2. A review of Resident 5's clinical records indicated, Resident 5's last TBS was administered on December 13, 2017. The facility discovered TBS was due on December 13, 2018, three months later. TBS was administered on March 25, 2019. 2a. A review of Resident 9's clinical records indicated, Resident 9's last TBS was administered on March 20, 2018. The facility discovered TBS was due on March 20, 2019, five days later. TBS was administered on March 25, 2019. 2b. A review of Resident 10's clinical records indicated, Resident 10's last TBS was administered on March 9, 2018. The facility discovered TBS was due on March 9, 2019, sixteen days later. TBS was administered on March 25, 2019. 2c. A review of Resident 11's clinical records indicated, Resident 11's last TBS was administered on July 18, 2017. The facility discovered TBS was due on July 18, 2018, eight months later. TBS was administered on March 27, 2019. 2d. A review of Resident 14's clinical records indicated, Resident 14's last TBS was administered on February 23, 2017. The facility discovered TBS was due on February 23, 2018, thirteen months later. TBS was administered on March 27, 2019. 2e. A review of Resident 17's clinical records indicated, Resident 17's last TBS was administered on July 18, 2017. The facility discovered TBS was due on July 18, 2018, eight months later. TBS was administered on March 25, 2019. 2f. A review of Resident 18's clinical records indicated, Resident 18's last TBS was administered on March 16, 2018. The facility discovered TBS was due on March 16, 2019, nine days later. TBS was administered on March 25, 2019. 2g. A review of Resident 20's clinical records indicated, Resident 20's last TBS was administered on March 9, 2018. The facility discovered TBS was due on March 9, 2019, sixteen days later. TBS was administered on March 25, 2019. 2h. A review of Resident 23's clinical records indicated, Resident 23's last TBS was administered on July 11, 2017. The facility discovered TBS was due on July 11, 2018, eight months later. TBS was administered on March 25, 2019. 2i. A review of Resident 25's clinical records indicated, Resident 25's last TBS was administered on March 16, 2018. The facility discovered TBS was due on March 16, 2018, nine days later. TBS was administered on March 25, 2019. 2j. A review of Resident 30's clinical records indicated, Resident 30's last TBS was administered on March 9, 2018. The facility discovered TBS was due on March 9, 2019, sixteen days later. TBS was administered on March 25, 2019. 2k. A review of Resident 36's clinical records indicated, Resident 36's last TBS was administered on March 16, 2018. The facility discovered TBS was due on March 16, 2019, nine days later. TBS was administered on March 25, 2019. An interview and review of the Immunization Report for the facility's residents, with the ICN, on March 26, 2019, at 1:45 PM, the ICN stated TBS was not performed annually for Residents 5, 9, 10, 11, 14, 17, 18, 20, 23, 25, 30, and 36. The ICN stated if staff did not document the TBS administration information or the TBS results in the resident's clinical record, then the resident did not have an annual TBS in accordance to the facility's policy and procedure. During an interview with the ICN, on March 28, 2019, at 7:51 AM, the ICN stated a TBS risk assessment had been conducted in January 2019 through the Infection Prevention and Control Program (IPCP). The ICN stated the risk classification was identified as medium risk which indicated the need for annual TBS. The ICN stated Resident 5, 9, 10, 11, 14, 17, 18, 20, 23, 25, 30, and 36 did not have documentation for an annual TBS in their clinical record. The ICN further stated Resident 5, 9, 10, 11, 14, 17, 18, 20, 23, 25, 30, and 36 should have had an annual TBS. The ICN stated the policy and procedure had not been followed for TBS. During a concurrent interview with the Quality Assurance and Performance Improvement (QAPI) committee which included the Administrator (ADM 1) and Infection Control Nurse (ICN), on March 28, 2019, at 1:57 PM, the ICN stated TBS had been missed for several residents. The ADM 1 stated the QAPI committee oversees the TBS process to ensure the delivery of quality care and services are provided to each resident. The ICN stated the QAPI committee had learned the facility did not screen the residents in accordance to the facility's policy and procedure during the recertification survey findings. The facility's policy and procedure titled Tuberculosis, Screening Residents revised July 2018, indicated Policy Statement: This facility shall screen all residents for tuberculosis infection and disease (TB) .Screening New Admissions or Readmissions: 1. The facility will screen referrals for admission and readmission for information regarding exposure to, or symptoms of, TB and will check results .7. Screening of new admissions and readmissions for tuberculosis infection and disease will be in compliance with state regulations . Serial Testing of Residents: .3. If the risk classification is identified as medium risk for transmission of TB, residents will receive an annual TST, with the exception of known converters (those who previous skin tests are positive). For known skin test converters, the physician will complete and review a symptoms questionnaire annually. 3. During an observation on March 24, 2019, at 12:24 PM, in the dining room, a soiled lunch tray with food waste was stored on the lunch cart with food trays that were being served to residents. During an interview with the Administrator (ADM 2), on March 24, 2019, at 12:24 PM, ADM 2 stated the used tray should not have been placed on the cart with the unused trays. During an interview with a Licensed Vocational Nurse (LVN 4), on March 24, 2019, at 12:28 PM, LVN 4 stated used trays are considered dirty trays and should not be mixed with clean trays. LVN 4 stated, It's an infection control issue. LVN 4 further stated mixing clean items with dirty items could cause cross-contamination (germs transferred from one surface or food to another) and lead to serious health infection. During an interview with the Infection Control Nurse (ICN), on March 28, 2019, at 8:11 AM, the ICN stated used trays with food waste are presumed to contain transmissible infectious agents. The ICN stated the soiled tray should not have been placed on the cart with trays that were being distributed to other residents. The ICN further stated the facility should have distributed the food trays in a manner which would have avoided the possibility for transfer of microorganisms (germs) to other residents and the environment. A review of the facility's policy and procedure titled Preventing Foodborne Illness-Food Handling dated December 21, 2018, indicated Policy Statement: Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. A review of the facility's policy and procedure titled Standard Precautions revised December 21, 2018, indicated Policy Statement: standard precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement their policy and procedure for Preventing Foodborne Illness- Food Handling in the kitchen when: 1. The refrigerator temperature and freezer temperature was not monitored for three consecutive days to ensure the refrigerator's temperature was within 36 degrees Fahrenheit (F- unit of measurement) to 41 degree F and the freezer temperature was zero degree F (food frozen solid). 2. The concentration of the sanitizer in the handwashing bucket was not tested for three consecutive days. 3. An opened bag of lettuce stored in the refrigerator did not have a use-by date (a date placed on food items by the kitchen's staff noting when the food items should no longer be used) and was available for use. 4. Cauliflower and parsley was stored in the refrigerator unlabeled, undated and was available for use. 5. The turkey pastrami, defrosting in the refrigerator, was mislabeled and did not have a shelf date, pull date, or use-by-date and was available for use. 6. An opened container of cranberry sauce, stored in the refrigerator, did not have a use-by-date and was available for use. 7. A garden salad, stored in an insulation plate in the refrigerator, was unlabeled and was available for use. 8. Two packets of taco seasoning, one box of Couscous rice (dish made from tiny granules of wheat), and one box of honey buns were expired and were available for use. 9. An open can of stax (potato) chips was stored in the dry storage area did not have an open date or use-by-date and was available for use. 10. An opened bottle of drinking water was placed on top of the food preparation table where sandwiches were being prepared. Findings: 1. During an observation with the Cook, on March 24, 2019, at 10:15 AM, in the kitchen, the freezer temperature was -1 degree F (unit of measurement); the refrigerator (refrigerator 1) temperature was 36 degrees Fahrenheit; and refrigerator 2's temperature was 38 degrees F. During a concurrent interview and record review of the freezer and refrigerator temperature logs with the Cook, on March 24, 2019, at 10:17 AM, the [NAME] stated refrigerator 1, refrigerator 2, and the freezer temperature were not recorded for three consecutive dates, March 21, 2019, March 22, 2019, and March 23, 2019. The [NAME] further stated if the temperatures were not recorded then the freezer and refrigerators were not monitored. The [NAME] stated refrigerator's temperature should range from 36 degree F to 41 degree F and the freezer's temperature should be at least zero degree F. The [NAME] stated bacteria growth starts to triple at 40 degree F and food items start to freeze at 32 degrees F. During an interview with the Director of Dietary Services (DDS), on March 24, 2019, at 10:58 AM, the DDS stated the refrigerator and freezer temperatures should be monitored daily and recorded three times a day for safety. The DDS stated food items stored at an unsafe temperature could cause foodborne illnesses (Illness caused by food contaminated with bacteria, viruses, and parasites). A record review of the facility's Freezer and Refrigerator Temperature Record (multiple units) dated 2012, indicated Record temperatures of freezer and refrigerators twice daily. Any unit not at proper temperature must be reported to the Dietary Service Supervisor or maintenance department at once. Proper Temperatures: Freezer 0 degree Fahrenheit recommended (Food must be solid). Refrigerator: 36 degrees Fahrenheit to 41 degrees Fahrenheit. Review of the facility's policy and procedure titled, Preventing Foodborne Illness-Food Handling, revised December 21, 2018, indicated Monitoring Refrigeration/Food Temperatures: 5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state-specific requirements. 2. During an observation with a Dietary Aide (DA 2), on March 24, 2019, at 10:20 AM, in the kitchen, the handwashing bucket was filled with water and contained cleaning cloths for wiping surfaces in the kitchen. During an interview with DA 2, on March 24, 2019, at 10:22 AM, DA 2 stated she had filled the handwashing bucket with a chemical sanitizer solution but had not tested the concentration of the sanitizer on March 24, 2019. DA 2 further stated the handwashing bucket for cleaning cloths was not tested on [DATE], March 22, 2019, and March 23, 2019. DA 2 stated the buckets should be filled three times a day and she was responsible for filling and testing the bucket solution. DA 2 stated she did not know why the solution concentration was not documented. During an interview with the DDS, on March 24, 2019, at 11:00 AM, the DDS stated the handwashing buckets are monitored to ensure that cleaning cloths are sanitary. The DDS further stated the cloths are used for wiping surfaces in the kitchen. The DDS stated education is needed for the sanitizer bucket care, maintenance, and use. Review of the facility's policy and procedure titled, Sanitizer Bucket for Cleaning Cloths, dated January 1, 2017, indicated policy: to monitor the hand washing bucket sanitizer to ensure that cleaning cloths are sanitary. Procedure: Sanitizer buckets are filled with warm water and an appropriate sanitizer at a high concentration to ensure that the solution stays effective .Test concentration of sanitizer with appropriate test strips and document. 3. During an observation with the Cook, on March 24, 2019, at 10:25 AM, an opened bag of lettuce was stored in the refrigerator 2. The bag of lettuce had an open date of March 17, 2019. There was no use-by-date observed on the bag. During an interview with the Cook, on March 24, 2019, at 10:26 AM, the [NAME] stated the bag of lettuce was not labeled with a use-by date. The [NAME] stated a use-by-date should have been attached to the lettuce package within seven days of opening the package to conserve nutritive value, flavor, color and prevent food borne illnesses. Review of the facility's policy and procedure titled, Food Preparation-Vegetables, dated 2012, indicated 2. Commercially pre-washed, pre-cut, and pre-packaged lettuce and other fruit and vegetables are considered edible without further preparation. They must be date mark once opened with a use-by date within 7 days of opening. 4. During an observation with the Cook, on March 24, 2019, at 10:28 AM, cauliflower and parsley was stored in the refrigerator 2. The cauliflower and parsley was unlabeled, undated, and was available for use. During an interview with the Cook, on March 24, 2019, at 10:29 AM, the [NAME] stated the cauliflower and parsley was not labeled and should have been labeled with a use-by-date. Review of the facility's policy and procedure titled, Food Preparation-Vegetables, dated 2012, indicated 2. Commercially pre-washed, pre-cut, and pre-packaged lettuce and other fruit and vegetables are considered edible without further preparation. They must be date mark once opened with a use-by date within 7 days of opening. 5. During an observation of the refrigerator 1 with the Cook, on March 24, 2019, at 10:33 AM, bacon and turkey pastrami was thawing in a pan on the lowest shelf. The turkey pastrami was labeled as ham, undated, and was available for use. During an interview with the Cook, on March 24, 2019, at 10:36 AM, the [NAME] stated the turkey pastrami had been mislabeled as ham and the turkey pastrami should have been dated. The [NAME] stated the bacon should not have been stored on top of the turkey pastrami during the thawing process to minimize possible contamination. During an interview with the DDS, on March 24, 2019, at 11:10 AM, the DDS stated the policy and procedure for thawing meat was not followed. The DDS stated the bacon and turkey pastrami should have been stored in separate pans to minimize possible contamination. The DDS further stated the bacon and turkey pastrami should have been labeled with a freezer pull date (date removed from the freezer) and a use-by-date. Review of the facility's policy and procedure titled, Food Preparation-Meat, Poultry, Fish, dated 2012, indicated 2b. Place thawing meat on leak-proof trays on the lowest refrigerator shelf. Date thawing meat with freezer pull date and use-by date. 6. During an observation with the Cook, on March 24, 2019, at 10:40 AM, an opened container of cranberry sauce was stored in the refrigerator 2, with an open date of March 15, 2019. The cranberry sauce did not have a use-by-date and was available for use. During an interview with the Cook, on March 24, 2019, at 10:43 AM, the [NAME] stated the cranberry sauce was not dated with a use-by-date and should have been dated with a use-by-date. Review of the facility's policy and procedure titled, Labeling/ Date Marking and Safe Storage of Refrigerated and Frozen Foods, dated January 1, 2017, indicated .Practices to maintain safe refrigerated storage include .labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date or frozen (when applicable) or discarded. 7. During an observation with the Cook, on March 24, 2019, at 10:46 AM, a garden salad was stored in an insulation plate in the refrigerator 2. The garden salad was unlabeled, undated, and was available for use. During an interview with the Cook, on March 24, 2019, at 10:47 AM, the [NAME] stated the garden salad was not labeled and did not have a use-by date. The [NAME] stated the salad should have been labeled with the name of the food item and dated with a use-by-date. Review of the facility's policy and procedure titled, Labeling/ Date Marking and Safe Storage of Refrigerated and Frozen Foods, date January 1, 2017, indicated .Practices to maintain safe refrigerated storage include .labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date or frozen (when applicable) or discarded. 8. During an observation with the DDS, on March 24, 2019, at 11:33 AM, in the dry storage area, two packets of taco seasoning had a manufacture's expiration date (a date placed on food items by the manufacturer noting when the food items should no longer be used) of September 1, 2017; one box of Couscous rice had a manufacture's expiration date of May 17, 2018; and one box of honey buns had a manufacture's expiration date of November 2018 and were available for use. During an interview with the DDS, on March 24, 2019, at 11:40 AM, the DDS stated the two packets of taco seasoning, one box of couscous rice, and the box of honey buns were expired. The DDS further stated the food items should have been removed from storage on or before the manufacture's expiration date. Review of the facility's policy and procedure titled, Safe Food Handling and Storage, dated September 2018, indicated Date any undated products you may have purchased and be sure to use them within the recommended time. 9. During an observation with the Director of Dietary Services (DDS), on March 24, 2019, at 11:43 AM, one can of stax chips was observed half full. The can of chips did not have an opened date or use-by-date. During an interview with the DDS, on March 24, 2019, at 11:44 AM, the DDS stated she had no way to identify when the can of chips had been opened. The DDS stated the can of chips should have had an opened date and use-by-date, and should have been discarded. Review of the facility's policy and procedure titled, Purchasing and Storing undated, indicated , This table is a general guideline for best product quality and overall safety. Where applicable always use any product by its use-by date marked on the package if purchase date is unknown or if quality or safety is compromised in any way, discard product. 10. During an observation with the Cook, on March 24, 2019, at 10:10 AM, DA 2 was preparing peanut butter and jelly sandwiches on the food preparation area. An opened bottle of water was stored on the food preparation table where the sandwiches were being prepared. During a concurrent interview with DA 2, on March 24, 2019, at 10:12 AM, DA 2 stated she had been drinking the water and did not know the bottle of water could not be stored on food preparation table. During an interview with the Cook, on March 24, 2019, at 10:14 AM, the cook stated the bottle of water should not be placed on the food preparation table to prevent cross-contamination. Review of the facility's policy and procedure titled, Standard Precautions, revised December 21, 2018, indicated Policy Statement: standard precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents.