Based on observation, interview, and record review, the facility failed to ensure the safe labeling, open date, and expiration date of eye drop medication for 2 (Resident 98 and Resident 100) out of 2 residents. These failures had the potential to result in residents being given medication with decreased potency and efficacy. Findings: During an observation of Medication Cart A on 11/4/24, at 11:45 a.m., with Assistant Director of Nursing (ADON), Resident 98's Latanoprost (medication to treat high pressure in the eye caused by glaucoma) Ophthalmic solution label indicated an expiration date of June 2026, to refrigerate until opening and to discard 42 days after opening. No open date was indicated on the label. During an observation of Medication Cart B on 11/4/24, at 12:00 p.m., with ADON, Resident 100's Latanoprost Ophthalmic solution label indicated an expiration date of June 2026, to refrigerate until opening and to discard 42 days after opening. No open date was indicated on the label. During interview on 11/4/24, at 12:05 p.m., with ADON, ADON stated the eye drops should have had an open date to know when the medication needed to be discarded as per instructions. ADON stated using the medication past the discard date may result in giving medication that is less effective. During review of resident 100's face sheet resident has a diagnosis of primary open - angle glaucoma (increase pressure in the eye, resulting in slow progressive vision loss), bilateral (both eyes) indeterminant stage (mid-level). During a review of Resident 98's Physician Orders, dated 10/25/24, indicated one droplet Latanaprost to each eye at bedtime for glaucoma. During a review of Resident 100's Physician Orders, dated 10/29/24, indicated one droplet Latanaprost to each eye at bedtime for glaucoma. During an interview on 11/8/24, at 9:57 a.m., with Pharmacy Consultant Supervisor (PC), PC stated that the eye drops should have an open and use by date to ensure the effectiveness of the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool used to guide care) functional status on mobility for one of two sampled residents (Resident 15). The MDS assessment inaccurately showed Resident 15 was not able to walk due to health and safety reasons. This failure resulted in an inaccurate reflection of Resident 15's medical condition and placed her at risk for receiving inappropriate care. Findings: During a review of Resident 15's admission Record, dated October 2023, the record indicated Resident 15 was readmitted to the facility in May 2019. During an interview on 11/02/23 at 5:14 p.m. with Restorative Nursing Assistant (RNA), RNA stated Resident 15 was able to walk with assistance in the hallways and outside on the patio. RNA stated he usually assisted Resident 15 for ambulation for at least three times per week. During a review of Resident 15's RNA Weekly Summary, dated 9/29/23 and 10/6/23 showed Resident 15 received RNA services for walking program three times a week. During a concurrent interview and record review on 11/03/23 at 9:55 a.m. with MDS Coordinator (MDSC), Resident 15's MDS assessment dated [DATE] was reviewed. The MDS assessment under Functional Abilities showed walking was not attempted due to medical condition. However, under Restorative Nursing Programs, the MDS assessment indicated Resident 15 walked for three days in the last seven calendar days. The MDSC stated MDS assessments were based on records and the information from direct care staff such as Nursing Assistants, Charge Nurses, and RNA involved in a resident's care during the look back period. The MDSC also stated it was an item coding error and it should have been coded as moderate assistance for walking. The MDSC also stated it was important to complete the MDS assessment accurately because an inaccurate assessment could affect Resident 15's plan of care. During a review of Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.17.1, dated October 2019, the manual indicated, The RAI process has multiple regulatory requirements. Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete and/or update the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 15) for a period of over four years. This failure resulted in an inaccurate reflection of Resident 15's medical status and had the potential to result in Resident 15 not receiving the care and services appropriate for her condition. Findings: During a review of Resident 15's admission Record, dated October 2023, the record indicated Resident 15 was originally admitted to the facility in December 2018. During a concurrent interview and record review on 11/3/23 at 11:58 a.m. with Director of Nursing (DON), Resident 15's PASARRs, dated 12/12/18 and 6/7/19 were reviewed. The DON stated the facility was expected to complete a PASARR screening prior to residents' admission to the facility. The DON stated the PASARR dated 12/12/18 was completed one week after Resident 15's admission to the facility and was inaccurately coded as No for Question 28 Has the resident been prescribed psychotropic medications (used to manage mental health conditions)? The DON stated Resident 15's clinical record showed that she received quetiapine (a psychotropic medication) 25 milligrams (mg) for hospital delirium (acute confusion) from 12/5/18 until 12/11/23. The DON stated the PASARR dated 6/7/19 was completed for Resident 15's readmission to the facility on 6/5/19. The PASARR dated 6/7/23 showed facility answered Yes to Question:17b Will the resident's stay at your facility likely to require less than 30 days of NF services? The DON stated Resident 15 did not leave and was a long-term resident at the facility. The DON stated the PASARR dated 6/7/23 did not reflect an accurate status of Resident 15. The DON stated the facility did not update and/or complete a new PASARR to reflect the actual status of Resident 15 since 6/7/19. During a concurrent interview and record review on 11/3/23 at 12:33 p.m. with Minimum Data Set Coordinator (MDSC), Resident 15's MDS assessment dated [DATE] was reviewed. The assessment showed Resident 15 had a diagnosis of Schizophrenia (a mental disorder characterized by disconnection from reality), Psychosis (condition that affects the brain processing of information) and had received psychotropic medication, but she was not eligible for Level II PASARR screening. The MDSC stated, Resident 15's mental illness diagnoses could have led her to have Level II PASARR screening, however she overlooked that need when she completed the MDS assessment. During a review of facility's Policy and Procedure (P&P), titled admission Criteria, dated March 2023, the P&P indicated. all new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre- admission Screening and Resident Review (PASARR) process .If the level 1 screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASRR representative for the Level II (evaluation and determination) screening process.

Based on observation, interview and record review, the facility failed to provide assistance needed for fingernail care for one (Resident 30) of three sampled residents when Resident 30 had long fingernails with blackish material under the nail tips. This failure had the potential for Resident 30 to be injured by long fingernails and develop an infection. Findings: Review of the Minimum Data Set (MDS Resident Assessment tool used to guide care), dated 8/25/23, indicated Resident 30's diagnoses included stroke (brain injury when blood flow to a part of the brain stops) and diabetes mellitus (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood). Resident 30 had clear speech, was able to understand others and be understood. Resident 30 required extensive physical assistance from one-person for personal hygiene, including combing hair, brushing teeth, shaving, washing, and drying face and hands. Review of Resident 30's Activities of Daily Living (ADLs) care plan, dated 8/25/23, indicated Resident 30 required extensive assistance with ADLs for shower, bathing, toilet, and hygiene. During an observation and concurrent interview on 10/30/23 at 10:23 a.m., with Resident 30, Resident 30 lay in bed. Resident 30 had long fingernails with blackish material under the nail tips. Resident 30 stated she would like to have her long fingernails trimmed. During an observation and concurrent interview on 10/30/23 at 10:25 a.m., with Licensed Vocational Nurse/Supervisor (LVN 1), and Resident 30, LVN 1 stated Resident 30's fingernails were long and had blackish material under the nail tips. LVN 1 stated he would ensure Resident 30's assigned licensed nurse trimmed the fingernails. During an interview on 10/30/23 at 10:36 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was Resident 30's assigned nurse. LVN 2 stated she did not know why Resident 30's fingernails were not trimmed. Review of the facility's policy and procedure titled, Fingernails/Toenails, Care of, revised February 2022, indicated: The purpose of this procedure are to clean the nail bed, to keep nails trimmed and to prevent infections. Nail care includes daily cleaning and regular trimming.

Based on interview and record review, the facility failed to ensure the pharmacist provided consultation services to ensure there was a record system for receipt and disposition and reconciliation of all controlled drugs maintained for three years. The failure to maintain records had the potential to result in drug diversion. Findings: During and concurrent interview and record review on 11/1/2,3 at 11:06 a.m., with Director of Nursing (DON), the controlled medication disposition binder was reviewed. The DON stated she had a huge stack of unorganized logs and medications packages for controlled medications which had been sent for disposal on 10/5/23. DON stated she had organized the logs and placed them in the disposition binder; the binder showed the last previous transfer for destruction date was 10/5/22, with no transfer for final disposal of controlled medication between 10/5/2022 to 10/5/2023. The DON stated she and the facility's Pharmacist (Pharm) were responsible to dispose of the controlled medications into the final incinerator container together. The DON stated Pharm had advised her the controlled medication disposal into the incinerator container should be completed on a quarterly basis, however she had not had the time to do so. The DON stated she was unable to find the controlled drug disposition records for the year of 2021. During a phone interview on 11/1/23, at 11:41 a.m., with Pharmacist (Pharm), Pharm stated the DON accumulated all the controlled drugs in need of disposal, then Pharm and the DON would reconcile the log and document any discrepancies. Pharm stated the controlled drugs in need of disposal would be placed in sealable plastic bags with a liquid in the bag, and then the entire plastic bag would be placed in an incinerator container. Pharm stated the incinerator container would go to a contractor for destruction. The Pharm stated controlled medication disposal should be done on a quarterly basis and the disposition documentation/log should be retained for 3 years. During a record review of the facility's policy and procedure titled, Discarding and Destroying Medications, dated 11/2022, completed medication disposition record are kept on file in the facility for at least two (2) years, or as mandated by state law governing the retention and storage of such records. Review of the California Codes for Pharmacy: 72371(c) (1) Patient's drugs supplied by prescription which have been discontinued and those which remain in the facility after discharge of the patient shall be destroyed by the facility in the following manner: (1) Drugs listed in Schedules II, III or IV of the Federal Comprehensive Drug Abuse Prevention and Control Act of 1970 shall be destroyed by the facility in the presence of a pharmacist and a registered nurse employed by the facility. The name of the patient, the name and strength of the drug, the prescription number, the amount destroyed, the date of destruction and the signatures of the witnesses required above shall be recorded in the patient's health record or in a separate log. Such log shall be retained for at least three years.

Deficiency Text Not Available

Based on observation, interview, and record review, the facility failed to maintain complete and accurate Medical Records for three (Residents 9, 30, and 15) of eleven sampled residents, when: 1. Licensed Vocational Nurse (LVN) 2 failed to immediately document in Resident 9's medical record, the administration of Resident 9's oxycodone (a controlled medication: medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence). 2. LVN 2 and Licensed Vocational Nurse 5 (LVN 5) failed to document administration of multiple medications for Resident 30 on 10/6/23, 10/14/23, 10/18/23, 10/19/23. 3. Resident 15's care plan indicated Resident 15 was restricted to her room for infection control reasons since 12/17/20, while observations and interviews indicated Resident 15 had left her room for ambulation therapy outside her room, as well as locomoting in a wheelchair in the lobby and dining areas. The failure to maintain complete and accurate medical records for Resident 30, Resident 9, and Resident 15's had the potential to result in missed or duplicative medication administration, and inappropriate care provision from inaccurate care plans. Findings: 1. During a concurrent observation and interview on 11/1/23, at 12:16 p.m., with LVN 2, at the medication cart, Resident 9's Medication Administration Record (MAR) and Controlled Drug Record (CDR) for oxycodone were reviewed. LVN 2 opened the medication cart and examined Resident 9's oxycodone supply. LVN 2 stated Resident 9 had 23 tablets of nine milligrams (mg) oxycodone myristate available in the medication cart supply. LVN 2 stated Resident 9's CDR indicated there should be 24 tablets available. LVN 2 stated she had administered one tablet of nine mg oxycodone to Resident 9 in the morning today but had not documented the administration on the CDR. LVN 2 stated Resident 9's MAR had no documentation of oxycodone administration for the 11/1/23, at 9 a.m., regularly scheduled nine mg dose of oxycodone. During an interview on 11/1/23, at 2:56 p.m., with the Director of Nursing (DON), the DON stated nurses were expected to document immediately after administration of medication. 2. During review of Resident 30's admission Record printed 10/31/23, the admission Record indicated Resident 30 was admitted to the facility in April 2023. During a concurrent interview and record review on 10/31/23, at 3:02 p.m., with the DON, Resident 30's MAR dated October 2023, and nursing progress notes dated 10/6/23 through 10/31/23, were reviewed. The DON stated she was unable to find any documentation in the MAR or the nursing progress notes to indicate nursing staff administered the following medications: 10/6/23 at 9 p.m.: Hydralazine (used for blood pressure) and Lantus Insulin (lowers blood sugar). 10/14/23 at 6:30 a.m.: Levothyroxine (a hormone), Pantoprazole (an antacid), routine Humalog Insulin (lowers blood sugar). 10/18/23 at 9:00 a.m.: Atorvastatin calcium (to lower cholesterol), Eliquis (a blood thinner), furosemide (promotes urination to decrease excess body fluids), Hydralazine, Lexapro (an anti-depressant), Isosorbide Mononitrate (lowers blood pressure), Metoprolol (lowers blood pressure), routine Humalog Insulin, and Ticagrelor (prevents blood clot formation). 10/18/23 at 11:30 a.m.: routine Humalog Insulin. 10/19/23 at 6:30 a.m.: routine Humalog Insulin. 10/19/23 at 11:30 a.m.: routine Humalog Insulin. During an interview on 10/31/23, at 3:18 p.m., with LVN 2, LVN 2 stated she had been Resident 30's charge nurse on 10/18/23 and 10/19/23 and was responsible for Resident 30's medication administration on those days. LVN 2 stated she had failed to document the medication administration on 10/18/23 because she had gotten sidetracked; LVN 2 was unable to provide an explanation for the lack of documentation on 10/19/23. During a phone interview on 11/03/23, at 2:17 p.m., LVN 5 stated she had been responsible for Resident 30's missed entries for 10/6/23 and 10/14/23. During a review of the facility's policy and procedure titled, Documentation of Medication Administration, dated 11/2022, the policy and procedure indicated, administration of medication is documented immediately after it is given and .documentation of medication administration includes, as a minimum reason(s) why a medication was withheld, not administered, or refused (as applicable) . During a review of the facility's policy and procedure titled, Administering Medications, dated 4/2019, medications are administered in accordance with prescriber orders, including any required time frame .the individual administering the medication initials the Resident's MAR on the appropriate line after giving each medication and before administering the next ones . 3. During a review of Resident 15's admission Record, undated, the record indicated Resident 15 was originally admitted to the facility in 2018 with a medical history of urinary tract infection (bladder infection) and Carrier of Carbapenem-Resistant Enterobacterales (CRE-an antibiotic resistant bacterial infection that can be transmitted by direct contact with an affected individual or indirect contact). During an observation on 10/30/23, at 10 a.m., outside Resident 15's room, the door to the room had signage which indicated, Stop, and Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). During a review of Resident 15's Infection Control care plan initiated 12/17/20, revised on 7/31/23, the care plan indicated, due to the regulatory infection precautions, the resident is remaining in the room. During a concurrent interview and record review on 11/1/23, at 8:30 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 15's Physician orders for the month of 11/2023 was reviewed. LVN 3 stated the order indicated Resident 15 was to be on Strict Contact Isolation with an order start date of 9/29/23. During a concurrent interview and record review on 11/02/23 at 5:14 p.m. with Restorative Nursing Assistant (RNA), RNA stated during exercise sessions, even though Resident 15 was on contact isolation, RNA provided physical assistance while Resident 15 walked in the hallways and on the outdoor patio. During a concurrent observation and interview on 11/3/23, at 9:19 a.m., with administrator (Admin), facility surveillance videos dated 10/23/23, and 10/25/23, were reviewed. Admin stated the surveillance video dated 10/23/23, showed Resident 15 in the lobby sitting on a wheelchair and chatting with the receptionist. Admin stated the surveillance video dated 10/25/23, showed Resident 15 seated on a wheelchair, wheeling herself in the dining area. 20

Based on observation, interview, and record review, the facility failed to ensure proper infection prevention and control practices when Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene during medication administration for Resident 2, Resident 5, and Resident 151. This failure to ensure proper hand hygiene had the potential risk for transmission of infection to Residents 2, 5, 151, and throughout the facility. Findings: During an observation on 10/31/23 at 08:58 a.m., Licensed Vocational Nurse (LVN) 3 prepared Resident 2's morning medications outside his room and put them on a medication tray. Without performing hand hygiene, she put on an isolation gown and a pair of gloves. LVN 3 stated Resident 2 was on Contact Isolation (infection control measures used for a resident with infectious disease that may be spread by touching). LVN 3 went inside Resident 2's bathroom, turned the faucet on, grabbed water for medication administration, poured water in each medicine cup with the same gloved hands. LVN 3 then closed Resident 2's room door by touching the doorknob, picked up a disposable stethoscope (a medical instrument for listening to someone's heart or breathing) and a 30 milliliter (ml) syringe, checked Resident 2's Gastrointestinal feeding Tube (GT, device used to give direct access to the stomach for supplemental feeding, hydration, or medicine) for placement with same gloved hands. LVN 3 then, flushed GT with 30 ml water using the syringe, with same gloved hands. LVN 3 then administered one-by-one morning medications via GT to Resident 2. Without changing gloves and/or performing hand hygiene, LVN 3 then administered an injection of enoxaparin sodium (a medication which lowers risk of getting blood clots) to Resident 2 in the left upper abdomen. During an observation on 10/31/23 at 09:53 a.m., in Resident 151's room, LVN 3 placed morning medications on a medication tray on Resident 151's bedside table, pulled the privacy curtain and without performing hand hygiene, administered morning medications by mouth to Resident 151. LVN 3 then went out of Resident 151's room and wheeled a portable Vital Sign Machine (a medical instrument used to measure temperature, pulse, breathing, and blood pressure) into Resident 151's room. Without performing hand hygiene, she put on a new pair of gloves and checked Resident 151's vital signs. LVN 3 then administered eye drops medications to Resident 151's both eyes. During an interview on 10/31/23 at 09:54 a.m. LVN 3 stated that she should have changed her gloves and do hand hygiene with gel sanitizer or soap and water during medication administration for Resident 2 and Resident 151 to prevent cross contamination. During an observation on 11/01/23 at 11:59 a.m. LVN 3 administered a nebulizer (inhalation) medication treatment to Resident 5. LVN 3 entered Resident 5's room, with gloved hands touched door and side cart near bed. An observation was made of LVN 3 setting up the nebulizer with medication for Resident 5 with the same gloves throughout administration. During an interview on 10/31/23 at 2:44 p.m. with Director of Nursing (DON), the DON stated that hand hygiene was important to prevent infections which could lead to sepsis, rehospitalization, prolonged stay at nursing homes, hindrance in residents' progress and rehabilitation. The DON stated staff was expected to perform hand hygiene in between different routes of medications, before and after administration of medications, and after touching any items in residents' rooms. The DON stated she was working as a DON since 2/2023 in the facility but did not conduct any medication pass observation for licensed nurses. The DON stated facility utilized Nurse Consultant from their contracted pharmacy company for medication administration observations for Licensed Nurses on a quarterly basis. The DON stated Hand Washing was the common concern reported on most recent nurse consultant visits on 5/17/23 and 9/26/23. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 08/2019, the P&P indicated, all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, visitors . use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c) before preparing or handling medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper storage of medication when the following was noted: 1. Two bottles of expired 20 milliliters (ml) of lorazepam (a medication used to treat anxiety) for Resident 10 were stored in a dedicated refrigerator for ready to use medications. 2. The lid of black colored Medication Disposal Bin was kept very loosely open in medication storage room. The failure to dispose of expired lorazepam medication, posed a potential risk of utilizing the medication with decreased effectiveness for anxiety to Resident 10. The failure to ensure proper security of the Medication Disposal bin posed a potential authorized/unauthorized access to medications in the bin. Findings: 1. During an observation on [DATE] at 09:57 a.m. in Medication room [ROOM NUMBER], with Licensed Vocational Nurse (LVN) 1, two bottles of 20 ml of lorazepam with expiration date of [DATE] for Resident 10 were kept in a dedicated refrigerator for ready to use medications. LVN 1 stated medications were expired and should not be kept in the refrigerator. During a telephone interview on [DATE] at 11:32 a.m. with the facility's Pharmacist (Pharm), Pharm stated as soon as medications were expired or discontinued, they should be placed in the designated disposal area in medication room [ROOM NUMBER] to be disposed or destroyed. During a record review of Resident 10's Physician orders, dated [DATE], the order indicated Resident 10 had an order for lorazepam give 0.25 milliliters (mls) by mouth every 4 hours as needed for anxiety. A review of the medication administration record indicated, Resident 10 last received a dose of lorazepam on [DATE] at 07:46 p.m. During a review of the facility's policy and procedure titled, Storage of Medications, dated 11/2020, indicated Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 2. During a concurrent observation and interview on [DATE] at 11:21 a.m. in Medication room [ROOM NUMBER], with the Director of Nursing (DON), a black colored Medication Disposal bin was kept next to the medication refrigerator. The lid to the medication disposal bin was easily removed. The disposal bin had pills, capsules, medication packages, nasal spray bottles, multiple use injection vials, and medication cups were easily accessible from the bin. The DON stated the lid to the medication disposal bin needed to be secured to the bin. The label on the disposal bin indicated, Hazardous Waste Pharmaceuticals: KEEP LID CLOSED, DO NOT REMOVE OR DISPENSE ITEMS FROM THIS CONTAINER . During a review of the facility's policy and procedure titled, Storage of Medications, dated 11/2020, the facility stores all drugs and biologicals in a safe, secure, and orderly manner.

Based on interviews and record review, the facility failed to ensure when it did not hire a full-time registered dietitian, the person designated to serve as the director of food and nutrition services met the federal and state educational qualifications for a dietary manager position. The lack of full-time, qualified oversight of food and nutrition staff placed residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or decreased nutrient intake which had the potential to result in malnutrition and/or death. Findings: During an interview on 10/30/23 9:35 a.m., with Dietary Supervisor (DS), DS stated he worked fulltime as the Dietary Supervisor. DS stated he had worked at the facility for one year. During an interview on 10/31/23 at 12:23 p.m., with Registered Dietitian (RD), RD stated he worked at the facility part time. RD stated he was usually at the facility two days a week. During an interview on 11/01/23 at 9:18 a.m., with DS, DS stated he had completed an online training course and had received a Food Manager certification. Review of the document titled, ServSafe Certification, with an examination date of 2/10/21, the document indicated DS had completed a standard training for the Food Protection Manager certification examination. The document indicated, Accredited by the American National Standards Institute-Conference for Food Protection (CFP), an accredited food safety exam that does not require classroom hours or necessarily involve a training program. During an interview and concurrent review on 11/01/23, at 10:29 a.m., with the Administrator (Admin), the DS ServSafe Certification, document was reviewed. The Admin stated the DS ServSafe certificate was not sufficient training to qualify DS for the dietary manager position.

Based on observation, interviews and record review, the facility failed to ensure storage and preparation of food under sanitary conditions when: 1. The facility failed to ensure two of two facility ovens were maintained in safe operating condition to provide cooked meals according to mealtime schedules: oven 1 was unable to cook chicken to the required food safety temperature; oven 2 was inoperable. 2. The facility failed to maintain the physical environment: the countertop toaster oven had brownish black debris both on the oven knobs and inside the oven; the kitchen floors had cracked tiles with blackish discoloration; a ceiling vent was covered with blackish, dusty material; the grease trap area was malodorous and not securely covered; a storage cabinet drawer did not fully close. These failures had the potential to result in food borne illnesses for residents who received food from the facility's kitchen. Findings: 1. During an observation on 10/30/23 at 1:15 p.m., with Dietary Supervisor (DS), in the kitchen, oven 2 had plates stored inside the oven. During a concurrent observation and interview on 10/31/23, at 11:23 p.m., with [NAME] (CK), in the kitchen, during lunch preparation, chicken breasts were cooked in oven 1. [NAME] (CK) measured the temperature of a chicken breast in the oven as 140 degrees Fahrenheit (F). The chicken remained in the oven for 15 more minutes, and CK rechecked the temperature of a chicken breast which still measured as 140 degrees F. CK removed the tray of chicken breasts from the oven onto to the top stove and continued cooking the chicken until the chicken breast temperature was measured as 170 degrees F. CK stated oven 1 was the only functioning oven in the facility. CK stated oven 1 delayed timely cooking and serving of residents' meals. CK stated oven 1 had a faulty fan that was not working properly so food trays had to be rotated in the oven for food to reach the necessary temperature to be safe for consumption. CK stated he had informed the Dietary Supervisor (DS) about the faulty ovens about three to six months ago. During an interview on 10/31/23 at 2:39 p.m., DS stated Maintenance Supervisor (MS) was aware of the faulty ovens. DS stated Administrator (Admin) had been informed of the faulty ovens and repairs needed in the kitchen about three to six months ago. During an interview on 10/31/23 at 2:03 p.m., MS stated he was aware of the need for oven replacement and repairs needed in the kitchen. During an interview on 11/01/23 at 9:38 a.m., with Admin and MS, Admin stated he was aware of the need to repair or replace the ovens. During a review of the 2022 Federal Food Code, the Food Code indicated equipment components such as doors and seals are to be kept intact and tight. 2. During an initial kitchen tour on 10/30/23, at 9:35 a.m., with the Dietary Supervisor (DS), the following were observed: the countertop toaster oven had brownish black debris both on the oven knobs and inside the oven; the kitchen floors had cracked tiles with blackish discoloration, a ceiling vent was covered with blackish, dusty material; the grease trap area was malodorous and not securely covered. During an observation in the kitchen on 10/30/23, at 1:15 p.m., with DS, the following were observed: a cabinet drawer did not fully close. During an interview on 10/30/23, at 1:20 p.m., with DS, DS stated the Administrator (Admin) and the Maintenance Supervisor (MS) were aware of the need for repairs in the kitchen. During an interview on 10/31/23 at 2:03 p.m., MS stated the facility had plans to replace the kitchen cabinet, ovens, plumbing, floorings and grease trap. During an interview on 11/01/23, at 9:38 a.m., with Admin and MS, Admin stated he was aware of identified concerns in the kitchen. MS stated he was not sure who was responsible for the cleaning the vents. During a review of the facility's policy and procedure titled, Sanitation, revised November 2022, indicated, The food service area is maintained in a clean and sanitary manner . All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects . All utensils, counters, shelves, and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide Resident 1's Representative (RR) with a summary of the baseline care plan. This failure resulted in the lack of information about Resident 1's care. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty swallowing) need for assistance with personal care, malignant neoplasm (abnormal growth, cancer) of connective and soft tissue, presence of a cardiac pacemaker (small device implanted in the chest to help control the heartbeat), and atrial fibrillation (irregular and very rapid heart rhythm). The record indicated RR as Resident 1's responsible party/representative. During a telephone interview with RR on 2/1/23 at 11:32 a.m., RR stated not having received a summary of Resident 1's care plan or even a telephone call from any facility representative during Resident 1's stay from 2/1/22 through 2/6/22. RR stated of not being informed about the plan of care to be provided by the facility. Review of Resident 1's Patient Care Timeline notes from the hospital dated 2/6/22 indicated, RR stated .No one [at the facility] can tell me what is happening. During a telephone interview and concurrent review of Resident 1's clinical record with the Director of Nursing (DON) 2 ,on 1/31/23 at 4:11 p.m., DON 2 stated the baseline care plan was developed for Resident 1 on 2/122 but the clinical record did not indicate a summary of the care plan was provided to RR. Review of the facility's policy and procedure titled, Care Plans-Baseline, last revised March 2022, indicated the resident and/or representative are provided a written summary of the baseline care plan that includes stated goals and objectives of the resident, a summary of the resident's medications and dietary instructions and any services and treatments to be administered by the facility. The policy also indicated provision of the summary to the resident representative is documented in the clinical record. Review of Resident 1's Baseline Care Plan Person-Centered Care Planning dated 2/2/22 indicated, E. Additional Notes signed and dated by DON 3, had no responses entered to the question if a printed copy of the Baseline Care Plan was provided to Resident 1 or RR.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to provide treatment and care in accordance with professional standards of practice in caring for the resident with a Foley catheter (a flexible tube that is passed into the bladder to drain urine) when: - Resident 1's urine characteristics (amount, color, odor, transparency) was not assessed and monitored for any changes. - Resident 1's intake and output (the measurement of the fluids that enter the body [intake] and the fluids that leave the body [output]) were not monitored per the physician's order. This failure contributed to Resident 1's transfer to the acute hospital and required intravenous (IV) fluids (administration of fluids into the person's veins) for fluid resuscitation (replenishing bodily fluids lost through sweating and bleeding). Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with diagnoses that included hypertension (high blood pressure), moderate protein calorie malnutrition, dysphagia (difficulty swallowing) and need for assistance with personal care. Resident 1 was admitted with a Foley catheter. Review of Resident 1's Order Summary Report for February 2022 indicated a physician order dated 2/1/22 for I & O (intake and output) x 1 month . The report also indicated an order dated 2/1/22 for Resident 1 to receive apixaban tablet (an anticoagulant, prescription medication to prevent blood clots) 5 milligrams (mg) twice daily. During a telephone interview with the Director of Nursing (DON) 1 on 1/31/23 at 4:11 p.m., DON 1 stated for a resident with a Foley catheter, intake and output monitoring would be recorded in the Medication Administration Record (MAR) by the licensed nurse assigned during the shift. Review of Resident 1's MAR for February 2022 did not indicate intake and output record/monitoring was done as ordered by the physician. Review of Resident 1's undated care plan for potential bleeding related to the use of anticoagulant medication indicated for staff to monitor urine for presence of blood. Review of Resident 1's undated Foley catheter care plan indicated for staff to monitor/record/report to MD for signs/symptoms of UTI or urinary tract infection, any infection in the bladder, kidneys or urethra (tube through which urine leaves the body). Another intervention to prevent a catheter associated urinary tract infection (CAUTI), included staff to provide catheter care every shift. Review of the facility's policy and procedure titled, Catheter Care, Urinary, last revised September 2014, for Input/Output, staff must Maintain an accurate record of the resident's daily output, per facility policy and procedure. Also, documentation of the character of urine, such as color, clarity, and odor should be recorded in the resident's medical record. During an interview and concurrent record review with the DON 2 on 9/6/22 at 12:52 p.m., DON 2 stated Resident 1's urine output was not monitored or documented in the medical record. During a telephone interview with Licensed Vocational Nurse (LVN) 1 on 9/7/22 at 2:15 p.m., LVN 1 stated, for residents with Foley catheter, if there was a written order for catheter care, it would be documented in the MAR, otherwise one only needed to do something about it if anything out of the ordinary was observed. During a concurrent interview and review of the facility's policy and procedure with DON 4, on 8/1/23 at 10:07 a.m., DON 4 stated intake and output monitoring is done for residents who were admitted with a Foley catheter. The facility's policy and procedure titled, Output, Measuring and Recording, last revised October 2010 indicated, the following information to be recorded on the bedside intake and output and/or in the resident's clinical record; the date and time the resident's urine output was measured and recorded, name and title of the individual who measured and recorded the urine output, amount and character of output, and the signature and title of the person completing the data. Review of Resident 1's Progress Notes indicated the following: -2/1/22 at 7:59 p.m., evening shift, Resident was admitted to the facility with a FC (Foley catheter) intact and draining well to yellow colored urine. -2/3/22 at 2:56 a.m., night shift, there was no documentation of Resident 1's urinary output or urine characteristic assessment. -2/3/22 at 11:44 p.m., no documentation of Resident 1's urinary output or urine character. -2/4/22 at 2:33 p.m., no documentation of Resident 1's urinary output or urine character. -2/4/22 at 9:28 p.m., no documentation of Resident 1's urinary output or urine character. -2/5/22 at 5:56 p.m., no documentation of Resident 1's urinary output or urine character. -2/5/22 at 11:14 p.m., no documentation of Resident 1's urinary output or urine character. -2/6/22 at 7:46 a.m., no documentation of Resident 1's urinary output or urine character. -2/6/22 at 3:58 p.m., Received resident in bed eyes closed. F/C [Foley catheter] intact draining hematuria (blood in urine). Resident 1's family requested for Resident 1 to be transferred to the acute hospital. -2/6/22 at 9:36 p.m., Resident 1 was picked up by ambulance at 5 p.m. and transferred to the hospital. Review of Resident 1's ED Provider Notes dated 2/6/22 indicated the physical exam showed Resident 1's vital signs as follows: blood pressure 80/40 (normal blood pressure is not less than 90/60 or not more than 120/80), pulse rate 130 (normal range 60-100 beats /minute) and respiration of 24 breaths/minute (normal range 12-18 breaths/minute). Review of Resident 1's Patient Care Timeline at the acute hospital dated 2/6/22 indicated Resident 1 arrived at the Emergency Department (ED) at 5:21 p.m. where Resident 1 received IV fluid of normal saline 0.9% 1,000 milliliters (ml) at 5:35 p.m. and another 1,000 ml NS (normal saline 0.9%) at 9:15 p.m. for fluid resuscitation. The timeline documentation also indicated urine analysis was performed that showed more than 180/HPF (high powered field, a technique in microscopy utilized in urine analysis) of RBCs (Red Blood Cell, normal range 0-2), more than 180 HPF of WBCs (White Blood Cell, normal range 0-5) and presence of large amount of bacteria and mucus. Resident 1 received 1 gram of Rocephin (antibiotic for bacterial infections, including severe or life-threatening forms) IV. The Patient Care Timeline also indicated the Resident's Representative (RR) stated .No one [at the facility] can tell me what is happening. I was there [at the facility] yesterday and [Resident 1's] urine was orange and today it was bloody.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to ensure one of 12 sampled residents (Resident 7) was aware of the benefits and limitations of having a knee high plastic zipped barrier at the entrance to her room. This failure resulted in Resident 7 to be unaware of the rationale for having a plastic zipped barrier at her door and potential for isolation. Findings: During a record review of Resident 7's admission record dated 7/9/21, showed Resident 7 was admitted to the facility on [DATE]. Resident 7's primary language was Russian. During an observation and interview, on 7/9/21, at 9:30 a.m., a horizontal knee-high, white colored plastic barrier, with a zipper at the center was blocking Resident 7's door. During an interview, on 7/9/21, at 9:41 a.m., and using the interpreter/ translation line, Resident 7 stated she was not aware why the plastic barrier was at her door. Resident 7 pointed at the plastic barrier and stated she felt, very bad to have a plastic barrier at her doorway. During an interview with the Director of Nursing (DON), on 7/7/21, at 11:45 a.m., DON stated Resident 7 was placed on contact isolation precautions for CRE (when a certain type of bacteria develop resistance to the group of antibiotics called carbapenems, the germs are called carbapenem-resistant Enterobacterales) infection in her urine. DON stated the facility installed the plastic barrier at Resident 7's door on 2/24/21 for protection of Resident 7 and other residents residing at the facility. DON further stated the plastic barrier was a reminder for Resident 7 to not to go out of her room. During an interview and record review, on 7/7/21 and 11:45 a.m., Resident 7's nursing progress notes dated 2/24/21 were reviewed. DON stated Resident 7's clinical record did not indicate the purpose, benefits and limitations of the plastic barrier was explained to the resident or her responsible party. During an interview with the Minimum Data Set Coordinator (MDSC), on 7/8/21, at 1;39 p.m., MDSC stated Resident 7 liked to go out of her room for a change of scenery and explore outside. MDSC further stated having the plastic barrier at Resident 7's door placed her at risk for isolation. During a review of the facility's policy and procedure (P&P) titled, Notice of Resident Rights and Responsibilities, dated 2001, the P&P indicated, Our facility shall inform the resident both orally and in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility.

Based on observation, interview, and record review, the facility failed to follow the physician order to apply a splint to one of 12 sampled residents (Resident 30)'s left contracted (shortening of the muscle, tendon, or scar tissue causing deformity and possibly permanent disability) arm. This failure had the potential to worsen Resident 30's left arm contracture. Findings: During a record review, with the Licensed Vocational Nurse 3 (LVN 3), on 7/8/21, at 10:32 a.m., Resident 30's physician orders dated 7/4/19 indicated to apply the wrist splint to Resident 30's left upper extremity from 8 p.m.-8 a.m. During an observation, on 7/721, at 7:14 a.m., in Resident 30's room, Resident 30 was sitting in a recliner without a splint applied to the left arm contracture. During an interview, on 7/8/21, at 9:37 a.m., LVN 3 stated she had not seen Resident 30 with a splint for the left arm for the last six months. During a concurrent interview and record review, with the Director of Rehabilitation (DOR), on 7/8/21, at 9:42 a.m., DOR stated by not applying the splint to Resident 30's left contracted arm, placed Resident 30 at risk for worsening of the contracture. During a concurrent interview and record review, with the Director of Nursing (DON), on 7/9/21 at 8:40 a.m., Resident 30's nursing progress notes from 4/30/21 through 6/19/21 were reviewed. DON stated he was unable to find any documentation indicating Resident 30 wore the splint and or had refused to wear the splint on the left contracted arm during that time period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide one resident (Resident 293) a therapeutic diet prescribed by a physician when a medical nutrition shake was not provided as ordered. This failure had the potential to cause a reduction in calorie and/or protein intake intended for the resident resulting in weight loss and/or muscle wasting. Findings: A record review for Resident 293, showed she was admitted to the facility on [DATE]with a diagnoses including but not limited to, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression, hallucinations, etc.) and Cognitive Communication Deficit (may occur after neurological damage such as a progressive brain disorder, stroke, etc. and the deficit results in difficulty with thinking and how to use language). Physician orders showed Resident 293 was prescribed a Regular diet on 6/14/21 and an Ensure Plus [a medical nutrition shake with concentrated calories and protein to help a patient gain or maintain weight and can also provide extra nutrients when a patient has a poor diet or low food intake resulting in malnutrition] with meals 240 ml (milliliters), on 6/13/21. In an interview with the Registered Dietitian (RD) on 7/8/21 at 9:30 a.m., she stated she initially recommended Ensure for Resident 293 because of weight loss. She stated Resident 293 had a Physician order for Ensure Plus three times per day. She said she documented in the Care Plan that Resident received this medical nutrition shake with meals. Review of the Plan of Care titled, Nutrition Status for Resident 293 printed on 7/9/21, showed the planned interventions included, Food Preferences . Offer meal alternatives, substitutions, supplements as appropriate . Serve diet as ordered . Supplement: Ensure Plus 240 ml with meals . In an interview on 7/9/21 at 9:15 a.m., the Dietary Services Supervisor (DSS) stated Resident 293 did not receive Ensure Plus with meals because it was not indicated on the meal tray ticket (the document placed on a resident's meal tray to show Food and Nutrition staff what foods to give to a resident. It includes resident diet, food preferences, food allergies, etc.). He stated if there was a diet order for Ensure Plus with meals, the medical nutrition shake would go on the meal tray. Review of the lunch meal tray ticket dated 7/7/21 showed the Ensure Plus or any other medical nutrition shake was not listed on the tray ticket. In an interview on 7/9/21 at 9:25 a.m., Licensed Vocational Nurse 4 (LVN 4) reviewed the Medication Administration Record (MAR) and stated resident 293 had an order for Ensure Plus with each meal. There was no documentation to identify the specific liquids consumed by the resident and the amount of each of these liquids to be able to calculate the nutrient intake from liquids. LVN 4 said the amount of liquids consumed by the resident were documented in the Intake and Output ( I&O) log but not the types of liquid consumed. In a comparison of Ensure Plus to Ensure Clear Nutrition Drink, the 8 ounce (237 ml) Ensure Plus provides 350 calories, 16 grams of protein, and 11 grams of fat, including omega-3 fatty acid (fat shown to be a very beneficial fat for the body and good health). The 10 ounce (296 ml) Ensure Clear provides 8 grams of protein, 180 calories, and 0 percent fat. Ensure Plus 3 times a day would provide 1,050 calories, 48 grams of protein, and 33 grams of fat. If the resident received three Ensure Clear drinks per day, this would provide significantly fewer calories and nutrients than Ensure Plus at 540 calories, 24 grams of protein, and 0 percent fat. In an interview with the RD on 7/9/21 at 11:01 a.m., she stated when diets were ordered by a physician, the order was written on a communication sheet and nursing staff gave it to the kitchen. The kitchen staff added the order to the tray ticket. Review of the Dietary Communication for Resident 293, signed by a licensed nurse and dated 6/13/21, showed under the category of Diet Orders, a list of diets with a box to check next to the diet. Other was also an option under diet orders. The Other box was marked and written next to the marked box was, Ensure Plus 240 ml each meals Typed at the top of the document and in large, bold, capital letters was, PLEASE MAKE A COPY AND GIVE COPY TO THE DIETARY STAFF.

Based on observation, interview, and facility document review, the facility failed to ensure the competency of the kitchen staff, who washed dishes, when she did not follow proper hand hygiene and glove use procedures (Cross-reference F 812) and she did not appropriately demonstrate how to check the sanitizer strength for the dish machine. The failure to ensure the competency for one of six staff on dishwashing, hand hygiene, and glove use procedures had the potential to result in cross-contamination of food. Findings: On 7/7/21 at 10:02 a.m., an observation and concurrent interview with Diet Aide 1 (DA 1) and the Dietary Services Supervisor (DSS), showed DA 1 washed soiled resident food dishes from breakfast and handled clean dishes without following current standards of practice as well as facility policy and procedures for proper hand hygiene and glove use (Cross Reference F 812). In addition, DA 1 said she usually washed dishes from breakfast and checked and documented the strength of the chemicals in the dish machine in the morning. She demonstrated how to check the chemical strength by dipping a chlorine test strip in water pooled in the dish machine after the dish machine completed the sanitizing cycle. Then she compared the strip to the color chart located inside the test strip container to assess the strength of the chlorine sanitizer solution. She stated the strip showed the strength was between 100 and 200 parts per million (ppm). The test strip was lighter than what the color chart showed for a strength between 100 and 200 ppm. Two surveyors and the DSS said the test strip showed the strength of the chlorine was 50 to 100 ppm. DA 1 stated the strength of the chlorine sanitizer should be 200 but it was okay if it was 100 ppm. She said 50 ppm was not okay. In an interview on 7/8/21 at 9:30 a.m., the Registered Dietitian stated the chlorine sanitizing solution for the dish machine should be 50 to 100 ppm. She stated DA 1 was new and may not have been trained for dishwashing yet. She said they still had her wash dishes because the kitchen was short staffed. Review of the policy and procedure titled, Sanitization dated 2001, showed the chlorine solution of the final rinse in a low-temperature dishwasher was to be 50 ppm. Review of the undated job description titled, Dietary Aide showed Essential Duties included to strip down returned trays and start washing dishes . Check and record chlorine concentration and water temperature of dishwashing machine at the beginning of shift . Operate dishwasher . The facility did not show evidence DA 1 was trained regarding dishwashing using the dish machine, hand hygiene, and proper glove use.

Based on observation, interview, and facility document review, the facility failed to prepare food in a manner to conserve nutritive value and that was palatable when the recipe was not followed for pureed broccoli and rice and pureed rice was very gummy and sticky. This failure had the potential to decrease the nutrients in food served and decrease food intake for two residents who received a pureed diet out of a facility census of 47. Findings: Review of the menu served for lunch on 7/7/21 and titled, Daily Spreadsheet showed residents prescribed a Regular texture diet received Red Pepper [NAME] Pilaf and Sauteed Broccoli Florets. Residents that were prescribed a pureed diet received pureed Red Pepper [NAME] Pilaf and pureed Sauteed Broccoli Florets. On 7/7/21 at 11:40 a.m., an observation and concurrent interview with the Dietary Services Supervisor (DSS), showed DSS pureed broccoli in a blender for the lunch meal for residents prescribed a pureed diet. DSS added scoops of cooked broccoli into a blender and a large scoop of butter. The DSS did not measure the butter. He added water to the contents in the blender directly from the tap at the food preparation sink and blended the broccoli for a few seconds. Then he added more water from the tap and continued to blend the broccoli. When he was finished blending, he scooped the pureed broccoli from the blender into a pan and placed the pan on the tray line for lunch food service. On 7/7/21 at 12:15 p.m., an observation of a test tray was done by sampling a pureed lunch meal with a concurrent interview with DSS. When the pureed rice was touched with a fork, the surface of rice was hardened but pliable. When tasted, the pureed rice had a very sticky and gummy texture and was not moist. DSS confirmed the rice was sticky and stated it might be sticky because he pureed the regular rice and added water. Review of the undated recipe used to prepare the broccoli for lunch on 7/7/21 titled, Sauteed Broccoli Florets (Fresh) showed the ingredients did not include butter. The recipe also showed to refer to Puree Recipe for the puree diet. Review of the undated recipe used for pureed vegetables titled, Pureed Vegetables showed the ingredients were seasoned vegetables, cooked and drained (reserve liquid), and thickener. The recipe directions stated to remove portions of vegetables required from the regular prepared recipe, drain and reserve cooking liquid, then process (or blend) until fine in consistency. If needed, add a small amount of reserved cooking liquid and process until smooth. Review of the undated recipe used to prepare rice for lunch on 7/7/21 titled, Red Pepper [NAME] Pilaf showed to refer to the Pureed Potatoes & [and] Other Grains recipe for the pureed diet. Review of the undated recipe title,d Pureed Pasta, Potatoes, [NAME] and Other Grains showed to use drained, cooked rice and the liquid ingredients were broth or 2 percent milk. The liquid ingredients did not include water. The directions showed to remove portions required from the regular prepared recipe and drain. Process (or blend) until fine in consistency. Then slowly add hot broth (or milk) with other ingredients listed and process until smooth. In an interview with DSS on 7/7/21 at 12:57 p.m., he stated he did not use milk or broth for the pureed rice because residents on a pureed diet might be lactose (a sugar in milk) intolerant or vegetarian. He stated he did not know if the current residents with a prescribed pureed diet were lactose intolerant or vegetarian. He also said he did not understand the difference between adding tap water instead of reserved water from cooking vegetables when pureeing the broccoli. Review of the two pureed diet lunch tray tickets dated 7/7/21 for Residents 11 and 43, did not show the residents were ordered a vegetarian diet or preferred a vegetarian diet. The tray tickets also did not indicate either resident had an allergy or intolerance to lactose or disliked milk. In an interview on 7/8/21 at 12 p.m., the Registered Dietitian (RD) stated the recipe needed to be followed and if the recipe was followed for pureed rice, the rice might not be sticky and gummy. The RD stated very sticky rice could be an aspiration (the act of inhaling a foreign body into the lungs such liquid). She also stated reserved water from cooking vegetables might have more flavor and agreed nutrients in food can be decreased if using tap water versus reserved water from cooking vegetables. Review of the policy and procedure titled, Standardized Recipes dated April 2007, showed standardized recipes shall be developed and used in the preparation of foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide one resident (Resident 293) her preferred foods as well as a physician ordered supplement in the consistency and flavor preferred by the resident. This failure had the potential to result in a decreased amount of caloric intake leading to weight loss for 1 of 47 residents residing at the facility. Findings: A record review for Resident 293, showed she was admitted to the facility on [DATE] with a diagnoses including but not limited to, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder, such as depression, hallucinations, etc.) and Cognitive Communication Deficit (may occur after neurological damage such as a progressive brain disorder, stroke, etc. and the deficit results in difficulty with thinking and how to use language.) Physician orders showed Resident 293 was prescribed a Regular diet on 6/14/21 and an Ensure Plus [a medical nutrition shake with concentrated calories and protein to help a patient gain or maintain weight and can also provide extra nutrients when a patient has a poor diet or low food intake resulting in malnutrition] with meals 240 ml (milliliters), on 6/13/21. Review of the document titled, Snacks and Supplements dated 2016, showed if a particular fortified food is disliked or refused, it should be replaced with a comparable fortified food the resident likes. The goal is to meet each individual resident's nutrient needs by adjusting the program accordingly. Review of the document titled, POC [Points of Care] Response Form for the task Amount Eaten showed from 6/11/21 to 7/9/21, the percent eaten of each meal was documented for a total of 83 meals for Resident 293. In this time frame the resident ate 0-25 percent for 13 meals, 26-50 percent for 33 meals, and the resident refused 26 meals. These numbers showed Resident 293 ate 50 percent or less for 54 of her meals and had refused 31 percent of her meals in this time frame. On 7/7/21 at 11 a.m., an observation showed five bottles of 296 ml, berry flavored, Ensure Clear nutrition drink with Resident 293's last name written on the cap of all five bottles. These drinks were located in the resident food refrigerator in the nursing station. In an interview on 7/7/21 at 11:16 a.m., the Director of Nursing (DON) stated some families volunteered to bring in supplements for residents when the facility told the family they only carried chocolate and vanilla. DON said the facility bought the supplements for residents if the family did not offer to provide them. In an interview with the Registered Dietitian (RD) on 7/8/21 at 9:30 a.m., RD stated she initially recommended Ensure for Resident 293 because of weight loss. RD further stated Resident 293 had a Physician order for Ensure Plus 3 times per day, and documented in the Care Plan that Resident received this medical nutrition shake with meals. She said she did not document the berry nutrition drink, brought in by the Resident's family member, in the Care Plan. RD also stated the Resident was probably receiving the berry medical nutrition drink in addition to the medical nutrition shake the facility provided with meals. Review of the Plan of Care titled, Nutrition Status for Resident 293 printed on 7/9/21, showed the plan included the interventions Food Preferences . Offer meal alternatives, substitutions, supplements as appropriate . Serve diet as ordered . Supplement: Ensure Plus 240 ml with meals . In an interview on 7/9/21 at 9:15 a.m., the Dietary Services Supervisor (DSS) stated Resident 293 did not receive Ensure Plus with meals because it was not indicated on the meal tray ticket (document placed on resident's meal tray to show Food and Nutrition staff what foods to give to a resident. It includes resident diet, food preferences, food allergies, etc.). He stated if there was a diet order for Ensure Plus with meals, the medical nutrition shake would go on the meal tray. Review of the lunch meal tray ticket dated 7/7/21 showed liquids the resident received were lemonade and ice cream and no preferences were listed. A Ensure Plus or another medical nutrition shake or drink was not listed on the tray ticket. In an interview on 7/9/21 at 9:25 a.m., Licensed Vocational Nurse 4 (LVN 4) reviewed the Medication Administration Record (MAR) and stated resident 293 had an order for Ensure Plus with each meal. She stated Resident 293's brother brought the Resident a different type of medical nutrition drink. He brought in the clear Ensure versus the shake. In an interview on 7/9/21 at 9:27 a.m., Certified Nursing Assistant 4 (CNA 4) stated when the resident did not eat, she gave Resident 293 the clear medical nutrition drinks that Resident 293's brother brought in. CNA 4 stated the resident did not eat much and only took liquids for a week or two. She said when the resident ate 50 percent or less, she offered other food, and offered the clear medical nutrition drink next. In a phone interview on 7/9/21 at 11:27 a.m., Resident 293's brother stated his sister liked the berry flavor Ensure nutrition drink. He said the facility did not provide the type she liked, and said she liked the juice not the shake, like the facility had. He stated he also brought his sister sodas and smoothies because these were things she liked when she was at the hospital. He also said his sister might eat if the facility provided foods she preferred. He said he would be able to provide the facility with a list of food and drinks his sister liked, but the facility did not ask him, and he did not realize the facility would provide her preferences. He also said his sister would not be able to verbalize her own preferences. On 7/9/21 at 11:50 a.m. in an observation and interview with DSS, and attempted interview with Resident 293, DSS stated he was responsible for getting residents' food and drink preferences. He stated he asked resident 293 her preferences by asking if she liked certain foods and she nodded. DSS asked resident 293 if she liked to eat and she nodded yes. Then he asked her if she liked lasagna, she nodded yes. He also asked if she liked fish, she nodded yes. The surveyor attempted to ask what foods she liked, and she did not answer. Resident 293 had a blank stare when she nodded to all of the questions and did not verbalize any preferences. DSS stated he asked family members resident food preferences if he was not able to get them from the resident.

Based on interviews and record review, the facility failed to act upon the pharmacist's identified medication irregularity for one (Resident 41) of 12 sampled residents when; 1. Licensed nurses did not hold midodrine (for low blood pressure) as ordered by the physician. 2. Resident 41 continued to received fludrocortisone (corticosteroid) twice daily instead of once every day. These failures had the potential for Resident 41 to receive unnecessary drugs and suffer adverse medication side effects. Findings: Review of the admission Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 6/2/21, indicated Resident 41's diagnoses included Atrial fibrillation (irregular heart rhythm) and concussion edema (swelling) of cervical spinal cord encounter. Review of Resident 41's physician orders dated 5/27/21 indicated the physician ordered midodrine 5 milligram (mg) tablet by mouth, two times a day for hypotension (low blood pressure), hold for systolic (top number) blood pressure (SBP) greater than 135. Review of the Medication Administration Record (MAR) dated 5/1/21 through 5/31/21, indicated Resident 41 was administered midodrine HCL (hydrochloride) tablet 5 mg, two times a day on 5/28/21 (140/90) and 5/31/21 (136/74) when the SBP was greater than 135. Review of the Medication Administration Record (MAR), dated 6/1/21 through 6/31/21, indicated Resident 41 was administered midodrine HCL tablet 5 mg two times a day, on 6/18/21 at 12 p.m. and 5 p.m., when the SBP was greater than 135. Review of the pharmacist's medication review recommendation dated 6/21 indicated Resident 41's midodrine medication was not held in accordance with the physician's order on 5/28/21 and 5/31/21 at 12 p.m. when midodrine doses were administered when the SBP was above 135. Review of the hospital transfer orders dated 5/25/21 indicated Resident 41 was prescribed fludroocortisone (controls the sodium and fluids in the body) 0.1 mg by mouth, one time daily. Review of the physician orders dated 5/26/21 indicated Resident 41 was ordered fludrocortisone tablet 0.1 mg by mouth, two times a day related to concussion and edema of the cervical spinal cord. Review of the MAR dated 5/26/21 through 5/31/21, indicated Resident 41 was administered fludrocortisone tablet 0.1 mg by mouth two times daily. Review of the pharmacist medication regimen review (MRR) recommendation dated 6/1/21 indicated Resident 41 was administered fludrocortisone tablet 0.1 mg BID (two times daily) but the hospital transfer orders dated 5/21/21 was to give fludrocortisone 0.1 mg, one time a day. During an interview on 7/9/21 at 10:28 a.m., the Director of Nursing (DON) stated he was aware of the consultant pharmacist MRR recommendations, and the pharmacist had informed him of Resident 41's midodrine and fludrocortisone discrepancies. DON could not provide documentation of having followed up or obtained clarification with the physician. Review of the MAR dated 6/1/21 through 6/31/21, indicated Resident 41 continued to receive fludrocortisone 0.1 mg by mouth two times a day. During an interview on 7/9/21 at 11:20 a.m., the Consultant Pharmacist (CP) stated MRR recommendations and findings are given to the DON. CP stated she had notified the Administrator (Admin) of some delays with the follow up of residents' MRR recommendations. During an interview on 7/9/21 at 11:38 a.m., Admin stated CP had informed him of the delayed response to the MRR recommendations. Admin further stated the facility would continue to inform the nursing staff to promptly follow up on the MRR recommendations. The facility's policy and procedure titled, Medication Regimen Review (MRR) and Reporting dated 09/18 indicated, A record of the consultant pharmacist's observations and recommendations is made available in an easily retrievable format to nurses, physicians and the care planning team within 48 hours of MRR completion. Should the consultant pharmacist detect a potentially clinically significant medication issue that requires urgent action to protect the resident , he/she will promptly alert the direct care nurse for immediate action. If prescriber intervention is required, facility staff will ensure proper communication is provided to the attending physician, nurse practitioner or physician's assistant to ensure resolution by midnight of the next calendar day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure the competency of the Dietary Services Supervisor (DSS) and the Registered Dietitian (RD) when: 1. DSS did not ensure: the kitchen was maintained in a safe and sanitary manner and maintenance needs were reported for the kitchen (Cross-reference F 812); food preparation methods conserved nutritive value of the food (Cross-reference F 803); food was palatable (Cross-reference F 804); resident food preferences were provided (Cross-reference F 806); and kitchen staff were trained on perspective duties (Cross-reference F 802); 2. DSS did not ensure there was a system for dating food with appropriate use-by-dates; 3. DSS did not ensure thermometers were calibrated; 4. The RD did not provide consultation to DSS to ensure the kitchen was maintained in a safe and sanitary manner (Cross-reference F 812) and foods were prepared in a manner to conserve nutritive value and flavor and were palatable (Cross-reference F 804). These failures to ensure the competency for two of two staff (RD and DSS) who were in charge of Food and Nutrition oversite had the potential to result in cross-contamination of food and decreased nutrient intake for 46 residents who consumed food from the kitchen out of a facility census of 47. Findings: 1. Review of the undated job description titled, Dietary Supervisor showed DSS was responsible for providing supervision to the Dietary Department to ensure quality of food and assist in the preparation and service of regular meals and therapeutic diets, order supplies, maintain the area and keep equipment in sanitary condition. The essential duties included to direct and participate in food preparation and service of food that is safe and appetizing and is of quality and quantity to meet each residents' needs in accordance with physicians order; direct and supervise all dietary functions and personnel; train dietary employees; maintain kitchen and food storage areas in a safe, orderly, clean and sanitary manner; and inspect the Dietary Department regularly to ensure it is safe and sanitary. During the Federal recertification survey from 7/6/21 to 7/9/21, multiple observations, interviews, and document reviews for Food and Nutrition Services showed: Kitchen areas were not clean including cabinets used to store cooking equipment with residue build-up on the inside surface, a wall located next to cooking equipment with over 50 dead flies stuck to it, window sills located directly behind a steam table with dirt and grime build-up, and the floor in the dry food store room with dirt and grime build-up; food preparation equipment was not stored clean; areas in the kitchen were not maintained including a screen door with multiple holes, a countertop with laminate peeling away exposing particle board, and a freezer with broken plastic on the inside surface; food preparation and cooking equipment was not maintained including cutting boards with a significant amount of scratches, non-stick frying pans with deep scratches on the cooking surface, a food processor with cracks and tape holding on the handle, and a spatula and a spoodle (a serving tool that is a cross between a ladle and a spoon) with rough, worn handles, and reside imbedded in the rough surface; the 3-compartment sink and the dirty side of the dish machine were back to back and dirty water from the dish machine area splashed clean pots and pans in the 3-compartment sink area; refrigerated food was not stored at an appropriate temperature; and DSS did not prepare food in a manner that conserved nutritive value when water was added to pureed food when the recipes called for broth, milk, or conserved water from cooking vegetables; DSS did not ensure the palatability of food when pureed rice was very sticky and gummy; a kitchen staff did not follow proper hand hygiene and glove use procedures when washing dishes, and did not demonstrate how to check the dish machine sanitizer strength according manufacturer's instructions; and DSS did not ensure resident food preferences were obtained. (Cross-reference F 802, F 804, F 806, F 812). In an interview on 7/7/21 at 10:02 a.m., DSS stated he covered a cook position on Monday and Tuesday since the beginning of June because a cook retired at the end of May. He said it was difficult to cook and do his supervisor tasks at the same time. 2. During the initial tour of the kitchen on 7/6/21 at 11:08 a.m., and concurrent interviews with DSS and [NAME] 1, four different types of cheese were stored in the reach-in refrigerator and labeled with use-by dates ranging from 26 days to 6 months. These dates were as follows: shredded, orange cheese (not in original package) opened 7-5-21 and use-by 7-25-21 (26 days), 3 packages of American cheese slices (not in original package) opened 7-3-21 and use-by 7-31-21 (29 days). Two packages of sliced white cheese (not in original package) opened 6-14-21 and use-by 7-14-21 (31 days), cream cheese (in original package) opened 6/25/21 and use-by 12/25/21 (6 months). Some other opened items in the refrigerator included Greek yogurt opened 7/5/21 and use-by 8/1/21 (28 days), and sour cream (in original package) opened 6/22/21 and use-by 7/22/21 (31 days). DSS stated he thought the chesses should be used by one week after opening, but had to follow up. DSS further stated he was not aware if the staff had a reference that showed how long a food product should be dated to use-by after the food was opened. [NAME] 1 stated there was no list to show how long open food containers could be stored. On July 9 at 12:17 p.m., DSS produced a document to show how long opened packages of food could be stored. The list was untitled and undated and read Section 3: Receiving, Inventory and Storage, Page 3-13 and 3-14, at the bottom of the pages. The document did not include shredded cheese. It showed cream cheese could be stored in an unopened package for 2 weeks but did not show how long an opened package could be stored. Pasteurized processed cheese could be stored in an open package for 3-4 weeks. The list did not show how long open packages of sliced cheddar, edam, [NAME], and Swiss could be stored for. The document also showed an open container of sour cream could be stored up to 2-3 weeks and yogurt 7-10 days. According to this list, the cream cheese, yogurt, and sour cream, found in the reach-in refrigerator on 7/6/21, were dated beyond the recommended use-by date. It could not be determined by this list if the shredded cheese was stored with an appropriate use-by date. Review of the policy and procedure titled, Food Receiving and Storage dated 2001, showed all refrigerated foods will be labeled with a use-by date. 3. In an interview on 7/7/21 at 9:05 a.m., DSS stated the thermometers used in the kitchen were not calibrated because the thermometers were digital thermometers. In an interview and observation on 7/8/21 at 9 a.m., DSS stated he knew if a thermometer was not working when the battery of the thermometer died, and he could not turn it on. He said as long as the thermometer turned on, it should be accurate. He also stated he could tell if a thermometer was not working correctly by taking the temperature of food, and if the temperature was not correct, then the thermometer might not be working. DSS showed the type of thermometers used in the kitchen. The thermometer had small buttons on the handle. One button was labeled CAL. Manufacturer's instructions for the thermometer were requested but the DSS did not provide them. In an interview with RD on 7/8/21 at 9:30 a.m., she stated the digital thermometers should be calibrated daily. Review of the policy and procedure titled, Food Preparation and Service dated 2001, showed food thermometers used to check food temperatures are calibrated for accuracy. Review of the manufacturer's instructions for the digital thermometer that DSS showed was used in the kitchen named [name brand] Advanced Pocket Digital Thermometer, showed the thermometers were Field Calibratable. 4. Review of the undated job description titled, Registered Dietitian showed the RD's essential duties included, monitoring food services operations to ensure conformance to nutritional, safety, sanitation and quality standards; monitor food control systems such as food temperatures, preparation methods, presentation of food in order to ensure that food is prepared and presented in an acceptable manner. The supervisory requirements of the RD's job was to assist with the overall supervision and management of the dietary staff. During the Federal recertification survey from 7/6/21 to 7/9/21, multiple observations, interviews, and document reviews for Food and Nutrition Services showed: Kitchen areas were not clean, including cabinets used to store cooking equipment with residue build-up on the inside surface, a wall located next to cooking equipment with over 50 dead flies stuck to it, window sills located directly behind a steam table with dirt and grime build-up, and the floor in the dry food store room with dirt and grime build-up; food preparation equipment was not stored clean; areas in the kitchen were not maintained including a screen door with multiple holes, a countertop with laminate peeling away exposing particle board, and a freezer with broken plastic on the inside surface; food preparation and cooking equipment was not maintained including cutting boards with a significant amount of scratches, non-stick frying pans with deep scratches on the cooking surface, a food processor with cracks and tape holding on the handle, and a spatula and a spoodle (a serving tool that is a cross between a ladle and a spoon) with rough, worn handles, and reside imbedded in the rough surface; the 3-compartment sink and the dirty side of the dish machine were back to back and dirty water from the dish machine area splashed clean pots and pans in the 3-compartment sink area; refrigerated food was not stored at an appropriate temperature; the DSS did not prepare food in a manner that conserved nutritive value when water was added to pureed food when the recipes called for broth, milk, or conserved water from cooking vegetables; the DSS did not ensure the palatability of food when pureed rice was very sticky and gummy; a kitchen staff did not follow proper hand hygiene and glove use procedures when washing dishes, and did not demonstrate how to check the dish machine sanitizer strength according manufacturer's instructions; and DSS did not ensure resident food preferences were obtained. (Cross-reference: F 802, F 804, F 806, and F 812). In an interview on 7/8/21 at 9:30 a.m., RD was interviewed about the consultation she provided to DSS in the kitchen. She stated she worked at the facility one day per week and did monthly and quarterly inspections in the kitchen. RD did not provide documentation of monthly or quarterly inspections, and stated she also gave staff in-services. RD did not provide documentation for in-services she conducted for Food and Nutrition staff. RD was asked about the concerns found in Food and Nutrition Services by the surveyor. 1. The RD was asked about a staff who did not follow proper hand hygiene procedures and glove use while washing dishes, when she touched clean dishes after removing soiled gloves, and also donned new gloves without washing hands. RD stated when one person washed dishes, they had to take off dirty gloves and put on clean gloves before putting away clean dishes. RD did not state hands had to be washed between removing soiled gloves and donning new gloves. She also stated the dishwasher was new so she might not have been trained for washing dishes yet. 2. RD was asked about refrigerator temperatures when the refrigerator thermometer read 41 degrees Fahrenheit (F) and food stored in the refrigerator was above 41 degrees F. RD stated she checked the refrigerators by looking at the thermometer, and if the thermometer read 41 degrees F, hopefully the food temperature would be 41 degrees F. RD said she did not take the temperatures of food in the refrigerator unless she was giving an in-service. 3. RD was asked if she identified the screen door on the back door of the kitchen that had a significant number of worn holes, in her inspection reports. She stated she did not identify holes in the kitchen's outside screen door and said the holes were not okay because flies could get in. 4. RD was asked if she identified non-stick frying pans and cutting boards that had significantly scratched surfaces. She said she was aware that some pans were old, and staff should not use pans that were scratched, but she did not recommend to staff or DSS to not use the old, scratched pans. She also stated she was aware there were scratched cutting boards but not aware staff were still using them. 5. RD was asked if she identified the broken, cracked strip of plastic with the rough edges, inside the reach-in freezer. She stated the broken, plastic strips on the inside of the reach-in freezer were okay as long as the freezer was keeping the appropriate temperature. 6. RD was asked if she was aware the laminate was coming detached on the counter in the dish machine area. RD stated she was aware of the laminate peeling off, but she did not report it,and it was unsanitary, and rodents could get under that space. 7. RD was asked if she identified the large steam table tray pans with a significant amount of black and yellow residue on the inside surface. She said she did not identify the condition of the pans used to hold water on the steam table because she went into the kitchen when the tray line was conducted, and the pans were covered. 8. RD was asked if she identified the windowsills and window tracks located behind the steam table, with a significant amount of dirt and grime build-up. She said she did not look at the windows to ensure the windowsills and window tracks were clean. In an interview with RD, on 7/8/21, RD was asked for her expectation on preparing food and using recipes when it was found DSS added water to food when the recipe called for milk, broth, or conserved water from cooking vegetables. She stated recipes should be followed, then said it was okay to add water when pureeing a food, even if the recipe indicated to add milk or broth and did not show to add water. She also said when pureeing vegetables, it was okay to use tap water if the recipe indicated to use reserve water from cooking vegetable. Then she stated the reserve water could have more flavor and adding tap water could decrease nutrients. In an interview on 7/9/21 at 11:01 a.m., the observation of the sticky, gummy pureed rice was discussed with RD. RD was asked if she sampled the food at the facility, and only sampled the Regular food sometimes when she ate her lunch. Review of the policy and procedure titled, Standardized Recipes dated April 2007, showed standardized recipes shall be developed and used in the preparation of foods. Review of the document provided by the facility titled, Food Receiving and Storage, revised October 2017, read .9. Refrigerated foods must be stored below 41 degrees F . 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee . According to the 2017 Federal Food Code, foods that are potentially hazardous, such as foods that are Time/Temperature Control for Safety Food or food that requires time/temperature for safety to limit pathogenic microorganism growth or toxin formation, shall be maintained at 41 degrees F or less except during preparation, cooking, or cooling, or when time is used as a control. Review of the document titled, Proper Wearing of Gloves in Healthcare dated 2019, showed when gloves are used, handwashing must occur prior to putting on gloves or when gloves are changed. According to the 2017 Federal Food Code, hands are to be washed after handling soiled equipment or utensils; and cloth gloves may not be used in direct contact with food unless the food will subsequently be cooked. Review of the facility's policy titled, Sanitation, revised October 2008 indicated, . The food service area shall be maintained in a clean and sanitary manner.1. All kitchens, kitchen areas . shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. During a review of the facility's policy titled, Sanitation, revised October 2008 indicated, . The food service area shall be maintained in a clean and sanitary manner .2. All utensils . and equipment shall be kept clean, maintained in good repair and shall be free from corrosions . that may affect their . proper cleaning .3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary . According to the 2017 Federal Food Code, all food-contact surfaces are to be clean to site and touch, and cooking equipment is to be free of soil accumulation. In addition, nonfood-contact surfaces are to be kept free of an accumulation of food residue and other debris. During a review of the facility's policy titled, Sanitation, revised October 2008 indicated, . 2. All utensils . and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Review of the policy and procedure titled, Sanitization dated 2001, showed counters and equipment shall be maintained in good repair and shall be free from breaks, corrosions, open seems, cracks, and chipped areas that may affect proper use or cleaning. Also, seals, hinges, and fasteners will be kept in good repair. According to the 2017 Federal Food Code, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a nonabsorbent and smooth material. Also, nonfood-contact surfaces are to be free of unnecessary ledges, projections, and crevices to allow for easy cleaning. According to the 2017 Federal Food Code, if doors are kept open for ventilation or other purposes, the opening shall be protected against the entry of insects and rodents by screens or a curtain. If screens are used the screen is 16 mesh to 25.4 mm (16 mesh to 1 inch)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to store, prepare, and distribute food safely when: 1. Perishable food was not stored in a reach-in refrigerator at 41 degrees Fahrenheit (F) or below. 2. Dirty water from the dirty side of the dish machine area splashed into the adjacent 3-compartment sink area where clean pans were stored. 3. Dietary staff did not follow proper hand hygiene and glove use procedures when cleaning and handling dishes and handling ready to eat food. 4. Multiple areas and surfaces in the kitchen were dusty, had buildup of debris and grime including two food equipment storage cabinets, floors in the dry storage room, over 50 dead flies stuck on the wall by the toaster, and dust and dirt build up in the window tracks and sills that ran all along the length of the windows behind the tray line steam table. 5. Cooking and food service equipment was not maintained and stored in clean condition including a large frying pan, a half hotel pan, 5 large pans used to hold hot water on the steam table, and a large mixing bowl. 6. Food preparation and serving utensils in the kitchen were not maintained in good condition including six of six cutting boards, 3 nonstick frying pans, a metal spatula, a spoodle and a food processor. 7. Areas in the kitchen were not maintained to allow for proper cleaning and to prevent pests from entering the kitchen including a screen door with holes, a counter with laminate coming detached exposing particle board, and 3-door freezer with a cracked and broken plastic strip along the inside surface, close to the freezer doors. 8. There was no air gap (a gap of air in a drain to prevent contamination of food equipment if there was a sewage back-up) in the drain for the ice machine and the small food preparation sink. 9. Dietary staff allowed a thermometer that was not cleaned to come into contact with food ready to serve. 10. Food located in the resident nourishment refrigerator at the nursing station was not in a sealed container. These failures to follow proper sanitation and food safety practices placed 44 residents that received food from the kitchen, out of 47 residents residing at the facility, at risk for food borne illnesses. Findings: 1. Perishable food was not stored in a reach-in refrigerator at 41 degrees Fahrenheit (F) or below. During an observation on July 6, 2021 at 11:08 a.m., and concurrent interview with the Dietary Services Supervisor (DSS), the internal and external thermometers of the reach-in refrigerator located next to the kitchen door read 41 degrees Fahrenheit (F) and 40 - 41 degrees F respectively. The temperature of three perishable foods were measured, including Time Temperature Control for Safety (TSC) food (Food with a higher probability of growing harmful microorganisms if not stored according to current standards of practice). The foods were stored in plastic containers inside the refrigerator, and the temperature was taken with calibrated thermometers. The food temperatures were as follows: -Egg Salad with a prepared date of 7/4/21 and use-by date of 7/7/21 was 45.3 degrees F (surveyor thermometer) and 47.3 degrees F (DSS thermometer) -Spaghetti Sauce with a prepared date of 7/5/21 and use-by date of 7/10/21 was 44.2 degrees F (surveyor thermometer) and 45.0 degrees F (DSS thermometer) -Opened canned peaches, placed in a plastic container was 43.7 degrees F (surveyor thermometer) and 44.6 degrees F (DSS thermometer) DSS confirmed the foods measured were stored in the refrigerator overnight and were not yet removed from the refrigerator that day. He also said foods need to be stored at 41 degrees F or below for safety. During an interview on July 8, 2021, at 8:55 a.m., DSS stated the temperatures of the refrigerator thermometers were recorded on a paper log once a day, at the start of the a.m. shift approximately 4:30 to 5:00 a.m. DSS stated temperatures of food stored in the refrigerator were not routinely monitored if the refrigerator was meeting the temperature of the refrigerator and if the temperature of the refrigerator was above 41 degrees F, staff might check the food temperature. During a review of the document provided by the facility titled, Food Receiving and Storage, revised October 2017, read .9. Refrigerated foods must be stored below 41 degrees F . 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee . According to 2017 Federal Food Code, foods that are potentially hazardous such as foods that are Time/Temperature Control for Safety Food or food that requires time/temperature for safety to limit pathogenic microorganism growth or toxin formation, shall be maintained at 41 degrees F or less except during preparation, cooking, or cooling, or when time is used as a control. 2. Dirty water from washing dishes in the dishwashing area splashed into the adjacent three compartment sink area where clean pans were stored. During an observation on 7/7/21 at 9:28 a.m., a Dietary Aide (DA 1) used the sprayer on the dirty side of the dish machine area and sprayed the resident food bowls from returned breakfast trays. During this task, splashes of water sprayed from the dirty dishes and reached the three compartment sink area. Two surveyors stood at the three compartment sink area, between the sink and the reach-in freezers, and were splashed with water from the dirty side of the dish machine. The three compartment sink and the dirty side of the dish machine with the sprayer, were located back to back with a low back splash separating the workstations that did not prevent splashing of water crossing over to each of the dishwashing areas. The three compartment sink had steam tray pans air drying after being washed and sanitized. DSS confirmed there was splashes from when soiled dishes were sprayed onto the dirty side of the dish machine and stated the splash could contaminate the three compartment sink area where cleaned items were air dried. According to the 2017 Federal Food Code, cleaned equipment and utensils shall be stored: In a clean, dry location; and where they are not exposed to splash, dust, or other contamination; and at least 6 inches above the floor. 3. Dietary staff did not follow proper hand hygiene and glove use when cleaning and handling dishes and handling ready to eat food. During an observation on 7/7/21 at 9:28 a.m., DA 1 used the sprayer on the dirty side of dish machine and sprayed the resident food bowls returned from the breakfast trays. DA 1 washed the dirty dishes wearing gloves, removed the gloves and proceeded to place clean dry domes on the utility cart from the clean side of the dish machine. She then donned a new pair of gloves and continued to handle clean food trays, pulled out a dish rack from the dish machine that was just washed and handled a large clean pot on the clean side of the dish machine. DA 1 did not wash her hands after removing her gloves, prior to starting to work with clean dishes, racks, and pots and before donning new gloves. During an interview on 7/7/21 at 10:02 a.m., DSS stated when there was one person at the dish machine, staff needed to wash hands prior to going from dirty to clean side of the workstations. On 7/7/21 at 11:40 a.m., [NAME] 1 used cloth potholders to remove a large pan of bread rolls from the oven. When he held the pan, the potholders came into contact with the rolls. In an interview on 7/8/21 at 12:30 p.m., DSS stated oven mitts and cloth potholders were not washed or cleaned. He said they were discarded when they started to look old. He said if food was touched with the mitts or cloth potholders, they could contaminate the food and the food would have to be discarded. Review of the document titled, Proper Wearing of Gloves in Healthcare dated 2019, showed when gloves are used, handwashing must occur prior to putting on gloves or when gloves are changed. According to the 2017 Federal Food Code, hands are to be washed after handling soiled equipment or utensils; and cloth gloves may not be used in direct contact with food unless the food will subsequently be cooked. 4. Multiple areas and surfaces in the kitchen were dusty, had buildup of debris and grime including , two food equipment storage cabinets , floors in the dry storage room, over 50 dead flies stuck on the wall by the toaster, and dust and dirt build up in the window tracks and sills that ran all along the length of the windows behind the tray line steam table. During an initial tour of the kitchen on 7/6/21, from 10:29 a.m. to 12:10 p.m., observation and concurrent interview with DSS showed: Two equipment storage cabinets that held cooking pots, sheet pans and muffin tins had a dark powdery film on the bottom interior surface, that was easily removed with a dry paper towel. There were also brown, white, and yellow bits of debris build up toward the corners of the cabinets. The items stored in the cabinets came into direct contact with the bottom inside surface of the cabinets. DSS stated the cabinets were dusty and dirty inside. He also said they cabinets were on a cleaning schedule and they did not look like they were cleaned in over a week; The floor under the wire storage racks, which held an open container of potatoes, dry condiments, canned fruits and vegetables and boxed starch products had a build-up of dark gray grime in and around the back wheels of the storage rack, and accumulation of residue that got darker going towards the walls and corners. DSS confirmed the floors were not clean; There were over 50 dead flies stuck on the wall in the steam table area, next to where 2 toasters were stored. The wall had an oily sheen on the surface with the dead flies. DSS confirmed there were dead flies on the wall and said the wall was not clean; There was a thick layer of dark gray / black grime in the window tracks, along the back-wall windows above the food tray steam table. The substance was loose and was easily removed when wiped with a paper towel. DSS confirmed the windowsills were dirty and stated kitchen staff were responsible for cleaning around the windows. Review of the facility's policy titled, Sanitation, revised October 2008, indicated . The food service area shall be maintained in a clean and sanitary manner.1. All kitchens, kitchen areas . shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects. 5. Cooking and food service equipment was not maintained and stored in clean condition including a large frying pan, a half hotel pan, 5 large pans used to hold hot water on the steam table and a large mixing bowl. During an observation on 7/6/21 at 10:26 a.m., and concurrent interview with DSS, in the kitchen, five steam table hot water pans were set up in the steam table and had a layer of yellow/black residue, covering a large portion of the bottom and sides of the inside surface. [NAME] 1 stated the pans were just old and the residue remained after washing. DSS confirmed there was residue on the inside surface of the pans. In a consecutive observation, a half hotel pan, located under the steam table in a storage area for clean pans, had a yellow and white sticky film on the entire inside bottom surface. DSS stated the pans were used to serve resident food or cakes. DSS stated it was not okay for staff to put it back in the clean area with residue on the pan. During an observation on 7/6/21 at 11:29 a.m., and concurrent interview with DSS, in the kitchen, a frying pan located next to the stove on a storage rack for clean pots and pans had residue on the cooking surface. The residue was white and orange in color and sticky to the touch. DSS confirmed residue and stated the condition was not okay. During an observation on 07/07/21, at 09:05 a.m., [NAME] 1 scrubbed the steam table hot water pans with steel wool and was not able to remove the black/yellow residue. During an observation on 7/7/21, at 11:40 a.m., during tray line set up, a large metal mixing bowl was knocked to the ground. [NAME] 1 picked up the bowl and returned it to bottom shelf of a storage rack for clean cooking equipment and put smaller bowls inside the large mixing bowl. During an interview on 7/8/21, at 9:00 a.m., DSS stated anything that falls on the floor needs to go straight to the dish machine, and a mixing bowl that fell on the floor should not go back on the storage rack. In an interview on 7/8/21 at 9:30 a.m., the Registered Dietitian (RD) stated when items such as pots, pans, or other items come out of the dish machine dirty, they need to be washed over again. During a review of the facility's policy titled, Sanitation, revised October 2008 indicated, . The food service area shall be maintained in a clean and sanitary manner .2. All utensils . and equipment shall be kept clean, maintained in good repair and shall be free from corrosions . that may affect their . proper cleaning .3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary . According to the 2017 Federal Food Code, all food-contact surfaces are to be clean to site and touch, and cooking equipment is to be free of soil accumulation. In addition, nonfood-contact surfaces are to be kept free of an accumulation of food residue and other debris. 6. Food preparation and serving utensils in the kitchen were not maintained in good condition including six of six cutting boards, 3 nonstick frying pans, a metal spatula, a spoodle and a food processor. During an observation on 7/6/21, at 11:29 a.m., and concurrent interview with DSS, in the kitchen, six out of six cutting boards were noted to be rough on both sides. The cutting boards had deep scratches on both sides and were discolored in the center cutting surface area. The DSS stated food and grease can get caught in the scratches and the cutting boards were not okay. As the observation of the kitchen continued, 3 non-stick frying pans, located on a rack for clean pots and pans, had deep scratches on the cooking surface. The DSS stated the frying pans were not okay. A drawer located under a preparation table had spoodles (large spoons that can also be used as ladles) and spatulas. One metal spatula had a plastic handle with a rough surface with melted areas and visible dark residue. One spoodle had a white residue on the handle surface. DSS confirmed the handles of the spatula and spoodle were in poor condition. He said he ordered new cooking tools and showed they were located in a separate drawer under the food preparation table. He left the spatula and spoodle he stated were not in good condition in the drawer and said it was his responsibility to make sure equipment that was not in good condition was changed out. A food processor, located on a preparation table, had tape holding the handle together. The inside bowl of the food processor was broken with a cracked center cylinder, and the lid was cracked and broken. DSS stated the food processor was used for ground and chopped foods for residents. On 7/9/21 at 9:15 a.m., DSS stated he had new cutting boards and frying pans in the storeroom, but he forgot to use them. During a review of the facility's policy titled, Sanitation, revised October 2008, indicated . 2. All utensils . and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. 7. There was no air gap in the drain for the ice machine and the food preparation sink. During an observation on 7/6/21, at 11 a.m., in the kitchen, a plastic drainpipe that led from the back of the ice machine to a floor sink drain under the ice machine was identified. The end of the drainpipe was immersed inside the drain on the floor. During an observation on 7/7/21 at 9 a.m., and concurrent interview with MS, in the kitchen, a food preparation sink had a plastic drainpipe that [NAME] directly into a raised floor sink located under the food preparation sink. MS confirmed there was no air gap for this ice machine drain and the food preparation sink drain. According to the 2017 Federal Food Code, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. Also, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch. 8. Areas in the kitchen were not maintained to allow for proper cleaning, and to prevent pests from entering the kitchen. Areas included a screen door with holes, a counter with laminate coming detached exposing particle board, and 3-door freezer with cracked and broken plastic strip along the inside surface close to the freezer doors. During the initial kitchen observation tour on 7/6/21, at 10:26 a.m., the three-door reach-in freezer had cracked and broken plastic strips along the length of the bottom inside surface trim which created rough edges and an uneven finish. As the tour continued, the end of the clean dish machine counter, next to the microwave, had a section of laminate that was detached from the counter exposing particle board underneath. During an observation on 7/7/21 at 9:05 a.m., and concurrent interview, the Maintenance Supervisor (MS) stated he was not informed the countertop with the detached laminate was in need of repair. MS also said he was not aware of the cracked and broken strip of plastic inside the three door reach-in freezer. During an observation on 7/7/21, at 9:35 a.m., and concurrent interview with MS, the back door of the kitchen was open with the screen door closed. The screen door had over 13 worn though holes, ranging from ½ inch to 3 inches in length, halfway up the screen and at the base of the door frame. MS confirmed there were holes in the screen. He said he was not aware of maintenance needs in the kitchen unless he was told and there were multiple ways to request maintenance service including putting a request in the maintenance binder or in the morning stand-up meeting. He said maintenance did not routinely round in the kitchen for needed repairs. MS stated repairs were needed. DSS confirmed the process for reporting maintenance needs and said he did not notice the laminate coming off the counter and he was not concerned about the broken plastic strip inside the reach-in freezer. He stated he would only be concerned of the freezer was not maintaining a proper temperature. During an interview on 7/8/21, at 10:29 a.m., RD indicated the detached laminate was reported over two months ago by the previous supervisor and was uncertain if follow up was initiated. RD also stated it was not okay to have holes in the screen door because flies could come in. Review of the policy and procedure titled, Sanitization dated 2001, showed counters and equipment shall be maintained in good repair and shall be free from breaks, corrosions, open seems, cracks, and chipped areas that may affect proper use or cleaning. Also, seals, hinges, and fasteners will be kept in good repair. According to the 2017 Federal Food Code, nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a nonabsorbent and smooth material. Also, nonfood-contact surfaces are to be free of unnecessary ledges, projections, and crevices to allow for easy cleaning. According to the 2017 Federal Food Code, if doors are kept open for ventilation or other purposes, the opening shall be protected against the entry of insects and rodents by screens or a curtain. If screens are used the screen is 16 mesh to 25.4 mm (16 mesh to 1 inch) 9. Dietary staff allowed a thermometer that was not cleaned to come into contact with food ready to serve. During an observation on 7/7/21, starting at 11:40 a.m., tray line set up was in progress, [NAME] 1 took a thermometer out of the probe sheath (cover) and placed it directly into a piece of chicken in a pan on the steam table. The thermometer was not cleaned or sanitized after taking the probe out of the cover and touching the food. Then [NAME] 1 took the temperature of a rice pilaf in a pan on the steam table by placing the thermometer so the handle was partially submerged in the rice. During an interview on 7/8/21, at 9:00 a.m., DSS said the handle of the thermometer was never cleaned and should not touch the food. DSS said if the handle touched the food, there was the potential for contamination of the food. DSS also stated the probe should be wiped with the sanitizer swab (pad) before taking the temperature of the food because the probe sheath was not considered clean. According to Federal Food Code 2017, equipment food-contact surfaces and utensils shall be cleaned: Before using or storing a food temperature measuring device; and at any time during the operation when contamination may have occurred. 10. Food located in the resident nourishment refrigerator at the nursing station was not in a sealed container. During an observation on 7/7/21, at 11 a.m., of the Nursing Station Resident Food Refrigerator a purple colored smoothie drink was dated 7/5/21 with Resident 12's room number. The beverage was in a clear disposable cup with plastic lid and an open, uncovered straw in the drink with one end exposed to air. During an interview on 7/7/21, at 11:16 a.m., the Director of Nursing (DON) stated the straw would be considered dirty if the resident had sipped (drank) from it prior to placing in the refrigerator. During an interview on 7/8/21, at 12:57 p.m., Resident 12 stated the beverage was brought in from a family member (nephew), she drank some of it then asked for the staff to put it in the refrigerator. During an interview on 7/8/21 at 9 a.m., RD stated it was not okay to have a drink stored in the refrigerator with a straw in the drink because the straw made it an open container and food should not be stored in an open container. RD also stated if the straw was used, it could contaminate other items stored in the refrigerator. During a review of facility policy titled, Foods brought by Family/Visitors during pandemic, not dated indicated .7 Non-perishable foods will be stored in re-sealable containers with tight-fitting lids Perishable foods must be stored in a container with tightly fitting lids in a refrigerator. Containers will be dated and labeled.

During an observation, on 7/7/21, at 8 a.m., LVN 1 entered Resident 37's room to administer medications. LVN 1 gave oral medications to Resident 37. Without performing hand hygiene and or donning gloves, LVN 1 administered Epoetin (helps the body make red blood cells) injection on the resident's lower left abdominal quadrant. During another observation of LVN 1 on 7/7/21, at 8:16 a.m., LVN 1 entered Resident 23's room to administer medications. LVN 1 touched the curtain with bare hands, grabbed a pen from her pocket, and moved Resident 23's bedside table. LVN 1 gave the Enoxaprin (helps prevent blood clots) injection in Resident 23's left arm without performing hand hygiene and donning gloves. LVN 1 then gave resident the oral medications and left the room. During an interview, on 7/7/21, 8:50 a.m., LVN 1 stated she is supposed to wash hands and put on gloves before giving injections to Resident 37 and 23. During an interview on 7/7/21, at 11:45 a.m., DON stated staff were required to sanitize hands and wear gloves before administering injections to the residents to prevent cross contamination. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene dated 2001 which indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: c. Before preparing or handling medications; f. Before donning sterile gloves; m. After removing gloves. Hand hygiene is the final step after removing and disposing of personal protective equipment. Based on observation, interviews, and record review, the facility failed to ensure the infection control program for was fully implemented for COVID-19 and revised their policy and procedure (P&P) to include when and whom to report possible communicable disease or infections when; 1. The facility did not report an outbreak of nausea, vomiting, and diarrhea to the California Department of Public Health (CDPH) of a gastroenteritis (sometimes called stomach flu) outbreak. 2. There was no screening of staff members for COVID-19 (a new coronavirus causing a respiratory illness and outbreak that is easily spread) symptoms from 7/3/21-7/5/21 prior to providing care to the residents. 3. The facility did not immediately test residents with nausea, vomiting, and diarrhea to rule out possible COVID-19. 4. There was no surveillance and verification of staffs' COVID-19 vaccination status. 5. The licensed nurse did not perform hand hygiene prior to and after administering medications between residents. 5. The licensed nurse did not don gloves while administering injections to Residents 35 and 37. These deficient practices had the potential to result in the spread of infections, including COVID-19. Findings: During an observation and facility tour on 7/6/21 at 10:45 a.m., Residents 33, 35, 37, and 41 rooms were on isolation precautions for nausea, vomiting, and diarrhea. During an interview on 7/6/21 at 10:54 a.m., Licensed Vocational Nurse 3 (LVN 3) stated the facility had an outbreak of nausea, vomiting, and diarrhea. During an interview on 7/6/21 at 11:08 a.m., the Director of Nursing/ Infection Preventionist (DON/IP) stated the facility noticed there were residents with loose stools, nausea, and vomiting on 6/30/21. DON stated residents with nausea, vomiting, and diarrhea were monitored and placed on isolation precautions. During an interview on 7/06/21 at 12:24 p.m., the Administrator (Admin) stated the outbreak of nausea, vomiting and diarrhea started on 6/30/21. Admin stated the facility did not notify the Department until 7/6/21 during the survey. Note: The facility notified the local public health department on 7/2/21 of an identified gastroenteritis outbreak. During a review of the employee symptoms screening log with the DON/IP, in the presence of the Admin, certified nursing assistants 2, 3, 7, 8, and LVN 5, they were not screened for COVID-19 symptoms on 7/3/21 through 7/5/21 prior to providing care for residents. During an interview on 7/8/21 at 8:06 a.m., the Admin stated he expected staff to complete COVID-19 screening prior to working with the residents. During a review of the surveillance log dated 7/1/21 through 7/5/21 in the presence of the DON/IP, six residents were noted to have one to three episodes of nausea, vomiting, and diarrhea. During an interview on 7/8/21 at 8:10 a.m., the DON/IP stated the facility had an outbreak of nausea, vomiting, and diarrhea. DON/IP stated these signs or symptoms could potentially be consistent with COVID-19. DON stated the facility did not immediately test residents with nausea, vomiting, and diarrhea to rule out COVID-19. During a review of the list of residents and staff COVID-19 vaccination status on 7/9/21 in the presence of the Admin, facility did not have a list of staffs' COVID-19 vaccination status. During an interview on 7/9/21 at 8:44 a.m., the Admin stated the facility had not verified or kept a log of their staff's COVID-19 vaccination status. Admin further stated the facility plans to hire a full-time IP. The facility's P&P titled, Reporting Communicable Diseases, revised July 2014, did not include when and whom to report suspected and confirmed communicable diseases to CDPH. The facility' sP&P titled, Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures revised 6/2021 indicated; Anyone entering the facility including staff is screened and triaged for signs and symptoms of and exposure to others with SARS-Co-V-2 infection, including fever, cough, shortness of breath or difficulty breathing, nausea or vomiting and/or diarrhea. Record review of the P&P titled; Coronavirus Disease (COVID-19) - Testing and Return to work criteria for Healthcare Personnel dated August 2020 indicated; 6. Facility will have daily monitoring of the percentage of residents and staff that are fully vaccinated and resume routine diagnostic screening of all staff (regardless of vaccination status) within one week if the percentage of residents and staff who are fully vaccinated drops below 70%. Testing will continue for at least 2 weeks and continue until meeting the required >70% of residents and staff are fully vaccinated for one full week. 7. Residents or staff with signs or symptoms potentially consistent with COVID-19 will be tested immediately using Rapid POC (point of care) test to identify current infection, regardless of their vaccination status.