**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to honor a food request for one of one sampled residents (Resident 59), when a Licensed Vocational Nurse (LVN) denied his verbal request for a biscuit and did not offer him an alternative item. This failure resulted in Resident 59's individual preference or choice being devalued (reduce or underestimate the worth of importance of) and not being treated with honor or respect. Findings: During an observation on 5/30/23, at 12:10 p.m., in the resident dining room, Resident 59 asked licensed vocational nurse (LVN) 2 if he could have a biscuit instead of two pieces of toast on his plate. Three other residents at his table had biscuits. Resident 59 went and sat back down and five minutes later got up to ask again. Resident 59 was not given the biscuit and did not receive an alternative. During an interview on 5/30/23, at 12:16 p.m., with LVN 2, LVN 2 stated, if Resident 59 would like an alternative then he needed to finish his current meal first and then Resident 59 could have a biscuit. LVN 2 stated, Resident 59 was a diabetic, but Can't deny him if that's what he wants. During a review of Resident 59's Order Summary Report- Dietary (OSRD), dated 6/1/23, the OSRD indicated, .Diet- Reduced Concentrated Sweets (RCS- a diet avoiding foods with a lot of sugar or high calorie sweeteners) diet, regular texture, thin consistency, related to Type 2 Diabetes Mellitus (a disease of inadequate control of blood levels of glucose) without complications . During a review of Resident 59's Meal Ticket (MT), dated 5/30/23, the MT indicated, Noon Meal .Diet Order: RCS .Diet Cons: Regular .Bread* 1-each .Apple Crisp* . During an interview on 6/1/23, at 11:38 p.m., with the Registered Dietician (RD), the RD stated, the RCS diet should be getting smaller portions of the concentrated sweets, such as, a smaller dessert or no whip cream on top of dessert. The RD stated, the RCS diet was not a diet for carbohydrate (essential nutrients which include sugars, fibers and starches) control, it was for sweets only. The RD stated, Resident 59's request for a biscuit should have been honored and it was his right to receive one if he wishes. The RD stated, it was not proper to have Resident 59 finish his meal first and get the biscuit as a second serving. During an interview on 6/1/23, at 2:20 p.m., with the Dietary Supervisor (DSS), the DSS stated, she never received a request for Resident 59 to have a biscuit from staff, if she did, she would have honored the request. During an interview on 6/1/23, at 2:41 p.m., with Resident 59, Resident 59 stated, he looked on the menu board before lunch, read the menu and saw they were having biscuits for the day. Resident 59 stated, he did not know why he received bread instead of a biscuit like other residents at his table. Resident 59 stated, he was upset and bothered that he did not receive a biscuit. During a review of Resident 59's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 59's MDS assessment indicated, Resident 59's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 14 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 59 was cognitively intact. During an interview on 6/2/23, at 10:17 a.m., with the Director of Nursing (DON), the DON stated, he was unsure of what the RCS diet consisted of and he would defer to the RD or DSS. The DON stated, LVN 2 should have notified the DSS of Resident 59's biscuit request. The DON stated, it appears Resident 59's rights were not honored. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 2/2021, the P&P indicated, . b. be treated with respect, kindness and dignity . f. communication with and access to people and services, both inside and outside the facility . h. be supported by the facility in exercising his or her rights . The facility's definition of an RCS diet was requested, but not provided. The facility provided a document titled, Controlled-Carbohydrate Diet (CCD), dated January 2022, CCD indicated, .The American Diabetes Association states the terms reduced concentrated sweets (RCS), no sugar added and ADA diets are inappropriate because these terms do not reflect current nutrition recommendations . The controlled-carbohydrate diet meets the RDA of the National Academies for persons 51 and over .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to inventory personal property for one of one sampled residents (Resident 14) when Resident 14's hand-held radio was not inventoried (item entered in to a list). This failure resulted in Resident 14's property being lost or stolen and the facility not replacing it. Findings: During a concurrent observation and interview on 5/30/23, at 9:46 a.m., with Resident 14, in Resident 14's room, a small black hand-held radio was seen on his nightstand next to his bed. Resident 14 stated, he had a box sized radio missing a year or so ago and was not replaced. Resident 14 stated, it was a boom box. Resident 14 stated, the small radio on the nightstand was a different radio and his other boom box size radio was never replaced. During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 14's MDS assessment indicated Resident 14's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 14 was cognitively intact. During an interview on 5/31/23, at 3:52 p.m., with the Social Services Director (SSD), the SSD stated, Resident 14 has had the black radio that is bedside since she has been here. The SSD stated, she had been working at the facility for about a year. The SSD stated, I know he [Resident 14] said the black radio was stolen, but he already has a radio. I discussed it with the conservator about replacing it, but it wasn't on his inventory sheet. The SSD stated, it was the program counselor's responsibility to update the inventory sheets. During a concurrent interview and record review on 5/31/23, at 3:54 p.m., with the SSD, Resident 14's Inventory List (IL), dated 1/5/12 was reviewed. The IL indicated, no record of the current black radio that was on Resident 14's nightstand. The SSD stated, there were no other inventory lists made for Resident 14 and the current black radio he had was not on the IL in the chart. The SSD stated, program counselors could not find His current black radio on an inventory sheet either. The SSD stated, The inventory sheet is there as evidence to show if things go missing. The SSD stated, the facility can not replace items if they are not on the inventory sheet. During a concurrent interview and record review on 6/1/23, at 10:55 a.m., with the Director of Nursing (DON), Resident 14's IL, dated 1/5/12 was reviewed. The IL indicated, no record of the current black radio that was on Resident 14's nightstand. The DON stated, The inventory list is not updated when it should have been. DON stated, Everything in the room that is a personal item, should be on the inventory list. DON stated, IL should be updated at admission and as needed by staff. During a concurrent interview and record review on 6/1/23, at 10:55 a.m., with the DON, the facility's policy and procedure (P&P) titled, Personal Property, dated August 2022, was reviewed. The P&P indicated, .10. The resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary . The DON stated, The policy was not followed for [Resident 14]. He should have had the radio on his inventory list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to allow residents to submit grievances (complaints) anonymously (not being named or identified) for one of four sampled residents (Resident 60) when the grievance box was inaccessible (not able to be accessed) for residents to submit grievances anonymously. This failure resulted in Resident 60 not being able to voice concerns without discrimination, or fear of reprisal (retaliation). Findings: During an interview on 5/31/23, at 11:38 p.m., with Resident 60, the Resident 60 stated, handing the grievance form to a staff member to place in the grievance box would no longer make him anonymous. Resident 60 stated, I want to stay anonymous, so that I feel safe. Resident 60 stated, if staff knew it was him making the complaint, he would be embarrassed and get upset. During a review of Resident 60's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 60's MDS assessment indicated Resident 60's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 60 was cognitively intact. During a concurrent observation and interview on 5/31/23, at 1:54 p.m., with the Activities Director (AD), in the locked nursing station (NS), grievance box 1 was observed to be located on the door of the schedule coordinator's office inside the nursing station, inaccessible to residents. The AD stated, the resident would have to give their grievance to staff and staff would have to put it in the grievance box for them. The AD stated, the resident would not be anonymous anymore by giving their form to a staff member. During a concurrent observation and interview on 5/31/23, at 1:54 p.m., with the AD, in the south wing hallway, grievance box 2 was observed to be located behind two locked double doors, outside of the unit, inaccessible to residents. The AD stated, the resident would have to give their grievance to staff and staff would have to put it in the grievance box for them. The AD stated, the resident would not be anonymous anymore due to having to give their form to a staff member. The AD stated, there were only two grievance boxes in the facility. During a concurrent interview and record review on 5/31/23, at 2:39 p.m., with the Social Services Director (SSD), the facility's policy and procedure (P&P) titled, Grievances/Complaints, Filing, dated April 2017, was reviewed. The P&P indicated, .2. Residents, family and resident representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal .5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously . The SSD stated, After reviewing the P&P, we are to have it anonymous, but I can see now how it currently isn't anonymous. The SSD stated, she was the facilities grievance officer and was responsible for checking the grievance boxes. The SSD stated residents must give their grievances to staff members to place in the boxes for them because the grievance boxes were located behind locked doors. The SSD stated, Those resident grievances are no longer anonymous because staff will know it is from the resident. During an interview on 5/31/23, at 3:03 p.m., with the Director of Nursing (DON), the DON stated, residents did not have direct access to the two grievance boxes and must give their grievance form to a staff member to put in the grievance box for them. The DON stated, The grievance is no longer anonymous at the point of giving it to the staff member.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS- assessment of healthcare and functional needs) assessment accurately reflected the resident's status for one of five sampled residents (Resident 3) when Resident 3 had an open skin wound and was coded with intact skin in the MDS assessment. This failure resulted in an inaccurate assessment of Resident 3's skin condition and had the potential for Resident 3's needs to go unmet. Findings: During a review of Resident 3's face sheet titled admission Record, undated, the face sheet indicated, resident 3 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a serious mental disorder in which people interpret reality abnormally) and anxiety disorder (a mental disorder in which people have persistent and excessive worry that interferes with daily activities). During a review of Resident 3's MDS assessment, dated 5/15/23, the MDS assessment indicated Resident 3's Brief Interview for Mental Status (BIMS-screening tool used in nursing facility to assess cognition) assessment score was 15 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 3 has no cognitive deficit. During a concurrent observation and interview on 5/30/23, at 10:00 a.m., Resident 3 was observed walking in the hall in clean clothes in no apparent distress. Resident 3 had an open wound to his face on his left cheek. Resident 3 did not respond to questions about care but did say hi. During a concurrent interview and record review on 5/31/23, at 4:25 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 3's Care plan, dated 1/6/2023 and Program Counselor note, dated 5/24/2023 at 11:47 a.m., were reviewed. Resident 3's Care plan, dated 1/6/2023 indicated, .Alteration in skin integrity related to left facial pustule dt [due to] non compliance with good hygiene and non compliance with not picking at his skin . Left Facial Tumor (Assessed by NP [Nurse practitioner]) .1/6/2023. Date initiated 9/25/2020 . Assess progress of skin weekly . observe/report any skin irritation, eruption, rashes, redness, itchiness to MD [doctor] promptly . observe/report s/s [signs/symptoms] of skin infection such as local fever, redness, drainage, tenderness, pain, swelling from affected site(s) to MD promptly . Program Counselor note, dated 5/24/2023 at 11:47 a.m., indicated, DISCHAGE PLAN REVIEW: Resident was seen in staffing today with [MD 2] [calm] an [and] pleasant during the visit. IDT (Interdisciplinary team-multiple disciplines working together)reminded and educated resident regarding his refusal to have growth/lesion on his left cheek be checked out by a specialist . LVN 1 stated Resident 3 said Resident 3 scratched at the lesion and we would see blood on his pillow. LVN 1 stated if the wound was draining the nurses will try to clean it but he was non compliant and will refuse. During a concurrent interview and record review on 6/1/23, at 10:39 p.m., with LVN 1, Resident 3's Nursing Weekly Summaries, dated 5/13/2023, 5/20/2023 and 5/27/2023, were reviewed. LVN 1 stated the no skin problems was documented on 5/13/2023, 5/20/2023 and 5/27/2023 but are not accurate as he has the wound on his cheek for some time. LVN 1 stated only 5/13/2023 documented that Resident 3 refused skin assessment times three. During an interview on 6/2/2023, at 9:41 a.m., with the Director of Nursing (DON), the DON stated his expectation was nursing weekly summaries to be accurate and the nurses should document if the resident refuses to be assessed. The DON stated his expectation was the MDS assessment to be performed accurately and MDS should match the assessment of the resident when it was reported to Centers for Medicare and Medcaid Services (a government agency which provides health coverage). During a concurrent interview and record review on 6/2/23, at 10:31 a.m., with the Minimum Data Set Registered Nurse) MDSN 1, the MDSN 1 reviewed Resident 3's MDS admission assessment Section M dated 5/15/23, Section M indicated, .Skin Conditions . D. Other lesions other than ulcers, rashes, cuts (e.g. cancer lesion) . [coded as No] . The MDSN 1 reviewed Section M and stated she had entered a No for other skin conditions. The MDSN 1 stated the skin conditions, other lesions in Section M was inaccurate and should have been coded as Yes.

Based on observation, interview, and record review, the facility failed to ensure it was free of accident hazards when they did not use a wet floor sign to identify a hallway floor that was wet from mopping. This failure had the potential to result in residents, staff, and visitors slipping on the wet floor and sustaining a fall or injury. Findings: During a concurrent observation and interview on 6/1/23, at 3:10 p.m., with the Infection Preventionist (IP), in the Program Building hallway, wet floor was noted with no sign to indicate that the floor was wet. IP stated, there was no sign to indicate that the floor was wet. IP stated, housekeeping would come to mop after the residents have had their snacks. IP stated, She [housekeeper] knows better than to leave it [floor] wet like that without putting up a wet floor sign. During an interview on 6/2/23, at 2:09 p.m., with the Housekeeping Manager (HKM), HKM stated, housekeepers are supposed to have the wet floor sign up before they start mopping. They were only supposed to mop half of the hallway at a time because residents and staff come in and out of the program building we don't want them to slip. During a review of the facility's policy and procedure (P&P) titled, DAMP MOPPING, undated, the P&P indicated, .HALLWAYS AND COMMON AREAS: Use 'Wet Floor' signs to mark the wet side of floor (mop ½ hallway at a time) . During a review of the facility's P&P titled, Section F: Safety and Sanitation, dated 2/18/20, the P&P indicated, .Wet floor signs will always be used when floors are wet .

Based on interview and record review, the facility failed to complete a performance evaluation of a nurse aide at least every 12 months for one of two sampled Certified Nurse Assistant (CNA 7), when CNA 7 did not have a performance evaluation review. This failure had the potential to result in residents to not receive the appropriate care and services performed by CNA 7. Findings: During a concurrent interview and record review on 6/5/23, at 10:42 a.m., with the Director of Staff Development (DSD), CNA 7's Employee File (EF), dated 4/24/22 was reviewed. The DSD stated, the EF indicated, CNA 7 was hired on 4/24/22. The DSD stated, the EF indicated CNA 7's annual Performance Evaluation (PE) was not in the file and should have been completed in April 2023. The DSD stated, CNA 7's PE form could be with the Director of Nursing (DON), who was responsible for the completion of direct care staff evaluations. During an interview on 6/5/23, at 3:15 p.m., with the DON, the DON stated his expectations of staff annual PEs were that they should be completed within the month the staff was hired and the PE should be filed in the EF. The DON stated CNA 7 worked the night shift and he was not able to complete CNA 7's PE. The DON stated the importance of staff PEs was to allow the facility to inform the staff if they were meeting the facility's expectations and if there were any areas requiring improvements. The DON stated it was his responsibility to complete CNA 7's PE and he did not have an excuse for not completing it timely. The DON stated since CNA 7's PE was not completed, CNA 7 was not provided with an opportunity for a pay raise, was not made aware of her job performance and any improvements if required were not addressed. The DON stated PEs should be completed annually to meet regulatory requirements. During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated September 2020, the P&P indicated, . The job performance of each employee shall be reviewed and evaluated at least annually . Performance evaluations may be used in determining employee promotions, shift/position transfers, demotions, terminations, wage increases . to improve the quality of the employee's work performance . The written performance evaluations will contain the director's and/or supervisor's remarks and suggestions, any action that should be taken (e.g., further training, etc.), and goals . The completed performance evaluation will be sent by the director or supervisor to the director of human resources to be placed in the employee's personnel file. A copy will be provided to the employee .

Based on observation, interview and record review, the facility failed to destroy controlled (drugs that are tightly controlled because of their abuse potential or risk) medications per facility policy for one of two sampled medication storage rooms, when controlled substances were discarded in an unlocked medication destroy bin accessible to all staff members. This failure had the potential to result in the potential diversion (transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illegal use) of controlled medications. Findings: During an observation on 6/2/23, at 1:35 p.m., in the Nursing Station (NS), the nursing station was accessed by key via two different doors. The nursing station had a connected hallway around 10-feet long and the medication storage room was at the end of the hallway. The nursing station, connected hallway and medication storage area were all in the same room. The medication room was accessible to any employee with a key to the nurse's station. Observed in the nursing station area, were two certified nursing assistants, one person who was the scheduler and two Licensed Vocational Nurses (LVN) at their computers, with their backs to the other staff in the room. During a concurrent observation and interview on 6/2/23, at 1:50 p.m., with LVN 1, in the medication storage room, a white medication destroy bin (WMDB) with a blue unlockable lid was observed on the floor next to the medication cart. The opening to the WMDB was an estimated nine-inches in diameter and two-feet deep. Inside the WMDB were an estimated 50 medications of various tabs, pills, vials (small container made of glass, used especially for holding liquid medications) and clear packages with white residue. LVN 1 stated, the WMDB was not locked and a person could stick their arm in and access the disposed medications. LVN 1 stated, there were more than 50 pills . random pills, unsure of what they are inside of the WMDB. LVN 1 stated, any staff with a key to the nurse station could access the WMDB. LVN 1 stated, all staff have a key to the nursing station that work on the unit, including administration who also have keys. LVN 1 stated, the WMDB was where controlled medications are disposed of. LVN 1 stated, the controlled medications were disposed by crushing with a pill-crusher in a clear package and then dumping the medication and the clear package into the WMDB. LVN 1 stated, there were clear packages with white residue on them in the WMDB. LVN 1 stated, the residue inside the packages could be a narcotic (medication with numbing or paralyzing [causing a person or part of the body to become partly or wholly incapable or movement] properties). LVN 1 stated, she was unsure if there was a policy regarding medication disposal and if there was, she had never read it. During a concurrent observation and interview on 6/2/23, at 2:32 p.m., with the Assistant Director of Nursing (ADON), in the medication storage room, the WMDB was observed. The ADON stated, every medication that needs to be disposed went into the WMDB, but only controlled medications were crushed. The ADON stated, any staff member with keys can access the WMDB because there wasn't a door to the medication storage room. The ADON stated, there were roughly 100 or more pills inside of the WMDB. During a concurrent observation and interview on 6/2/23, at 2:32 p.m., with the Director of Nursing (DON), in the medication storage room, the WMDB was observed. The DON stated, there was not a door to the medication storage room and it was possible for anyone to go in and open the WMDB because it was not locked. The DON stated, a person could stick their arm in the WMDB and take out anything they wanted. During an interview on 6/5/23, at 10:15 a.m., with the Pharmacy Consultant (PC), the PC stated, there was a chance someone could come in the room and access the WMDB because there was not a locked door to the medication storage room. The PC stated, there was a possibility of getting a controlled medication from the WMDB because the facility was not disposing the medication in a drug buster solution (DBS- solution that makes the controlled medication ineffective or harmless). The PC stated, the DBS, makes the controlled medication unretrievable and adds an extra layer of protection. The PC stated, he thought the facility was already using the DBS for controlled substances and did not know they were not. During an interview on 6/5/23, at 2 p.m., with the DON, the DON stated, the facility had some holes that needed to be fixed and stated there should be improvements to their medication disposal process. During a concurrent interview and record review on 6/5/23, at 2 p.m., with the DON, the facility's policy and procedure (P&P) titled, Discarding and Destroying Medications, dated November 2022 was reviewed. The P&P indicated, .Medications that cannot be returned to the dispensing pharmacy (e.g., non-unit dose medications, medications refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, state and local regulations governing management of non-hazardous waste and controlled substances . 7. For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the Environmental Protection Agency recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. B. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage . The DON stated, the facility was not following this P&P.

Based on observation, interview, and record review the facility failed to provide dental services to meet the needs of each resident and follow its policy titled, Dental Services, for one of eight sampled residents (Resident 34), when Resident 34 broke his dentures in November 2022, informed staff and no dental appointment was made. This caused Resident 34 to miss out on foods that he enjoyed due to not having his dentures to use. Findings: During a review of Resident 34's Face Sheet (document that provides demographic information on the resident i.e. name, date of birth , insurance, contact information and diagnosis), dated 6/2/23 and Brief Interview for Mental Status (BIMS- a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility), dated 3/21/23, the Face Sheet indicated Resident 34 was admitted to this facility on 6/15/2018 with diagnosis of Schizoaffective Disorder Bipolar Type (a mental illness that can affect your thoughts, mood and behavior), Diabetes type 2 (A chronic condition that affects the way the body processes blood sugar.), and essential hypertension (abnormally high blood pressure that's not the result of a medical condition). The BIMS indicated Resident 34 had a score of 15 meaning his cognition was intact (0-15 scale-a score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). During a concurrent observation and interview on 5/30/23, at 3:49 p.m., with Resident 34, Resident 34 was seen sitting on his bed, looked clean and smelled like he just took a shower. Resident 34 stated his dentures had been broken since November 2022 and he informed staff, but they had not done anything to repair or get them replaced. Resident 34 stated he only ate softer food but would like to go back to eating everything. Resident 34 walked to the bathroom and opened a pink container that was sitting on the sink, inside were a pair of dentures and one piece was seen broken in half. During a review of Resident 34's Care Plan titled, Dental Care Plan, under the section Focus on the Care plan indicated, [name of resident 34] has oral/dental health problems r/t him being edentulous (lacking teeth). [name of resident 34] has upper and lower dentures that he uses most of the time. [name of resident 34] lower denture is loose due to the loss of bone due to years of not having teeth or dentures prior to allowing facility to help him get dentures. [name of resident 34] was educated on risk vs. (versus) benefits of using dentures to help him chew his food. Risk includes possible dental infections, pain, weight loss, and difficulty chewing food. Benefits include better oral health, decreased possibly of dental infections, pain and difficulty chewing food. Facility will refer [name of resident 34] to ancillary services as needed. 7/26/21: [name of resident 34] received his full set of dentures today. Fitting and adjustment provided. Reviewed and restated on 3/21/23 by [initials of Social Services Director (SSD)] SSD Date initiated: 9/25/2019 Revised on: 3/21/23 . Interventions . Coordinate arrangements for dental care, transportation as needed/as ordered. Date Initiated: 9/25/2019 Revision on: 9/28/2022 Monitor/document/report to MD (medical doctor) PRN (as needed) s/sx (signs and symptoms) of oral/dental problems needing attention: pain . Teeth missing, loose, broken, eroded, decayed . Date Initiated: 9/25/2019 Revision on: 9/28/2022 . During an interview on 6/2/23, at 10:33 a. m., with the SSD, the SSD stated she started working here 7 months ago and at that time Resident 34 mentioned his dentures did not fit but she was not aware that Resident 34's dentures were broken. The SSD stated the dentist came to the facility every 2 months and she was informed that Resident 34 could not get new dentures until it had been a year since he got his new ones. The SSD stated Resident 34 was on the list to get to be seen by [company name of dental mobile services] to get x-rays, then will be seen by [dentist name]. The SSD stated Resident 34 reminded her daily he needed work on his dentures. The SSD stated, Yes, ill-fitting, and broken dentures are considered an emergency, but he has not verbalized having issues eating so it is not an emergency for this patient. Weights are being monitored. The SSD stated she would call [company name of mobile dental services] to see when Resident 34 had his appointment. During an interview on 6/2/23, at 10:33 a.m., with Schedule Coordinator (SC) 1 of [company name of mobile dental services], SC 1 stated Resident 34's last dental appointment was on 4/28/22, she stated he had missed his annual exam on 7/22. SC 1 stated Resident 34's next scheduled appointment was made today for 6/7/23. During a concurrent interview and record review on 6/2/23, at 10:33 a.m., with the SSD, Resident 34's Social Services notes were reviewed. The SSD stated there were no notes to indicate why the resident missed his appointment in July of 2022. The SSD stated she had a list that the residents go on who are to be seen next for dental. The SSD showed the list she kept at her desk and confirmed Resident 34's name was not on it. During a concurrent interview and record review on 6/2/23, at 2:40 p.m., with the SSD, Resident 34's Quarterly Review Assessment (QRA) dated 12/21/22 and 3/21/23 were reviewed. The QRA for 12/21/22 indicated, . Res [resident] recently broke his dentures and would like to get them replaced . The SSD stated she wrote the QRA dated 3/21/23 and it indicated, . Res recently broke his dentures and would like to get them replaced . The SSD stated she copied the previous QRA note dated 12/21/22 but did not know Resident 34's dentures were broken. During an interview on 6/2/23, at 3:04 p.m., with the Administrator (ADM), the ADM stated his expectation when a resident had broken dentures was for the Social Services Department to get that resident an appointment as soon as possible. The ADM stated broken dentures could affect a resident's ability to eat and thus affect their weight. During an interview on 6/5/23, at 9:48 a.m., with SC 2, SC 2 stated Resident 34 had Medi-cal insurance and this insurance covered Resident 34's dentures to be fixed and/or replaced once a year. During a review of the facility's policy and procedure (P&P) titled, Dental Services, dated 12/16, the Dental Services P&P indicated, . 10. If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services and the reason for the delay .

Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment for two of three sampled pill crushers (device for crushing medications) when the pill crushers were not free of medication residue (white substance). This failure had the potential to result in cross-contamination (process by which bacteria is transferred from one substance or object to another, with harmful effect) of medications and possibly cause serious harm, or death. Findings: During a concurrent observation and interview on 6/2/23, at 1:50 p.m., with Licensed Vocational Nurse (LVN) 1 in the medication room, two of the pill crushers were observed to have residue on them. LVN 1 stated, residue is from medications probably. LVN 1 stated, she was unsure of what medications the residue was from. LVN 1 stated, the same residue was on both pill crushers and it shouldn't be dirty like that. LVN 1 stated, don't want to cross-contaminate and if not cleaned properly, could put residents in harm's way. LVN 1 stated, she was unsure when the pill crushers were last cleaned. LVN 1 stated, the two pill crushers were used for crushing narcotics when needed. During an interview on 6/5/23, at 11:40 a.m., with the Infection Preventionist (IP-professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections), the IP stated, she saw the white residue on both of the [pill crushers]. The IP stated, potential hazards for sure. IP stated, that cross-contamination could occur, a nurse could get the medication residue on their finger and not realize it and potentially pass on the unknown medication residue to a resident. The IP stated, she was not sure how staff were cleaning the pill crushers. The IP stated, Licensed Nurses should clean the pill crusher after every medication pass. During a review of manufacturer guideline titled, [Brand Name] Crusher In-Service, the manufacturer guideline indicated, .may be cleaned regularly with a damp cloth. A facility approved disinfectant wipe may also be used when indicated .The frequency in which the pill crusher is cleaned is dependent on a facility's cleaning and disinfection protocol . The facility cleaning and disinfection protocol was requested, but not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services for 93 out of 93 sampled residents when: 1. [NAME] 1, [NAME] 2 and Dietary Supervisor (DSS) did not know they need to do cool down process (is an essential process used in food production to prevent foodborne illness. Bacteria grow best in food in the temperature range 135°F to 41°F, also referred to as the temperature danger zone. Cooked Foods not served immediately must be cooled quickly to minimize bacterial growth. If cooked foods left for improper cool down process, cooked foods can become unsafe to eat in a matter of hours) for cooked bean. (Cross referred 812) 2. Dietary Aide 1 did not follow manufacturer guideline time length to submerse kitchen ware into [NAME] (sanitizer) in the sanitizing sink. 3. [NAME] 1 did not follow manufacturer instructions time length to test the concentration of the [NAME] in the sanitizing sink. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) for all residents who received foods from the kitchen. Findings: 1. During an observation on 5/31/23, at 9:44 a.m., a pan of cooked bean labeled dated 5/30/23 with the used date of 6/3/23 was observed in the walk-in refrigerator. During a concurrent interview and record review, on 5/31/23, at 9:56 a.m., with DSS and [NAME] 2, Safe Ways to Cool Foods guideline posted next to Cool down Log, undated was reviewed. DSS stated, the cooked bean found in walk in refrigerator was made by [NAME] 1 yesterday morning. DSS stated, they never did cool down process for cooked bean so there was no cool down process done for yesterday cooked bean. [NAME] 2 stated, she and other cooks never did cool down process for the cooked bean. DSS reviewed the guideline and stated cooked bean was one of the food items needed to have cool down process. During a phone interview, on 6/1/23, at 3:17 p.m., with the Registered Dietician (RD), the RD stated, the cooked bean stored in the walk-in refrigerator needed to have cool down process. The RD stated, improper cooling of cooked bean could cause foodborne illness. The RD expectation was Cooks to follow the Safe Ways to Cool Foods guideline. During a review of the facility's job description titled, COOK, undated, the job description indicated, . Adhering to . food safety guidelines during meal preparation . During a review of the facility's job description titled, DIETARY SUPERVISOR, undated, the job description indicated, . Monitoring staff to confirm they adhere to all . safety and procedural guidelines within the department . 2. During a concurrent observation, interview, and record review on 5/31/23, at 11:15 a.m., with Dietary Aide (DA) 2, in front of 3 compartment sinks (sinks used for manual washing kitchen ware. 1st sink is for wash, 2nd sink is for rinse and 3rd sink is for sanitizer), Three Sink Washing and Sanitizing procedure provided by [NAME] vendor posted above 3 compartment sinks was reviewed. DA 2 was observed dipping a serving bowl for 1 second into [NAME] solution in the sanitizing sink and then placed the serving bowl onto drain board. DA 2 dipped 2 serving pans into [NAME] solution in the sanitizing sink for 3 second and then placed the 2 serving pans onto the drain board. DA 2 stated, she was not sure how long she needed to submerge the serving bowl and serving pans into [NAME] solution in the sanitizing sink. DA 2 stated, she never read the Three Sink Washing and Sanitizing procedure posted above 3 compartment sink. Reviewed Three Sink Washing and Sanitizing procedure with DA 2, DA 2 read the Three Sink Washing and Sanitizing procedure and stated , she needed to submerge kitchen ware into [NAME] sanitizing sink for at least 1 minute. During a phone interview, on 6/1/23, at 3:17 p.m., with the RD, the RD stated, dietary staff did not follow manufacturer guideline for time length to submerse kitchen ware into [NAME] in the sanitizing sink which could cause cross contamination. The RD expectation was for dietary staff to know the policy and procedure (P&P), to follow the P&P, and to follow manufacturer guideline and procedure. During a review of the facility's job description titled, DIETARY AIDE, undated, the job description indicated, . Adhering to sanitation and food safety guideline . During a review of the facility's P&P titled, Manual Washing: Three Compartment Sink Method, revised 2/18/20, the P&P indicated, . 5. Submerse in the sanitizing sink according to the chemical vendor's time requirements. 3. During a concurrent observation and interview, on 5/30/23, at 10:59 a.m., with [NAME] 1, [NAME] 1 was observed using the [NAME] test strip to test the concentration of the [NAME] solution in the sanitizing sink. [NAME] 1 dipped the [NAME] test strip into [NAME] solution for approximate 3 seconds and took the [NAME] test strip out. [NAME] 1 stated, it only needed 3 seconds to dip [NAME] test strip to test the concentration of the [NAME]. During an interview, on 5/30/23, at 3:47 p.m., with the DSS, the DSS stated, the [NAME] test strip needed to dip into [NAME] in the sanitizing sink for 10 seconds to test the concentration of the [NAME] in the sanitizing sink. During a phone interview, on 6/1/23, at 3:17 p.m., with the RD, the RD stated, the [NAME] test strip needed to dip into [NAME] in the sanitizing sink for 10 seconds to test the concentration of the [NAME] in the sanitizing sink. The RD's expectation was dietary staff followed the [NAME] test strip container instructions. During a review of the [NAME] test strip container instructions, undated, the instructions indicated, Dip for 10 seconds. During a review of the facility's job description titled, COOK, undated, the job description indicated, . Adhering to sanitation and food safety guidelines .

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Pest Control, when the facility did not maintain an environment free of pests. This failure had the potential to result in illness related to cross contamination of food. Findings: During an observation on 5/30/23, at 3:16 p.m., a fly was noted flying above the steam table. During an observation on 5/30/23, at 3:17 p.m., a fly was noted flying near the two-compartment sink. Dietary Supervisor (DSS) saw the fly, attempted to swat it with her hand. During an observation on 5/30/23, at 3:23 p.m., there was a fruit fly inside a box of moldy cucumbers on the counter near the two-compartment sink. During a concurrent observation and interview on 5/31/23, at 9:40 a.m., a house fly landed on the prepared cups of ice water. DSS stated, she killed the fly from yesterday. During an observation on 5/31/23, at 10:28 a.m., a house fly landed on the steam table (table that uses steam to provide consistent heat that surrounds food pans, used to hold prepared foods at safe temperatures for extended amounts of time). During an interview on 5/31/23, at 11:54 a.m., with the Maintenance Supervisor (MS), MS stated, the company we use for pest control was just here yesterday. MS stated, they come once per month. No one notified MS there was any problems with flies. During a concurrent observation and interview on 5/31/23, at 2:45 p.m., with Dietary Aide (DA) 1, in hallway outside of kitchen, 2 flies were noted. DA 1 validated, there were two flies. During a concurrent observation and interview on 5/31/23, at 2:56 p.m., with DSS, in front of the ice machine, black ants noted crawling across the floor. DSS stated, those are ants, and [pest control company] was just here yesterday. During a concurrent observation and interview on 5/31/23, at 3:01 p.m., with MS, in front of the ice machine, black ants noted. MS stated, Those are ants, they shouldn't be here. MS stated, the pest control company usually sprays in here, but they didn't spray inside yesterday. During a concurrent observation and interview on 5/31/23, at 4 p.m., with the Administrator (ADM), ants were noted crawling in front of the ice machine. The ADM stated, they will get some ant spray. During an interview on 6/1/23, at 3:17 p.m., with the Registered Dietician (RD), RD stated, they should not have any pest or rodents in the facility at all because it can cause residents or staff to get sick. During a review of the facility's P&P titled, Pest Control, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

**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 created and/or revised for four of 37 sampled residents (Resident 49, 296, 58 and 73), when: 1. Resident 49 and Resident 296 had a change of condition (a change in a person's health or functioning), and their care plans did not reflect the care the residents were currently receiving. 2. Resident 73 lost 20 pounds in 6 months and his care plan for weight loss did not provide current interventions to help the resident maintain his weight. 3. Resident 58 gained unplanned 10 pounds for one month. Interdisciplinary Team (IDT-a group of health care professionals from different fields who work toward a common goal for the resident) did not develop an individualized care plan and implement effective interventions. These failures had the potential for residents to not receive the care required to meet their needs. Findings: 1. During a review of Resident 49's admission Record (AR), dated 10/17/22, the AR indicated, Resident 49 was admitted to the facility on [DATE] with a primary diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally), anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), and extrapyramidal movement disorder (side effects of medication causing movements one cannot control). During a review of Resident 296's AR, dated 6/5/23, the AR indicated, Resident 296 was admitted to the facility on [DATE], with a primary diagnosis of disorganized schizophrenia (a person who has symptoms to include showing little or no emotions in their facial expressions, voice tone, or mannerism). During an interview on 10/21/22, at 1 p.m., with the Director of Nursing (DON), the DON stated Resident 49 was placed on denial of rights (DOR) for sexual activity (not allowed to have sex in the facility) due to her impaired judgement on 10/12/22. During an interview on 10/21/22, at 1:58 p.m., with Resident 296, Resident 296 stated, staff told him to stay away from Resident 49, but Resident 49 came into his room anyways. Resident 296 stated, on 10/14/22, Resident 49 stated she wanted a baby, she pushed him onto his bed, pinned his arms down on the bed and tried to kiss him. Resident 296 stated, he was able to get Resident 49 off and informed Licensed Vocational Nurse (LVN) 5 about what happened. Resident 296 stated after he informed LVN 5, an officer came and spoke to him about the allegation between him and Resident 49. Resident 296 stated since the allegation, a staff member was always with Resident 49, so he felt safe in the facility and a staff member checked on him every fifteen minutes. During a concurrent observation and interview on 10/21/22, at 2:21 p.m., with Resident 49, in the Administrator's office, Resident 49 paced back and forth and responded to internal stimuli (behaving or interacting as if someone or something else was present). Resident 49 stated, on 10/14/22, she sat down next to Resident 296 in his room, hugged him, and tried to kiss him but he did not kiss her. Resident 49 stated she was with a man, and he snitched (to tell someone of authority that someone else has done something bad) on her. Resident 49 stated she was on one to one (ratio of one staff and one resident) since 10/14/22, which meant she always had a staff member with her. Resident 49 stated she felt safe in the facility. During an interview on 10/21/22, at 2:40 p.m., with LVN 5, LVN 5 stated, on 10/14/22, Resident 296 asked her and two male Certified Nurse Assistants (CNA) to go to his room and he told them Resident 49 seduced him, pinned him down and tried to kiss him. LVN 5 stated she notified her supervisor and Administrator (ADM) about Resident 296's allegations. LVN 5 stated she informed staff to watch Resident 49 until she received orders for one to one. LVN 5 stated she notified the local police department (LPD), conservators and physicians for both residents and she received orders to place Resident 49 on one to one with staff. LVN 5 stated Resident 296 was placed on every fifteen-minute checks (when a staff member visually sees and documents the resident's activity in the facility), and a new intervention implemented was counseling with a Program Counselor (PC) for the next three days. During an interview on 10/21/22, at 3 p.m., with Minimum Data Set LVN (MDSN) 2, the MDSN 2 stated he was aware of the allegation involving Resident 49 and Resident 296, but he did not know the details of the situation because he was not present when it happened. MDSN 2 stated he has not noticed any changes in behavior to Resident 49 or Resident 296 since the allegation. During an interview on 10/21/22, at 4 p.m., with the Activities Director (AD), the AD stated a new intervention implemented for Resident 296 was one to one counseling with her. The AD stated, Resident 296 has not had any behavior changes since the allegation and had improved with his group hours and learned about his diagnosis (the process of identifying a disease based on a person's symptom). During an interview on 10/21/22, at 4:11 p.m., with PC 2, PC 2 stated, Resident 49 had new interventions of one to one with a CNA or PC and her medications were adjusted. PC 2 stated Resident 49's behaviors had improved since the new interventions were implemented and Resident 49 had been re-directable (to change the course or direction). During an interview on 5/18/23, at 2:53 p.m., with the DON, the DON stated he was immediately notified by LVN 5 of the allegation that involved Resident 49 and Resident 296. The DON stated, Resident 296 had improved himself and did not have any issues or behavior changes after the allegation. During a concurrent interview and record review on 5/18/23, at 4 p.m., with the DON, Resident 49's Care Plan (CP-summarizes a person's health conditions, specific care needs, and current treatments) titled, Sexually Inappropriate, dated 9/28/22 was reviewed. The CP indicated, . Per preadmission assessment [Resident 49] was noted making sexually inappropriate comments . Interventions . After any incidents of sexually inappropriate behavior, [Resident 49] will be given follow-up counseling within 24 hours of incident . [Resident 49] will attend Behavior Modification group to help her learn sexually appropriate behavior, boundaries, and rules . Staff will provide [Resident 49] with clear and concise description of inappropriate behavior . The DON stated, the CP indicated there were no new interventions implemented for the allegation that occurred on 10/14/22. The DON stated the facility implemented interventions for Resident 49 which included one to one with a CNA or PC, medications reviewed, and redirection of behaviors but the CP was not revised to indicate the new interventions implemented for this allegation. During a concurrent interview and record review on 5/18/23, at 4:15 p.m., with the DON, Resident 296's CP, dated 2/24/21, was reviewed. The DON stated, the CP indicated Resident 296 did not have a CP associated with the allegation that occurred on 10/14/22. The DON stated a CP for Resident 296 could have been initiated, but he was not sure what to tell his licensed nurses as to why a CP should be created for this allegation. During a concurrent interview and record review on 5/18/23, at 4:30 p.m., with the DON, the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022 was reviewed. The DON stated, the P&P indicated, .The comprehensive, person-centered care plan .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The DON stated the interventions were the services the facility was providing to the residents and Resident 296 should have had a CP created for this allegation to include the interventions the facility provided to Resident 296. The DON stated, the interventions implemented for Resident 296 consisted of every fifteen-minute checks by a CNA, all staff were notified to keep Resident 49 and Resident 296 separated for safety and one to one counseling with a PC. The DON stated the interventions were implemented for Resident 296. The DON stated, the facility should have monitored Resident 296 for any acute changes and revised the interventions if required. The DON stated the importance of following the CP policy was to ensure the resident's plan of care was up to date and progressed as planned. During a concurrent interview and record review on 6/2/23, at 10:49 a.m., with LVN 1, Resident 49's CP, dated 9/26/22 and Resident 49's Order Summary Report (OSR), dated 6/5/23 were reviewed. The OSR indicated, Resident 49 had orders on 5/3/23 for . Spironolactone Oral Tablet (drug used to treat heart failure (occurs when the heart muscle does not pump blood as well as it should), Give 25 mg (unit of measure) by mouth two times a day for To Decrease Libido [a person's sexual desire] . LVN 1 stated Resident 49's response to Spironolactone was not monitored nor was a CP created. LVN 1 stated when a new medication was ordered, the license nurse should create a CP, notify the conservator, and start the medication. LVN 1 stated the importance of creating a CP was to monitor the new medication for any adverse effects (undesired effects of a medication) and monitoring of any changes in behavior of the resident. LVN 1 stated if a CP was not created when a new medication was ordered, the facility would not be able to monitor the effectiveness of the medication and if the resident had any side effects to the medication. During an interview on 6/5/23, at 2 p.m., with MDSN 2, MDSN 2 stated a CP should be created or revised within 72 hours of a new medication ordered. MDSN 2 stated Resident 49 was ordered a new medication called Spironolactone which was ordered to decrease her libido. MDSN 2 stated he forgot to create a care plan specific to this new medication for Resident 49. MDSN 2 stated if he created a CP for Spironolactone, the interventions could include: give prescribed medications, counseling of resident if behaviors occurred, monitor for 72 hours, and refer to a psychiatrist for medication evaluation. MDSN 2 stated when a new medication was ordered, it was his responsibility to create or revise the resident's CP. MDSN 2 stated it was important to create or revise a CP for continuity of care (an approach to ensure that the care team was cooperatively involved in ongoing healthcare management toward a shared goal of high-quality medical care). MDSN 2 stated if a CP was not created or revised when a resident had a change of condition, the resident's treatment plan would not be updated and accurate. During a record review of Resident 49's CP titled, Sexually Inappropriate, dated 9/28/22 and Resident 49's OSR, dated 5/3/23, the CP indicated, on 10/14/22 and 12/29/22, Resident 49 had two episodes of sexually inappropriate behavior towards two male residents in the facility. The CP indicated, on 10/14/22 and 12/29/22, there were no revisions to the interventions to further prevent Resident 49's sexually inappropriate behavior towards others. The CP indicated, on 6/5/23, the CP was revised to include, . Administer medications as ordered . Spironolactone 25 mg PO [by mouth] BID [two times a day] to decrease libido .Resident will be placed on Q [every]15 minute checks for behavior if sexually inappropriate behavior occurs .Will refer to (resident's physician) as needed . The OSR indicated, Spironolactone was ordered on 5/3/23 and the CP was not revised until 6/5/23. During an interview on 6/5/23, at 2:58 p.m., with the Administrator (ADM), the ADM stated he expected licensed nurses to create or revise care plans during an annual review, quarter review or when a resident had a change of condition. The ADM stated the IDT should do their part to update care plans and follow through with any new interventions or treatments. The ADM stated the importance of a created or revised CP was use the CP as a communication tool for staff to be updated on how to best treat and care for a resident who had identified problems and the interventions specific to the resident. The ADM stated if the CP was not created or revised, direct care staff would not be aware of the resident specific interventions and there would not be a continuity of care. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . includes measurable objectives and timeframes . describes the service that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . reflects currently recognized standards of practice for problem areas and conditions . interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers . Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change . 2. During a review of Resident 73's admission Record (AR-document that provides demographical information to include name, date of birth , date of admission, insurance, diagnosis), dated 6/1/23, and Brief Interview for Mental Status (BIMS-screening tool used in nursing facility to assess cognition) , dated 2/9/23, were reviewed. The AR indicated Resident 73 was admitted on [DATE] from a Psychiatric Hospital with the following diagnosis's schizophrenia and anxiety disorder. The BIMS indicated Resident 73 had a score of 15 meaning his cognition was intact (A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). During a concurrent observation and interview on 5/30/23, at 3:58 p.m., Resident 73 was seen lying in bed with a blanket that covered him. Resident 73 spoke softly and did not maintain eye contact. Resident 73 stated he did not know how long he had been here at the facility. Resident 73 stated he did not like the food, had not been in any altercations, and did not want to answer any more questions. During a concurrent interview and record review on 6/5/23, at 10:05 a.m., with the DON, Resident 73's care plans were reviewed. The DON stated Resident 73's oral intake was obviously a behavioral issue, ever since his sister told him she would not be bringing him [name of fast-food restaurant] this saddened and upset him. The DON reviewed the care plan for Resident 73's diet, dated 11/3/22, the care plan indicated, [Resident 73's name] on a regular diet regular texture thin consistency RD (registered dietician) wt. (weight) review 11/17/22 . 176# (pounds 11/15). 2/2/23 quarterly rev (review) CBW (Current body weight) 167# = 6.7% x 3 mo. (months). 4/6/23 PRN (as needed) health shakes per resident request 1-daily. 5/11/23: quarterly rev, CBW: 155# (5/3) significant wt. change x 3, 6 mo. PO (oral intake) 49% resident avoids eating food from facility, so family brings him fast-food. Dated Initiated: 11/03/2022 Revision on: 05/12/2023 Goal [Resident 73's name] will be encouraged to consume meals with 76-100% daily. Encourage stable weight. Maintain hydrated QD (every day). No significant wt. loss -5# (negative 5 pounds). Date Initiated: 11/30/2022 Revision on: 5/11/2023 . Interventions monitor weekly weights x 4 weeks then monthly weights notified MD/RD [medical doctor/registered dietician] of any significant weight change. Date Initiated: 11/03/2022. Position CNA (certified nursing assistant) NRCHG (charge nurse) DIETS (dietician) . The DON stated, I would bring it up to the weight management committee and the RD and put in the interventions that we are already doing to help with his dietary. There is no program. The care plan needs work. The DON stated Resident 73 had no program involvement related to his oral intake and this was something they planned to implement for him. During an interview on 6/1/23, at 12:23 p.m., with Resident 73, Resident 73 stated, I'm having trouble waking up in the morning. Resident 73 stated he did not want to bother staff, he would prefer cereal and would eat if he could do it later in the morning. During a concurrent interview and record review on 6/1/23, at 4:10 p.m., with the Registered Dietician (RD), Resident 73's weights, meal intake, and dietary care plan were reviewed. The RD stated after a review of his weights and meal intake since admit, That is pretty significant intake was not good. The RD stated it would be beneficial to closely monitor his weights and oral intake every week so we could continue to intervene as necessary. The RD stated it was reasonable for the resident to request to have a later breakfast of cold cereal. The RD stated she attempted to update the care plan every time she saw the resident. The RD stated she should have put in an updated care plan. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 3/22, indicated, .Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 10. When possible, interventions address the underlying source(s) of the problem area(s) not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the residence condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly in conduction with the required quarterly MDS (minimum data set- part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) assessments . 3. During a review of Resident 58's admission Face Sheet, dated on 6/1/23, the admission Face Sheet indicated, .Resident 58 was admitted to the facility on [DATE]. Resident 58's diagnoses included: Schizoaffective Disorder (mental disorder that affects a person's ability to think, feel, and behave clearly) Bipolar type (is a mental health condition defined by periods (or episodes) of extreme mood disturbances that affect mood, thoughts, and behavior), Hypothyroidism (medical condition which thyroid gland doesn't make enough of the thyroid hormone), Anxiety and Extrapyramidal and Movement disorder . During a review of Resident 58's Minimum Data Set (MDS- a standardized assessment and care-planning tool) dated 5/10/23, the MDS indicated Resident 58 was not on a physician-prescribed weight gain regimen in the last month. During a review of Resident 58's weights showed: 11/2/22: 224 pounds (lbs) 12/8/22: 221 lbs 1/5/23: 220 lbs 2/2/23: 220 lbs 3/2/23: 219 lbs 4/2/23: 220 lbs 5/2/23: 230 lbs During a review of Resident 58's IDT Weight Management Assessment note, dated 5/8/23, IDT Weight Management Assessment note indicated, .Weight Gain; Current weight (wt.): 230 Lbs.Wt. past 30 days: 220 Lbs.Recent wt. Gain: 10 Lbs. per 1 month 4.5 % . Expected Weight Gain . Resident was noted to ask for seconds during major meals.IDT Recommendations: 1) Encourage resident to diet and exercise. 2) MD will order labs and will relay the results in a timely manner. 3) Will review monthly weights. 4) Registered Dietitian (RD) will assess resident . During a review of Resident 58's Registered Dietician (RD) monthly wt. review progress note, dated 5/18/23, RD monthly wt. review progress note indicated, .Weights: 230 pounds (#) (5/2/23), 220 # (4/2/23), 219 # (3/2/23), 220 # (2/2/23), 220 # (1/5/23), 221 # (12/8/22), 224 # (11/2/22), 223 # (10/2/22), 222 # (9/2/22), 218 # ( 8/2/22), 222 # (7/5/22), 226 # ( 7/2/22), 213 # ( 6/2/22) . Weight change: + 10 #/ (4.5 %) for 1 and 3 month, +6 # (2.7 %) for 6 month. Resident weight has been between 220 -230 # x 8 months. BMI (Body Mass index) 35 reflects obesity class II status. Diet: Regular diet. PO intake (amount eating): 98 % x 21 meals Resident was not in room upon arrival. Resident has excellent PO intake .Will continue to monitor resident's PO intake, weights, follow up prn (as needed) per facility protocol. Goal is to avoid further significant weight gain . During a review of Resident 58's care plan, undated, the care plan indicated, .Focus: RD monthly weight review: Current body weight 230 # x 8 months, Revised on 5/18/23 .Goal weight: Maintain current weight 220 # +/- 5 #. Intervention: will monitor weekly weights x 4 weeks then monthly weights. Date initial: 11/5/2021 . The care plan did not address the causes for unplanned weight gain, there was no resident specific interventions and parameters for monitoring to prevent further unplanned weight gain. During a concurrent interview and record review, on 6/2/23, at 9:40 AM, with Minimum Data Set Registered Nurse 1 (MDSN 1) and MDSN 2, Resident 58's care plan was reviewed. MDSN 1 stated, MDS nurses and RD reviewed resident's nutrition care plan. MDSN 1 and MDSN 2 admitted Resident 58's care plan revised on 5/18/23 did not have any intervention and monitoring for unplanned weight gained. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, Revised 1/12/2018, the P&P indicated, .The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight change for our residents.Care Planning:1. Care planning for weight change or impaired will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address to the extent possible: .a.The identified causes of weight change . b. Goals and benchmarks for improvement; and .c. Time frames and parameters for monitoring and reassessment .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices for 93 of 93 residents who receive food from the kitchen when: 1. Ice machine was not kept in sanitary condition and put residents at risk for foodborne illness (stomach illness acquired from ingesting contaminated food). 2. The can opener in the kitchen was not kept in sanitary condition which could transfer to residents' foods. Dietary staff did not clean the can opener after use. This had the potential to cause foodborne illness and cross contamination. 3. The walk-in refrigerator had rusting storage shelves and had the potential to harbor bacterial growth. 4. Worn out green cutting board. 5. Hood filter above stove covered with grease and dust. 6. Dust: silver storage shelves stored clean kitchen ware in the dish washing area, light bulb grid in the walk-in refrigerator, steam table stainless storage shelves storage clean kitchen ware covered with dust. Vent above steam table, light above steam table. 7. Floor: walk in refrigerator under storage shelf had brown/black grime, 6 strawberries under food storage shelf. Reach in refrigerator and underneath the dish washing machine the floor was covered with trash, dust, and dirty cups. This had the potential to attract pest or rodents. 8. Worn out gasket in walk in refrigerator. 9. No cooling log for cooked beans. (Cross reference F802) 10. [NAME] and white fuzzy substance found on the strawberries and cucumbers in walk in refrigerator. These failures had the potential to cause foodborne illness for all residents in the facility. Findings: 1. During an interview on 5/31/23, at 2:30 p.m., with Maintenance Supervisor (MS), MS stated, he cleaned the ice machine, but only the parts that are external. He stated the company that the facility rented the ice machine from does a thorough cleaning every three months. MS stated, he checked that the drain line was flowing good and works on the bottom of the hopper. MS stated, I do not work on the inside of the machine. MS stated, the facility just got it about 5 months ago. The company was out here about 2-3 weeks ago. they told us the ice machine was clean did not need to be serviced at that time. During a concurrent observation and interview on 5/31/23, at 3:12 p.m., with MS, ice machine noted to have pinkish orange slimy substance near the water releasing component of the ice machine. Black substance build-up noted behind the white cover. MS stated, (contracted company) was here two to three weeks ago and said the ice machine did not need to be cleaned. facility has had the ice machine about five or six months. MS stated, the ice machine has not been cleaned yet. The contracted company said they would be here every three months. During an interview on 3/31/23, at 3:25 p.m., with Dietary Supervisor (DSS), DSS stated, she prepped ice water cups this morning from this ice machine. During an interview on 5/31/23, at 3:51 p.m., with the Administrator (ADM), the ADM stated, facility was getting ice from this ice machine, ice machine had been shut down, and the facility was reaching out to the contracted company. During a concurrent observation and interview on 5/31/23, at 4 p.m., with Administrator, Infection Preventionist (IP- professionals who make sure healthcare workers and patients are doing all the things they should to prevent infections), Director of Nursing (DON), and MS, there was a black discoloration on the inside of the white plastic panel covering the inner component of the ice machine. Administrator stated, he will stand by ice machine until they bring an out of order sign. During an interview on 5/31/23, at 4:54 p.m., with ADM, the ADM stated, It was pretty bad. referring to the ice machine. During an interview on 6/1/23, at 3:17 p.m., with Registered Dietician (RD), RD stated, the facility got a new ice machine a couple months ago. She had MS open up the front cover, but he said he could not open it the rest of the way. MS told her that the contracted company would be the ones who do the routine cleaning. RD stated, she was not able to look inside. RD stated, it is a potential health hazard and can cause sickness. RD said her expectation was for it to be cleaned monthly and be free of mold and any build-up. During a review of the Service Activity Confirmation, dated 9/22/22, the Service Activity Confirmation indicated, the ice maker was installed on 9/22/22. Semi Annual Maintenance. During a review of the sanitation review (completed by RD), dated 3/24/23, the sanitation review indicated, .Ice machine is brand new, however no documentation of monthly maintence. [sic] working with maintenece [sic] to schedule cleaning and obtain records . During a review of the facility's policy and procedure (P&P) titled, Sanitization dated 11/22, the P&P indicated, .Ice machines and ice storage containers are drained, cleaned, and sanitized per manufacturer's instructions. 2. During a concurrent observation and interview on 5/30/23, at 11:37 a.m., with DSS, in the kitchen, there was a can opener in the stand at the end of the counter. The can opener blade had some type of red brown sauce dried on it. The same substance was also on the handle. DSS stated, This is dirty. The can opener should be cleaned after each use. During a concurrent observation and interview on 5/31/23, at 11:17 a.m., with Dietary Aide (DA) 3, DA 3 was using the can opener to open a can of peaches, did not clean after. DA 3 then used it to open a can of pineapple. DA 3 stated, she did not wash the can opener after she used it. During an interview on 5/31/23, at 11:42 a.m., with DSS, DSS stated, they clean the can opener at the end of the shift, not in between each use. DSS stated, Are we supposed to? During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, the can opener should be cleaned after each use to prevent any cross contamination. RD stated, it should be cleaned after each use. RD stated, she needed to review the policy and in-service dietary staff that can opener should be cleaned after each use. During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, dated 11/22, the P&P indicated, Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness. cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines. 3. During an observation on 5/30/23, at 10:28 a.m., in the walk-in refrigerator, there was some black grime in the corner of the top of the door. During a concurrent observation and interview on 5/30/23, at 3:01 p.m., in the walk-in refrigerator, with DSS, rust was seen on the food storage shelves. DSS stated, those need to be replaced, rust was not supposed to be there. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, shelves are supposed to be free of rust, it can cause foodborne illness. RD stated, the expectation was for the food storage shelves to be replaced and kept free of rust. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers dated 11/22, the P&P indicated, .Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. Refrigerators and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary . 4. During an observation on 5/30/23, at 11:29 a.m., in the kitchen, the green cutting board was noted heavy use and very worn. During an interview on 5/31/23, at 9:46 a.m., with DSS, the DSS stated, green cutting board needs to be replaced. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, she felt like the cutting boards needed to be replaced. RD stated, she did not put it in her report or tell the DSS. RD stated, food and bacteria can get stuck in the grooves left by the knife and cause illness. 5. During an interview and observation on 5/30/23, at 3:34 p.m., with DSS, in the kitchen, vent and pipe in the ceiling covered in dust. DSS stated, dust could fall from pipe in ceiling onto containers of food. Oven hood filter had oil and dust mixed. DSS stated, it did not get clean enough in the dishwasher. DSS stated, they were supposed to be cleaning it one time per week, maybe it needs to be cleaned twice per week. DSS stated, steam table shelves have dust even though they are cleaned two times a week on Wednesday and Saturday. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, I cannot recall looking at the hood above the stove, mix of grease and dust on hood filter was a potential fire hazard and cross contamination. RD stated, the hood filter needs to be clean and free from dust and build up. During a review of the facility's policy and procedure (P&P) titled, Section F: Safety and Sanitation, dated 2/18/20, the P&P indicated, .Stove tops, ovens and hoods will be routinely cleaned to keep them free of grease build-up to prevent accidental grease fires. Wash grease filters in hoods over ranges at regular intervals to prevent grease build up that could result in a fire . 6. During an observation and interview on 5/30/23, at 3:25 p.m., with DSS, in the dishwashing area of the kitchen, DSS was showed the dust on the top shelf where the clean dishes were being stored. DSS stated, the dust should not be there because it could contaminate the clean kitchenware. During an interview and observation on 5/30/23, at 3:34 p.m., with DSS, in the kitchen, vent and pipe in the ceiling covered in dust. DSS stated, dust could fall from pipe in ceiling onto containers of food. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, light grate in the walk-in refrigerator, the steam table shelves, vent above and light above steam table were covered with dust. I expect the light grate in the walk-in refrigerator, steam table shelves and the vent and light above the steam table to be cleaned so that dust doesn't fall into the food. They should keep the kitchen clean and free from dust. 7. During an observation on 5/30/23, at 11:06 a.m., in the walk-in refrigerator, five of six packages of strawberries on the food storage shelf had a green and white, furry mold like substance. 6 old strawberries noted on the floor under the shelf. red stuff splattered on the wall behind the shelf. Rust on the wire shelves noted. Dirt and grim in the corners on the floor of the walk in refrigerator. Box of cucumbers on the food storage shelf were wilted and mushy to touch. [NAME] and white fuzzy substance noted on some of the cucumbers in the box. During a concurrent observation and interview on 5/30/23, at 3:07 p.m., with DSS, in the walk-in refrigerator, DSS was shown the floor in the corners behind the storage shelves. DSS stated, looks like dirt. DSS stated, if dirt accumulates people will get sick. DSS saw the dirt on the light grate cover and saw the strawberries on floor. DSS stated, they are supposed to sweep and mop every day at end of shift. During a concurrent observation and interview on 5/30/23, at 3:17 p.m., with DSS in the kitchen, dust and trash seen under the reach in refrigerator. DSS stated, the dust and trash should not be there. DSS stated, it could attract mice, or pest. During a concurrent observation and interview on 5/30/23, at 3:24 p.m., with DSS, in the kitchen, dust, dirty cups, and trash seen under the dishwasher. DSS stated, it looks like it needs to be swept and mopped under dishwasher. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, the expectation was that the floors were cleaned at least looked at daily. Dirt and trash could get into food, cause contamination, and attract pest. During a review of the facility's policy and procedure (P&P) titled, Section F: Safety and Sanitation, dated 2/18/20, the P&P indicated, .Floors are to be kept clean, dry, uncluttered and free of broken tiles or defective boards . During a review of the facility's policy and procedure (P&P) titled, Sanitization dated 11/22, the P&P indicated, .All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris . 8. During an observation and interview on 5/30/23, at 2:58 p.m., with DSS, in the kitchen, gasket was loose and worn on the walk-in refrigerator door. DSS stated, maintenance was aware and was told the seal was loose three weeks ago. During a concurrent observation and interview on 5/30/23, at 4:03 p.m., with MS, in the kitchen, gasket on the walk-in refrigerator was examined. MS stated, nobody came and said it was the round gasket that need to be repaired. MS stated, he looked for one but could not find one when he replaced the other seal around the frame. MS stated, it was a miscommunication with DSS. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, she had put the gasket needed to be replaced in a previous sanitation review. RD stated, if the gasket does not get replaced, it could affect the temperature of the refrigerator and potentially cause illness. During a review of the sanitation review (completed by RD), dated 3/24/23, the sanitation review indicated, .door gaskets in walk-in fridge need to be replaced, unsticking from door . During a review of the sanitation review (completed by RD), dated 1/20/23, the sanitation review indicated, .door gaskets in walk-in fridge need to be replaced, unsticking from door . During a review of the sanitation review (completed by RD), dated 10/29/22, the sanitation review indicated, .Door gaskets in walk-in fridge need to be replaced, unsticking from door . During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers dated 11/22, the P&P indicated, .Supervisors inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately . 9. During an observation on 5/31/23, at 9:44 AM, a pan of cooked bean labeled and dated 5/30/23, used by 6/3/23 was observed in the walk-in refrigerator. During a concurrent interview and record review, on 5/31/23, at 9:56 a.m., with DSS, the Safe ways to cool foods guideline, undated was reviewed. Safe ways to cool foods guideline indicated, cooked beans were one of the food items that needed to have the cool down process. DSS stated, [NAME] 1 made the cooked beans yesterday morning stored in the walk-in refrigerator yesterday morning. DSS stated, they never did cool down process for cooked beans. During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, the cooked beans stored in the walk-in refrigerator needed to have cool down process. The RD stated, improper cooling of cooked beans could cause foodborne illness. The RD's expectation was Cooks followed the Safe ways to cool foods guideline. During a review of the facility's job description titled, DIETARY SUPERVISOR, undated, the job description indicated, .Monitoring staff to confirm they adhere to all .safety and procedural guidelines within the department . During a review of the facility's policy and procedure (P&P) titled, Food Preparation and Service, dated 11/22, the P&P indicated, .Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness. Potentially hazardous foods are cooled rapidly. Large or dense foods are cooled using special interventions in order to meet the time and temperature requirements for cooling. For example. beans or legumes may be cooled in shallow pans or food containers may be placed in ice baths to expedite cooling . 10. During an observation on 5/30/23, at 11:06 a.m., in the walk-in refrigerator, five of six packages of strawberries on the food storage shelf had a green and white, furry mold like substance. 6 old strawberries noted on the floor under the shelf. red stuff splattered on the wall behind the shelf. Rust on the wire shelves noted. Dirt and grim in the corners on the floor. Box of cucumbers on the food storage shelf were wilted and mushy to touch. [NAME] and white fuzzy substance noted on some of the cucumbers in the box. During a concurrent observation and interview on 5/30/23, at 3:07 p.m., with DSS, in the walk-in refrigerator, DSS was shown the floor in the corners behind the storage shelves. DSS saw the strawberries on floor. DSS stated, they are supposed to sweep and mop every day at end of shift. During a concurrent observation and interview with on 5/30/23, at 3:23 p.m., with [NAME] 2, in the kitchen, [NAME] 2 was noted cutting cucumbers for cucumber, tomato, and onion salad. [NAME] 2 stated, she used cucumbers for the salad from the same box that the moldy ones were in. [NAME] 2 stated, she just used the ones that were ok During an interview on 6/1/23, at 3:17 p.m., with RD, RD stated, she did look at the produce in the walk in on Monday 5/29/23 during the sanitation review but did not see any issues. RD stated, expectation is the facility not use the moldy food. RD stated, facility should toss them out and buy new ones because moldy food can cause illness.

Based on interview and record review the facility failed to implement its policy and procedure that prohibit and prevent abuse titled, Abuse Investigation and Reporting for one of five sampled residents (Resident 1) when the interviews were not done with Licensed Vocational Nurse (LVN) 1 and LVN 2 that were on duty during the time of the reported event. This failure had the potential for resident 1's abuse to not be investigated thoroughly and place other residents at risk of being abused by the suspected abuser. Findings: During a concurrent interview and record review on 4/19/23, at 9:20 a.m. with the Administrator (ADM), the staffing sheets for 4/13/23 were reviewed. The ADM stated Resident 1 reported having visions of Resident 2 raping (unlawful sexual activity and usually sexual intercourse carried out forcibly or under threat of injury against a person's will) her in the middle of the night. ADM stated as part of their investigation into this abuse, the facility interviewed the evening shift nurses who worked on 4/13/23 from 2:45 p.m. to 11:15 p.m. The ADM stated he did not interview the night shift nurses (LVN 1 nor LVN 2) who worked on 4/13/23 from 10:45 p.m. to 7:15 a.m. During a review of Resident 1's admission Record indicated the facility admitted the resident on 1/5/23 with diagnosis of schizoaffective disorder (mental illness that can affect thoughts, mood and behavior), bipolar type (causing extreme mood swings that include emotional highs and lows). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment and care-screening tool) dated 4/12/23 indicated Resident 1's Brief Interview for Mental Status (BIMS- a mandatory tool used to screen and identify the cognition of residents upon admission, scoring is from 0-15) was a 15 meaning she has intact cognitive skills for daily decision making. During an interview on 4/19/23, at 10:15 a.m., with Resident 1, Resident 1 stated she has been having night terrors (feelings of great fear experienced on suddenly waking in the night) of Resident 2 raping her and that she woke up the other night on 4/13/23 around midnight and saw him leaving her room. During an interview on 4/19/23, at 3:40 p.m., with LVN 1, LVN 1 stated she worked night shift from 10:45 p.m. to 7:15 a.m. on 4/13/23 and had not been interviewed about the abuse reported by Resident 1. During an interview on 4/19/23, at 3:52 p.m., with LVN 2, LVN 2 stated he worked the night shift from 10:45 p.m. to 7:15 a.m. on 4/13/23 and the last time he worked was on 4/16/23 and he has not been interviewed by the facility about the abuse reported by Resident 1. During a review of the facility's policy and procedure titled, Abuse Investigation and Reporting, dated July 2017, the policy indicated, Policy Statement All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be .thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Policy Interpretation and Implementation Role of the Administrator . Role of the Investigator: 1. The individual conducting the investigation, will, at a minimum: a. Review the completed documentation forms; . g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; h. Interview the residence roommate, family members and visitors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately code one of 17 sampled residents (Resident 19) Minimum Data Set (MDS- assessment of memory and functional needs) assessment when Resident 19's tobacco use was not coded on an annual MDS assessment. This failure had the potential for Resident 19 to not receive an individualized plan of care based on specific needs. Findings: During an interview with Resident 19, on 11/14/19, at 10:20 a.m., she stated she was a cigarette smoker. Resident 19 stated facility staff supervised her during the times she smoked. During a record review for Resident 19, on 11/14/19, at 10:13 a.m., Resident 19 had a smoking assessment done on 8/20/19 which, indicated Resident 19 smoked. During concurrent interview and record review with the Minimum Data Set Coordinator (MDSC), on 11/14/19, at 2 p.m., she stated Resident 19 was a smoker. The MDSC reviewed the smoking assessment dated [DATE], and stated Resident 19 was a smoker. The MDSC reviewed Resident 19's annual MDS assessment dated [DATE], section J and verified Resident 19's tobacco use was not coded on the annual MDS assessment and should have been. During concurrent interview and record review with the Director of Nursing (DON), on 11/14/19, at 2:10 p.m., in his office, he stated Resident 19 was a cigarette smoker. The DON reviewed resident 19's MDS assessment dated [DATE], and stated the annual MDS was coded inaccurately and did not reflect Resident 19's cigarette smoking status. During a review of the facility's documents titled, Resident Assessment Instrument version #.0 Manual dated 10/18, indicated, .Tobacco use includes tobacco used in any form . If the resident states he or she used tobacco in some form during the 7 -day look back period code 1, yes .If the resident is unable to answer or indicates that he or she did not use tobacco of any kind during the look back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look back period .

Based on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (an advocate for residents) was notified of the acute care hospital transfer for nine of nine sampled residents (Resident 3, 18, 28, 47, 73, 87, 89, 443, and 444), when the residents were transferred to a general acute care hospital (GACH) on different days and the transfer of each resident was not communicated to the ombudsman office by the facility. This failure had the potential of not providing Residents 3,18, 28, 47, 73, 87, 89, 443, and 444 with access to the ombudsman and the benefit of an advocate who could inform them of their discharge and transfer rights. Findings: During a record review of Resident 47's progress notes dated 10/14/19 at 10/13 p.m., indicated, . [Resident 47] was noted disoriented, confused, agitated and incontinent . [called Resident 47's physician] [obtained order] to send to [GACH] for evaluation [due to] [residents increased confusion. [Public Guardian] notified via fax. During an interview with Licensed Nurse (LN) 1, on 11/13/19, at 12:23 p.m., LN 1 stated she did not make any notifications to the ombudsman office after Resident 47 was transferred to the GACH. During an interview with LN 2, on 11/13/19, at 12:35 p.m., LN 2 stated he did not know the ombudsman needed to be notified of residents transfer to the GACH. During a concurrent interview and record review with the Director of Staff Development (DSD), on 11/13/19, at 12:43 p.m., he stated the facility notified the ombudsman only after a resident was discharged from the facility. The DSD stated the facility did not notify the ombudsman after a resident was transferred to the GACH. The DSD reviewed the facility document titled, 2019 LIST OF RESIDENTS ON BED HOLDS undated, indicated a list of nine residents who were transferred to the GACH and required a bed hold. The DSD stated Residents 3, 18, 28, 47, 73, 87, 89, 443, and 444 were transferred to the hospital during their stay in the facility and there was no notification made to the ombudsman office of the transfer to the GACH. The DSD stated the facility did not have a policy and procedure to on ombudsman notification requirements following a resident transfer to the GACH. During an interview with the Administrator on 11/15/19, at 2:40 p.m., he stated the facility did not notify the ombudsman office following residents transfer to the GACH and the facility did not have a policy and procedure for this notification.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety when the kitchen dry storage area and walk in-refrigerator stored food items with dates beyond the use-by date and undated, unlabeled food items were available for consumption. These failures had the potential for residents to consume expired food and result in food borne illness. Findings: During a concurrent observation in the kitchen dry storage area on 11/12/19, at 8:35 a.m., a bag of opened potato chips with a use by date 11/9/19 and an opened bottle of red food coloring with a use by date 10/26/19 was available for consumption. During an interview with the Dietary Supervisor (DS), on 11/12/19 at 8:40 a.m., the DS stated the bag of potato chips and the bottle of food coloring needed to be thrown away. The DS stated consuming food items beyond the use by date could cause food borne illnesses to residents. During a concurrent observation and interview with the DS on 11/12/19, at 8:45 a.m., under the food preparation counter, two plastic unlabeled food grade containers were used to store sugar and coffee creamer. The DS stated dietary staff removed the sugar and creamer from their original boxes and poured the contents into the food grade containers. The DS stated the containers needed to be dated with the date the sugar and creamer were opened and transferred into the food grade containers. During an observation in the walk in refrigerator on 11/12/19, at 8:55 a.m., four bags of red cabbage with an expiration date of 10/9/19 were available for use. The DS confirmed the cabbage bags were expired and should have been discarded. During a review of the facility policy and procedure titled, Labelling and Dating of Food dated 1/13/18, indicated, Intent: All food will be dated, labeled, and prepared for storage to prevent contamination, deterioration, and dehydration .Guideline: Opened products can be stored in original containers if the container can be closed properly (examples: zip bags, jar, containers with tight fitting lids, bags, with twist fitting lids, bags with twist ties). All products must clearly be labeled with the date when the product was opened. Opened products that cannot be stored in original containers if the containers can be closed properly . All products must clearly be labeled with the date when the product was opened.