**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to trim and clean fingernails for three out of four sampled residents when Residents 30, 32, and 33 had long fingernails with dirty substances underneath them. This failure had the potential to result in Resident 30, Resident 32, and Resident 33's poor personal hygiene and risk for infection. FINDINGS: 1a. During a review of Resident 30's Face Sheet, dated August 2024, the Face Sheet indicated, Resident 30 was admitted on [DATE] with diagnosis that includes Hemiplegia (the loss of muscle function on one side of the body) and Hemiparesis (a relatively mild loss of strength in the arm, leg, and sometimes face on one side of the body) and Diabetes (a long-term chronic disease in which the body cannot regulate the amount of sugar in the blood). During a review of Resident 30's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated July 2024, the MDS indicated, Resident 30's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) was 15 out of 15, indicating cognitively intact mental status. The MDS assessment also indicated, Resident 30 was dependent with personal hygiene. During a review of Resident 30's care plan titled Activities of Daily Living (ADL-are those needed for self-care and mobility and include activities such as grooming), dated October 2023, the care plan indicated, Resident had an ADL deficit related to Cerebrovascular Accident (CVA-also called a stroke, occurs when blood flow to a part of the brain stops) with hemiplegia .personal hygiene: dependent .groomed daily .adl needs will be met daily .assist with ADL as needed. During a concurrent observation and interview on 8/19/24 at 8:38 a.m. with Resident 30 in her room, Resident 30's fingernails were about 1/2 inch long with brown matter underneath her fingernails. Resident 30 stated she preferred short nails and clean, but no staff assist her in trimming her fingernails. During a concurrent observation and interview on 8/19/24 at 8:45 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 30's room, Resident 30's fingernails were observed. CNA 1 stated, Resident 30's fingernails were long and dirty. CNA 1 also stated Resident 30 had a diagnosis of Diabetes and licensed nurses (LN) were responsible to trim her fingernails. During a concurrent observation and interview on 8/19/24 at 10:05 a.m. with Registered Nurse (RN) 2 in Resident 30's room. RN 2 stated he worked at the facility as a treatment nurse and could also provide fingernail trimming to diabetic residents. RN 2 stated Resident 30's fingernails were long and dirty. RN 2 also stated fingernails should be trimmed and cleaned. 1b. During a review of Resident 32's Face sheet, dated August 2024, the face sheet indicated, Resident was admitted on [DATE] with diagnosis of Disease of Spinal Cord (condition that cause damage and deterioration to the spinal cord. Spinal cord is a tubelike structure that consist of a bundle of nerves that extends from base of the brain and down the back that carries messages from the brain to the rest of the body). During a review of Resident 32's MDS dated [DATE], the MDS indicated, Resident 30's BIMS was 10 out of 15, indicating moderate impairment in mental status. During a review of Resident 32's care plan titled Activities of Daily Living (ADL), dated November 2023, the care plan indicated, Resident had an ADL deficit related to Spinal Cord Disease .personal hygiene: dependent .groomed daily .ADL needs will be met daily .assist with ADL as needed. During an observation on 8/19/24 at 7:54 a.m. in Resident 32's room, Resident 32's fingernails were 1/4 inch long with black colored matter embedded underneath his fingernails. During a concurrent observation and interview on 8/19/24 at 8:20 a.m. with CNA 1 in Resident 32's room, CNA 1 stated that Resident 30's fingernails were long and dirty. CNA 1 also stated Resident 32's fingernails should be trimmed and cleaned. During an interview on 8/19/24 at 10:20 a.m. with RN 1, RN 1 stated Resident 32's hands should be clean every day and fingernails should be trimmed as the need arises. 1c. During a review of Resident 33's Face sheet, dated August 2024, the Face sheet indicated, Resident was admitted on [DATE] with diagnosis of Cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a review of Resident 33's MDS dated [DATE] , the MDS indicated, Resident 33's BIMS was 5 out of 15, indicating severe impairment in mental status. The MDS assessment also indicated, Resident 33 required a maximum assist in personal hygiene. During a review of Resident 33's care plan titled Activities of Daily Living (ADL) dated May 2023, the care plan indicated, Resident 33 had an ADL deficit .groomed daily .ADL needs will be met daily .assist with ADL as needed. During an observation on 8/19/24 at 8:10 a.m. in Resident 33's room, Resident 33's fingernails were 1/4 inch long with black colored matter embedded underneath his fingernails. During a concurrent observation and interview on 8/19/24 at 8:15 a.m. with CNA 1, CNA 1 stated, Resident 33's fingernails were long and dirty. CNA 1 stated fingernails should be trimmed and cleaned when noted. During an interview on 8/22/24 at 9:06 a.m. with DON, DON stated she expected CNAs and LNs to check residents' fingernails during morning rounds. CNAs should provide nail care to non-diabetic residents and licensed nurses to diabetic residents if fingernails were long and dirty. DON stated that Residents fingernails should be trimmed and cleaned. DON also stated fingernails that left untrimmed and dirty could lead to infection when residents placed their hands in their mouth and skin breaks when residents scratched themselves. During a review of the facility's Policy and Procedures (P&P) titled, CARE OF FINGERNAILS/TOENAILS revised February 2018 was reviewed, the P&P 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. During a review of the facility's Policy and Procedures (P&P) titled, Activities of Daily Living (ADL), Supporting revised March 2018 was reviewed, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene.

Based on observation, interview, and record review, the facility failed to ensure safe storage of drugs and biologicals when: 1. Outdated or expired medications were stored in the medication room 2. A discontinued medication, including food items were stored in the medication cart These failed practices could contribute to unsafe medication use and storage in the facility. Findings: 1. During a concurrent observation and interview on 8/19/24 at 11:24 a.m., with the Infection Preventionist (IP) present, in the facility's medication room, the IP stated that the following items should have been discarded or placed in the designated discontinued or discard box next to sink inside the medication room: 1 Tube Feeding Formula, use by date 3/23/24 1 Box of COVID-19 Test Kit containing 34 test cards, kit lot number 192047, expiry date 4/30/23 3 Boxes of Sample Specimen Collection Kits containing individually packaged tubes and swabs, expiry dates 11/9/22 1 first aid kit, expiry date 1/31/22 27 Dextrose 5% Injection Bags 250 ml (milliliter), expiry dates 1/1/24 6 Normal Saline Pre-filled Flush Syringes 10 ml, expiry dates 8/31/22 2 Normal Saline Pre-filled Flush Syringes 10 ml, expiry dates 9/30/22 1 Normal Saline Pre-filled Flush Syringes10 ml, expiry date 11/30/23 2. During a concurrent observation and interview on 8/19/24 at 2:18 p.m., with Registered Nurse (RN) 1 present, the following items were stored on the third drawer, left hand side, of Medication Cart 1: 1 opened cough syrup bottle with no open date, name, or room number of resident 1 raspberry flavored yogurt cup 1 sugar free pudding cup During an interview with RN 1 on 8/19/24 at 2:20 p.m., RN 1 stated the cough syrup bottle was for Resident 11, which was no longer used. RN 1 stated, the medication should be labeled with an open date, including name and room number of Resident 11. RN 1 stated the medication had to be labeled to ensure it belonged to Resident 11 and not given to another resident. During an interview with RN 1 on 8/19/24 at 2:24 p.m., RN 1 stated the yogurt and pudding cups should not be kept inside the medication cart and should have been discarded. Review of the facility's Policy and Procedures (P&P), titled, Storage of Medications, revision dated 4/2019, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner . The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing . Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on interview and record review, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietician and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC S 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of qualified, full-time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 43 residents eating facility prepared foods. Findings: According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes the following: The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). During an interview on 8/19/24 at 9:10 a.m. with Dietary Supervisor (DS), DS stated she was the supervisor for the kitchen and worked with the facility as a supervisor for a year. During an interview on 8/19/24 at 9:30 a.m. with Registered Dietician Nutritionist (RDN), RDN stated she worked at the facility part time, once a week for 8 hours. During an interview on 8/22/24 at 10:00 a.m. with DS, DS stated she did not have a Dietary Manager Certification. DS also stated that she was currently enrolled and working on courses to obtain her certificate. During a review of facility's job description titled Dietary Supervisor revised 03/17/21, the job description indicated, Position Summary .Responsible for assisting in planning, organizing, developing and directing overall operation of Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure bowel movements (BMs) were documented for three of 12 sampled residents (Residents 9, 20 and 28), on 8/1/22 through 8/5/22. This failure had the potential to result ineffective bowel management for Residents 9, 20 and 28. Findings: During a concurrent interview and record review on 8/10/22, at 2:33 p.m., with Infection Preventionist (IP), the Bowel and Bladder Log, dated August 2022 was reviewed. The log indicated that BMs were not documented for Residents 9, 20 and 28 on 8/1/22 through 8/5/22, IP stated that their policy was for Certified Nursing Assistants (CNAs) to document BMs for residents every shift in the Bowel and Bladder Log. IP stated that it was important to document resident BMs because staff wouldn't know if residents had a bowel movement, when their last bowel movement was, or if they were constipated. IP stated that resident's may have been restless due to constipation, but they wouldn't have known if their BMs weren't documented. During an interview on 08/11/22, at 8:28 a.m., with CNA 1, CNA 1 stated that she was supposed to document resident BMs in the Bowel and Bladder Log every shift. During a record review of Resident 9's Minimum Data Set (MDS, an assessment tool used to guide care), dated 6/2/22, the MDS indicated resident 9's, Bowel Continence, was Always incontinent. During a record review of Resident 20's MDS, dated [DATE], the MDS indicated resident 20's, Bowel Continence, was Always incontinent. During a record review of Resident 28's MDS, dated [DATE], the MDS indicated resident 28's, Bowel Continence, was Always incontinent. During a review of the facility's policy and procedure (P&P) titled, Bowel (Lower-Gastrointestinal Tract) Disorders - Clinical Protocol, revised September 2017, the P&P indicated, .the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms. The P&P indicated, Examples of lower gastrointestinal tract conditions and symptoms include: .fecal incontinence. The P&P indicated, .the nurse shall assess and document/ report the following: .Quantitative and qualitative description of diarrhea (how many episodes in what period of time, amount consistency, etc.). The P&P indicated, The staff and physician will monitor the individual's response to interventions and overall progress; for example, overall degree of comfort or distress, frequency and consistency of bowel movements.

Based on interview and record review, the facility failed to ensure competency skills checks for one of three licensed nursing staff and one of two certified nurse assistants were completed. This failure had the potential for care to be provided by licensed nurses and certified nurse assistant in an unsafe and incompetent manner. Findings: During a concurrent interview and review of employee personnel files, on 8/10/22, at 2:35 p.m., with Director of Staff Development (DSD), the files indicated Licensed Vocational Nurse (LVN) 4 was hired on 5/24/20 and Certified Nurse Assistant (CNA) 2 was hired on 7/9/20. The personnel files also indicated there was no competency skills check done for LVN 4 and CNA 2 at the start of employment. DSD, indicated competency checklist was not in the employee file because it was not done. During an interview on 8/11/22, at 10:29 a.m., with the Infection Preventionist Director of Staff Development Consultant (IPDSDC), the IPDSDC confirmed, competency evaluation for LVN 4 and CNA 2 was not done. During an interview on 8/11/22, at 1:23 p.m., with the Director of Nursing (DON), DON stated, quality of care and safety of residents can be affected when LVN 4 and CNA 2 was not evaluated for competency skills. During a review of facility's policy and procedure (P&P) titled, Competency of Nursing Staff, dated May 2019, the P&P indicated, 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by State law. 2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care.6. Facility and resident-specific competency evaluations will be conducted upon hire, annually and as deemed necessary based on the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), and availability of routine and emergency drugs when: 1. Two out of 2 medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift; 2. There was no record of controlled drug destruction available upon request; 3. One out of 5 emergency kits (e-kit, a kit containing medications and supplies for immediate use during a medical emergency) was not replaced in a timely manner in accordance with the facility policy and procedures (P&P); 4. Two out of 5 e-kits expired; and 5. Expired and discontinued medications were not removed from active stock These failures had the potential for the facility to not have accurate accountability of controlled medications, abuse or misuse of these medications, use of ineffective medications or those with reduced potency, and medications being unavailable for use during an emergency. Findings: 1. On [DATE] at 12:50 p.m., a review of the controlled drug sign-in/sign-out for Medication Cart 2 alongside Licensed Vocational Nurse 1 (LVN 1) identified missing signatures by the outgoing and incoming nurse for each shift (7 a.m., 3 p.m., and 11 p.m.). LVN 1 acknowledged the record was missing signatures between nursing shift changes and stated, I think everyone knows to sign the narcotic book. A review of the controlled drug sign-in/sign-out sheet, dated [DATE] to [DATE], indicated 46 missing signatures (for the dates indicated) between nursing shift changes. On [DATE] at 11:13 a.m., a review of the controlled drug sign-in/sign-out for Medication Cart 1 alongside LVN 1 identified and confirmed multiple missing signatures by the outgoing and incoming nurse for each shift. A review of the controlled drug sign-in/sign-out sheet, dated [DATE] to [DATE], indicated 98 missing signatures (for the dates indicated) between nursing shift changes. During an interview on [DATE], at 11:58 a.m., with Director of Nursing (DON), when asked if nurses were expected to sign the controlled drug sign-in/sign out sheet between shift changes, DON stated, I believe so . let me get one of my nurses. During an interview on [DATE], at 12:01 p.m., with Infection Preventionist (IP) and DON, IP verified and stated the incoming and outgoing nurse were to count controlled medications together, and both sign the sheet between each shift change. The DON then stated, Looks like we need to practice. During an interview on [DATE], at 12:58 p.m., with Consultant Pharmacist (CP), CP confirmed the controlled sign-in/sign-out sheet had to be signed between shift changes to acknowledge a count of controlled drugs in the medication cart matched the controlled drug record. A review of the facility's policy and procedure titled, Medication Storage in the Facility, dated [DATE], indicated, At each shift change, a physical inventory of all controlled medications . is conducted by two licensed nurses and is documented on the controlled medication accountability record. 2. The controlled drug destruction log was requested for review during the survey. During an interview on [DATE], at approximately 1 p.m., with DON, DON was unable to locate the narcotic destruction log and stated he would try to find it. During an interview on [DATE], at 1:10 p.m., with CP, CP stated the narcotic destruction log stayed with the DON. During an interview on [DATE], at 11:16 a.m., with DON, DON confirmed he was not able to find or locate the narcotic destruction log. A review of the facility's policy and procedure titled, Disposal of Medications and Medication-Related Supplies, dated [DATE], indicated, The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form. 1. Date of destruction 2. Resident's name 3. Name and strength of medication 4. Prescription number 5. Amount of medication destroyed 6. Signatures of witnesses . The medication disposition form is kept on file in the facility for 3 years. 3. On [DATE] at 1:47 p.m., an inspection of the medication storage room with IP identified and confirmed an opened e-kit. Review of the drug removal records indicated medications were removed from the e-kit on [DATE], [DATE] and [DATE]. IP stated as soon as an e-kit was opened, it was to be reordered from the pharmacy and replaced immediately. She agreed that if this process was not followed, medications would potentially not be available when needed in an emergency. During an interview on [DATE], at 12:03 p.m., with DON, DON verified when an e-kit was opened it was to be reordered from the pharmacy and agreed the. He acknowledged and agreed the e-kit should have been reordered after it was first opened, more than 2 months prior. During an interview on [DATE], at 1:06 p.m., with CP, CP stated the opened e-kit should have been replaced after it was opened so emergency medications would be available when and if needed. A review of the facility's policy and procedure titled Medication Ordering and Receiving from Pharmacy, dated [DATE], indicated, . the nurse . notifies the pharmacy for replacement of the emergency drugs supply . used sealed kits are replaced with the new sealed kits within 72 hours of opening. 4. On [DATE] at 11:43 a.m., a concurrent interview and inspection of Medication Cart 2 with LVN 1 identified and confirmed a controlled medication e-kit with expiration date of [DATE]. Inside the e-kit LVN 1 verified four 0.5 milliliter (ml, a unit of measure) prefilled syringes of morphine sulfate 10 milligram/0.5 milliliter (mg/ml, a measurement) expired [DATE], and three 1 ml vials hydromorphone 2 mg/ml (a pain medication) expired [DATE]. LVN 1 stated the staff should have replaced the e-kit the month prior to it expiring. During a concurrent interview and record review on [DATE], at 12:44 p.m., with LVN 1, all e-kit replacement fax requests to the pharmacy were reviewed from [DATE] to [DATE]. There were no requests submitted to the pharmacy to replace the expired e-kits. During an inspection of the medication storage room on [DATE], at 1:51 p.m., alongside IP, an expired intravenous (IV) antibiotic e-kit with expiration date [DATE] was identified and confirmed. During an interview on [DATE], at 12:03 p.m., with DON, DON acknowledged the controlled drug e-kit and IV antibiotic e-kit were expired. He confirmed they should have been replaced prior to their expiration. During an interview on [DATE], at 1:02 p.m., with CP, CP stated the facility was notified in [DATE] of the two e-kits due to expire on [DATE]. He stated the facility was responsible for ensuring the kits were replaced prior to their expiration dates. 5. On [DATE] at 10:40 a.m., an inspection of the medication storage room with DON identified five oyster shell calcium 250 mg plus vitamin D expired on 7/2022 and three bottles sevelamer 800 mg tablets (a medication used to treat chronic kidney disease) for a resident that had been discharged . DON confirmed expired, discontinued and medications for residents who were no longer at the facility were to be removed from the active supply and destructed. A review of the facility's policy and procedure titled Medication Storage in the Facility, dated [DATE], indicated, Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal . A review of the facility's policy and procedure titled Disposal of Medications and Medication-Related Supplies, dated [DATE], indicated, Discontinued medications and medications left in the facility after a resident's discharge . are destroyed.

Based on observation, interview, and record review, the facility had a 6.9% error rate when two medication errors out of 29 opportunities were observed during a medication pass for two of seven Residents (Residents 1 and 30). These failures resulted in medications not given in accordance with the prescriber's orders and may affect the resident's clinical condition. Findings: 1. During a medication pass observation on 8/8/22, at 10:39 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed preparing five medications, including aspirin 81 milligrams (mg, a measurement) tablet for Resident 30. A review of Resident 30's medical record indicated a physician's order, dated 5/19/21, for aspirin enteric coated (E.C., a coating formulation that allows aspirin to pass through the stomach to the small intestine before dissolving) 81 mg one tablet daily. During an interview on 8/9/22, at 12:36 p.m., with LVN 1, LVN 1 confirmed the order was for aspirin E.C. and stated she could not recall whether or not she administered the correct aspirin formulation. During an interview on 8/10/22, at 1:44 p.m., with Director of Nursing (DON), DON confirmed any medication given to a resident must be given as ordered by a physician. During a review of the facility's policy and procedure titled, IIA2: Medication Administration- General Guidelines, dated October 2017, indicated, Medications are administered in accordance with written orders of the attending physician. 2. During a medication pass observation on 8/8/22, at 11:14 a.m., with LVN 1, LVN 1 was observed preparing five medications, including Senna 8.6 mg (a medication for constipation) for Resident 1. LVN 1 was unable to locate Senna 8.6 mg tablets in the medication cart and stated she would notify the physician. A review of Resident 1's physician's telephone orders, dated 8/8/22 at 3 p.m., indicated, D/C [discontinue] previous Senna orders [for] residents who has Senna. Change to Senna 8.6 mg [with] docusate sodium 50 mg 2 tabs [tablets] orally every morning. During an interview on 8/9/22, at 11:06 a.m., with LVN 1, LVN 1 verified the Resident 1's medication order for Senna was not updated to reflect the physician's telephone order. She stated Resident 1's Senna order was, still the same and I don't see any notes. During an interview on 8/9/22, at 12:05 p.m., with DON, DON stated it was the nurse's responsibility to communicate with the physician anytime a medication was not available for administration. During an interview on 8/9/22, at 12:08 p.m., with Infection Preventionist (IP), IP verified Resident 1's medication order for Senna was not updated to reflect the physician's telephone order given at 3 p.m. on 8/8/22. IP confirmed the Senna with docusate tablet was not administered to Resident 1 on 8/8/22, as ordered by the physician. A review of Resident 1's medical record indicated the order for Senna 8.6 mg tablets was not discontinued until 8/9/22, an entire day after the physician ordered for it to be discontinued. The medical record indicated Senna 8.6 mg with docusate 50 mg tablet, 2 tablets orally once daily for constipation, started 8/9/22. During an interview on 8/10/22, at 1:44 pm., with DON, DON confirmed medications should be administered as ordered by the physician. During an interview on 8/11/22, at 11:43 a.m., with DON, DON stated in his previous experience he would ensure telephone orders for medications were updated in a resident's record, within an hour. During a review of the facility's policy and procedure titled, Telephone orders, dated February 2014, indicated, Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record.

Based on observation, interview and record review, the facility failed to ensure proper storage of medications when: 1. Medications and biologicals requiring refrigeration were not stored within manufacturer's specifications; and 2. Medication storage room and medication refrigerator temperatures were not monitored routinely per facility policy and procedure (P&P) The deficient practices had a potential for improperly stored and inadequately monitored medications, which could lead to unsafe and ineffective medication use for residents. Findings: 1. On 8/10/22 at 2:16 p.m., an inspection of the medication refrigerator with Infection Preventionist (IP) identified an internal thermometer with a temperature that measured 25 degrees Fahrenheit. Inside the refrigerator were various types of resident insulins (medication to treat elevated blood sugar) and six vials of Aplisol (an injectable used to test for tuberculosis). When asked if 25 degrees Fahrenheit was a safe temperature to store Aplisol at, IP stated she did not know. She then looked at the manufacturer's box which indicated the product was to be stored between 36 to 46 degrees Fahrenheit and stated, No. During a separate inspection of the medication refrigerator on 8/11/22 at 10:36 a.m., with Director of Nursing (DON), the DON verified the internal thermometer measured 32 degrees Fahrenheit. DON stated he was uncertain if that was a safe temperature to store medications at and would need to check the facility policy. DON verified 32 degrees Fahrenheit was too cold and stated, that is outside the range, so we need to bump that up. DON acknowledged and agreed it was unsafe to administer medications when they were not stored correctly. During an interview on 8/11/22, at 11:23 a.m., with Consultant Pharmacist (CP), CP confirmed medications that required refrigeration should be stored between 36 and 46 degrees Fahrenheit. CP confirmed the facility was to regularly monitor the temperature to ensure it stayed within that range. A review of the facility's policy and procedure titled Medication Storage in the Facility, dated April 2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations . Medications requiring 'refrigeration' or 'temperatures between 2?C [degrees Celsius] (36?F [degrees Fahrenheit]) and 8?C (46?F)' are kept in a refrigerator with a thermometer to allow temperature monitoring . Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. 2. During a concurrent interview and record review on 8/08/22, at 1:10 p.m., with LVN 1, the medication room temperature log for 5/1/2022 to 8/2/22 were reviewed. The medication temperature log indicated temperature readings were documented in the morning and the evening. A review of the log identified 65 temperature readings that were not completed. LVN 1 acknowledged and confirmed temperatures were not routinely monitored. She stated nurses should check to see if temperatures for the medication room and refrigerator was logged, at least once on your shift. During a concurrent interview and record review on 8/08/22, at 1:13 p.m., with IP, the medication storage room temperature log was reviewed. IP confirmed the temperature monitoring for the medication storage room was not routinely performed. During an interview on 8/08/22, at 1:36 p.m., with DON, DON confirmed the temperature for the storage room and refrigerator should be documented, at least once (daily). DON acknowledged and agreed if there was any deviation from the manufacturer's storage specifications, it would not be possible to confirm whether the medications were still safe and effective for use without routine temperature monitoring. A review of the facility's medication refrigerator temperature log, dated May 2022 to August 2022, indicated a column for morning and evening temperature readings. Review of the document identified 75 temperature readings that were not performed. During an interview on 8/09/22, at 12:58 p.m., with CP, CP stated the medication storage room and refrigerator monitoring, should be done religiously. He agreed and confirmed temperatures for both should have been documented on the respective logs. A review of the facility's policy and procedure titled, Medication Storage in the Facility, dated April 2008, indicated, Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified.

Based on observation, interview and record review the facility failed to meet food safety requirements for food storage and kitchen sanitation when multiple surfaces had dust, food particles and/or granular particles, two cans were dented, two items were missing use by dates, and one bag potatoes contained potatoes with roots. These failures has the potential to compromise the safety of the food served through cross contamination and cause illness or hospitalization to residents who consume it. Findings: During the initial tour of the kitchen on 8/8/22 at 10:15 a.m. with Dietary Manager 1, (DM 1), the following was observed: 1. The cart used to transport various food products to residents was observed to have a granular substance on the shelves and imbedded in the grip on the handle of the cart. 2. The stainless-steel lip on the walls surrounding the dishwasher area was observed to have substantial dust over the length of the wall mounted lip. 3. The stainless-steel counter on the dirty side of the dishwasher was observed to be very wet with food particles on the surface. 4. The dishwasher was observed to have dry particles stuck to the exterior sides of the dishwasher and granulated particles on top of the dishwasher. 5. The tray rack used to store clean dishes was observed to have dust and dirt on each of the tray support lips inside the rack. 6. The drying pads used for drying clean dishes were observed to be worn to the point of leaving granular particulates on the trays underneath on three trays in the tray rack. 7. Three trays underneath the drying mats were observed to have granular particulates and a dried substance on the trays under the mats. 8. The countertop on the left side of the sink was tacky to the touch. 9. The drawers holding clean cooking utensils were observed to have granular particles on the inside of the drawers. 10. The shelf storing dry seasonings was observed to have a granular particles and dust underneath the bottles of dry seasoning. 11. The wall surface between the counter and stove on both sides of the stove was observed to have stains and dried substances splattered across the surface. 12. The floor between the counter and both sides of the stove were observed to have stains, splattered dried substances, and dust. 13. One can of tuna located in the dry storage area was observed to be dented. 14. One can of baked beans located in the dry storage area was observed to be dented. 15. A storage bin holding 17 soft and rooted potatoes was observed to be in the dry storage area labeled with a preparation date, (date placed in storage), of 7/12/22 and use by date (UBD), of 8/12/22. 16. A storage bin containing packaged dry pasta was observed to have white powder on the outside of pasta bags. 17. A one-gallon container of classic buttermilk dressing located in Refrigerator 1 was observed to be missing an opened on or a UBD on the container. 18. A one-gallon container of pickle relish was observed to be missing an opened on or a UBD on the container. During an interview with the DM1, on 8/8/22 at 11:15 a.m. DM1 stated it is the responsibility of the dietary aid to clean kitchen surfaces. DM1 stated the drying matts under the clean dishes on the trays in the rack were not changed appropriately and the trays were unclean. During an interview with the Dietary Assistant, (DA), on 8/8/22 at 11:30 a.m. DA stated keeping the surfaces in the kitchen clean is her responsibility. She stated she gets very busy and cannot get to cleaning kitchen surfaces. During an interview with Dietary Manager 2, (DM2), on 8/16/22 at 2:30 DM2 stated the kitchen follows the sanitation and storage standards set forth by RDs for Healthcare. During a review of a facility document titled, General Appearance of Food and Nutrition Department from RDs for Healthcare dated 2018, indicated Floors, floor mats and walls must be scheduled for routine cleaning and maintained in good condition, .Walls and ceilings must be washed thoroughly at least twice a year. Heavily soiled surfaces must be cleaned more frequently as necessary, .Leaking or severely dented cans and spoiled foods should be disposed of promptly to prevent contamination of other foods.

Based on observation, interview and record review, the facility did not treat one (Resident 2) of nine sampled residents in a dignified manner. Resident 2 asked to have his brief (diaper) changed and staff denied his request. This failure resulted in Resident 2 experiencing unnecessary distress. Findings: The record review on 2/12/20 of the document Face Sheet showed the facility admitted Resident 2 on 8/8/19. A record review of the document used to assess patients condition and care needs titled, MDS (minimum data set) 3.0 dated 1/31/20, showed Resident 2's diagnoses included dementia. (symptoms that affects memory, thinking, and social abilities, enough to interfere with daily life). The record review of the nursing Departmental Notes dated 1/17/20 to 1/23/20 showed Resident 2 was, Alert and responsive. A record review of the plan of care dated 8/8/19 indicated Resident 2 was dependent on staff for assistance with toileting, was unable to walk, and incontinent of bowel and bladder (unable to control urine or bowel movements), and was at risk for skin breakdown. The interventions included, Peri care (personal hygiene) every shift and after each incontinence and keep clean and dry. During an observation on 2/10/20 at 12:40 p.m., Resident 2 was observed in bed yelling out in distress and pointing down at the brief he was wearing. The facility's Director of Staff Development (DSD) was walking by and continued to walk down the hall past Resident 2's room without stopping. DSD stated, He does that. He (Resident 2) yells out. During concurrent interviews with Resident 2 and Licensed Vocational Nurse 2 (LVN 2) on 2/10/20 at 12:50 p.m., Resident 2 stated he had a bowel movement and continued to point to his brief. LVN 2 stated the staff do not change residents at meal times, and it will Have to wait. During a concurrent interview and observation at 1:15 p.m. (35 minutes after Resident 2 needed pericare), the Certified Nursing Assistant 3 (CNA 3) confirmed Resident 2 needed to be changed and proceeded to change his brief. A record review of the policy and procedure titled, Dignity dated 2009 showed, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times .Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by .promptly responding to the resident's request for toileting assistance .

Based on observation, interview and record review, the facility failed to provide personal hygiene care in a timely manner for one (Resident 2) of nine sampled residents. Resident 2 gestured to have his brief (diaper) changed and staff did not immediately respond. This failure resulted in Resident 2 experiencing discomfort and had the potential for skin breakdown. Findings: A record review of the document used to assess patients condition and care needs titled, MDS (minimum data set) 3.0 dated 1/31/20, showed Resident 2's diagnoses included dementia (symptoms that affects memory, thinking, and social abilities, enough to interfere with daily life). The record review of the nursing Departmental Notes dated 1/17/20 through 1/23/20 showed Resident 2 was, Alert and responsive. A record review of the care plan titled, Communication problem dated 8/8/19 indicated one goal was for Resident 2 to communicate needs daily. The interventions included for staff to become familiar with nonverbal cues, gestures and body language . A record review of the plan of care dated 8/8/19 indicated Resident 2 was dependent on staff for assistance with toileting, was unable to walk, and incontinent of bowel and bladder (unable to control urine or bowel movements). Resident 2 was at risk for skin breakdown. The interventions included, Peri care (personal hygiene) every shift and after each incontinence and keep clean and dry. During an observation on 2/10/20 at 12:40 p.m., Resident 2 was observed in bed yelling out in distress and pointing down at the brief he was wearing. The facility's Director of Staff Development (DSD) was walking by and continued to walk down the hall past Resident 2's room without stopping. DSD stated, He does that. He (Resident 2) yells out. During concurrent interviews with Resident 2 and Licensed Vocational Nurse 2 (LVN 2) on 2/10/20 at 12:50 p.m., Resident 2 stated he had a bowel movement and continued to point to his brief. LVN 2 stated the staff do not change residents at meal times, and it will Have to wait. During a concurrent observation and interview on 2/10/20 at 1:15 p.m., (35 minutes after Resident 2 had a BM), the Certified Nursing Assistant 3 (CNA 3) confirmed Resident 2 needed to be changed and proceeded to change his brief.

Based on observation, interviews, and record review, the facility failed to ensure competencies and skills for one of three sampled licensed nursing staff. This failure resulted in the licensed nurse not receiving the required skills competency check to ensure safe care of residents. [Refer to F 726 and F 759] Findings: During a record review on 02/13/20, the employee personnel file for LVN 2, hired 2/3/20, contained a document titled, Nurse Assistant Orientation & Competency Evaluation Nursing Skills Performance Satisfactory Completion dated 2/3/20. This document had no signature from LVN 2 or the skills evaluator, and the skills checklist was not completed. There was no licensed nursing skills check list in LVN 2's employee file. During an interview on 2/13/20 at 8:04 AM, the Director of Staff Development (DSD) stated the facility does a skills checklist for new nursing staff, and the skills checklist is done annually at time of hire. DSD further stated the competency is done by observing if staff are following protocols and watching nursing care being given to residents. During an interview on 2/13/20 at 2:06 PM, DSD stated the wrong form was used to evaluate LVN 2, and the Nursing Assistant Competency form, should have been completed. DSD stated the facility did not have a Licensed Nurse Competency done for LVN 2. During a concurrent interview and record review on 02/13/20 at 2:57 PM, the Director of Nursing (DON) was unable to find any documentation of LVN 2 being evaluated for medication administration competency by the pharmacy consultant.

Based on observation, interview, and record review, the facility did not maintain a medication error rate of 5% or less. The medication error rate was 7.69%. Resident 17 was administered the incorrect amount of pain medication. This failure resulted in the potential for ineffective pain relief. Findings: Record review on 2/10/20 of the document, Administering Medications, dated 2012, showed Medications shall be administered in a safe and timely manner, and as prescribed. Record review of the document, Face Sheet showed Resident 17 had diagnoses that included lung disease and muscle weakness. Record review of the document, Medication Administration Record dated 11/5/19, showed Resident 17 was to receive, Voltaren (antiinflammatory) 1% gel. Give 4 gms (grams) BID (twice a day) for pain in hands. Resident 17 also received, Gabapentin 600 mg tablet, give 1.5 tab (tablet) by mouth TID (three times a day) for neuropathy (a disease of the body's nerves which can cause numbness or weakness). During an observation of the medication pass on 2/10/20 at 8:10 a.m., Licensed Vocational Nurse 2 (LVN 2) administered Resident 17's Voltaren gel. LVN 2 stated there was a measuring device for the Voltaren but she was unable to locate it. LVN 2 further stated she would Just estimate, the amount and started to squeeze the tube of Voltaren gel into a cup. When asked if there was any consequence to not measuring the Voltaren gel, LVN 2 stated, No, I don't think so. LVN 2 then put one tablet of Gabapentin into another medication cup. The physician order was for 1.5 tab. During an observation and interview on 2/12/20 at 10:41 a.m., the facility's Director of Nursing (DON) stated medication should only be administered in the amount as ordered by the doctor and should be measured accurately or Not given. DON confirmed there was no measuring device for Voltaren gel in the medication cart.

Based on observation, interview and record review, licensed nursing staff did not store medication in a secured manner. A lidocaine patch (pain reliever] was left unattended on top of the medication cart. This failure had the potential for unauthorized access and use of medication by other persons which could result in harm. Findings: During an observation of the medication pass on 2/12/20 at 9:30 a.m., Licensed Vocational Nurse 2 (LVN 2) lifted the inoperable laptop computer from the top of the medication cart, and went to the nurses station to exchange it for another one. A lidocaine patch which had been underneath the laptop was left unattended. In a concurrent interview, LVN 2 confirmed the lidocaine patch was underneath the laptop because she was hiding, it and saving it to give to another resident. In an interview on 2/12/20 at 9:40 a.m., the Director of Nursing (DON) verified the lidocaine patch was left unattended on top of the medication cart. DON stated if a nurse leaves the cart for any reason, all medication must be locked and secured within the medication cart. A record review of the document, Medication Storage In The Facility dated 2008 indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review, the facility failed to ensure competencies and skills for kitchen staff. This failure resulted in the potential for food borne illness, inaccurate temperature testing of cooked foods, and physician ordered therapeutic diets not being made correctly by kitchen staff. Findings: During an observation on 2/10/20 at 11:45 AM, [NAME] 1 did not fill the scoop fully for the pureed diets during lunch tray line. There was not enough pureed meat for all residents receiving pureed diets. During an interview on 2/10/20 at 12:45 AM, the Dietary Manager (DM) stated [NAME] 1 should have made more pureed food to ensure residents were given the amount of pureed food as ordered by their physician. During a record review of employee file for [NAME] 1, employed since 2018, there was no orientation, no evaluation, or competency training contained in the employee file. During a record review of the Food Service in-services for dietary staff, there was no signature for [NAME] 1 on the attendance sign-in sheet for the months of 1/2019, 2/20/19, 11/2019, and 12/2019. During a record review of the dietary in-service for [NAME] 1, [NAME] 1 did not attend the dietary in-service conducted on 1/4/19 and given by the DM on scoop size. During a record review of [NAME] 1's employee file, a document titled Verification of Job Competency Demonstration-Cooks dated 2019, was only partly completed by [NAME] 1 and the DM. During an observation on 2/11/20 at 11:45 PM, DM demonstrated thermometer calibration for testing cooked food temperatures. Three of three kitchen thermometers were calibrated to zero instead of 32 degrees Fahrenheit. During a record review of the facility's policy and procedure titled, Thermometer Use and Calibration dated 2018 indicated, .3. If the thermometer does not read 32 degrees Fahrenheit, then the thermometer must be calibrated or discarded. During an interview on 2/11/20 at 10:25 AM, the dietician stated the facility does brief monthly in-services for dietary staff. Training for new staff, including hands on training is done mostly by DM. The Dietician does training based on audits (evaluation) and emergency procedures. The Dietician stated she had not viewed the staff training logs for in-services done by the DM. The dietician did not recall providing dietary education to [NAME] 1. During an interview on 2/11/20 at 10:27 AM, the Dietician stated the kitchen thermometers are calibrated by the kitchen staff once a week. During an interview on 2/12/20 at 9:47 AM, the administrator (ADM) stated the dietician is expected to do in-service for dietary staff.

Based on observation and record reviews, the facility failed to ensure food for residents was prepared under sanitary conditions. This failure had the potential to cause food borne illness. Findings: During an observation on 2/10/20 at 10:23 AM, [NAME] 1 used a soiled cleaning towel with debris present to wipe down the kitchen food preparation counters, then placed the counter with container of cooked food on top of it. [NAME] 1 then picked up the soiled towel from the counter and placed it in the sink near the raw meat was thawing in a pan. [NAME] 1 left the soiled towel in the sink for a couple of minutes before removing the towel from the sink. [NAME] 1 did not clean the sink after removing the soiled towel. During a record review of the facility's policy and procedure titled, Cleaning and Sanitizing(undated) indicated, 1. Food contact surfaces must be cleaned .b. each time there is a change from working with raw foods to working with ready-to eat food, and 7. Food contact surfaces and utensils must be sanitized before each use. During a record review of the facility's policy and procedure titled, Cleaning and Sanitizing (undated) indicated, 5. Keep sinks clean and sanitized.

Based on observation and interview, the facility failed to ensure that one of two dumpsters were closed shut. This failure resulted in unsanitary conditions and attracted flying pests. During an observation on 2/10/20 at 10:15 a.m., one of two dumpsters was left open and overfilled with garbage that had insects flying above it. During an interview on 2/11/20 at 9 a.m. with Maintenance Director, he stated that the garbage is picked up on Monday, Wednesdays and Fridays. No trash was picked up on Monday. Review of the facility's policy titled, Food-Related Garbage and Rubbish Disposal indicated, all garbage and rubbish containers shall be provided with tight-fitting lids or covers and must be kept covered when stored. Outside dumpsters .will be kept closed and free of surrounding litter.

Based on observation, interview, and record review, the facility failed to ensure for one of eight sampled residents (Resident 20), that the call light was in working order. This failure resulted in Resident 20 being unable to turn the call light on to request help from facility staff. Findings: During an observation and interview, on 2/11/2020 at 8 a.m., Resident 20 stated her call light was broken. The button to press and turn on the call light was missing. During an immediate interview on 2/11/2020, at 8 a.m., with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated the call light was not broken and retrieved the call light from underneath the blankets and confirmed Resident 20's call light was broken. CNA 3 notified the Maintenance Director (MTN). During an interview and record review on 2/11/2020 at 8:10 a.m., MTN stated Resident 20's call light was broken and he replaced it. MTN provided the weekly maintenance log for the facility's call light system, and Resident 20's call light was checked and working on 2/7/20. MTN further stated the CNAs are supposed to write down anything that needs repair in the maintenance log. There was no request for Resident 20's call light to be repaired. During an interview on 2/11/2020 at 8:43 a.m., with the Director of Staff Development (DSD), DSD stated the CNAs are supposed to check their residents' call lights each shift to ensure the call lights are working. During a review of the facility's policy titled, Maintenance Inspections (undated), indicated call lights are to be inspected daily. During a review of the facility's policy titled, Answering the Call Light dated and revised October 2010, indicated all defective call lights were to be reported to the nurse supervisor promptly.

Based on observation, interview, and record review, the facility did not notify the physician for changes in condition for four(Residents 24, 28, 194 and 297) of nine sampled residents. Resident 297 had incomplete vital sign (temperature, pulse, respiratory rate, blood pressure) records, and was subsequently sent to the hospital's emergency department (ED). The doctors were not notified when Resident 28 stopped eating, and of Residents 24 and 194's elevated blood pressure (BP). These failures resulted in the staff's failure to identify and monitor for changes in condition which had resulted in, or had the potential, for a decline in the resident's health. Findings 1. A record review of the document, Face Sheet showed Resident 24 had diagnoses that included cerebrovascular disease (condition that affects blood supply to the brain- also known as a stroke). During an observation of the medication pass, on 2/10/20 at 8:10 a.m., Licensed Vocational Nurse 2 (LVN 2) checked Resident 24's BP, which was 188/102 (normal range 120/80). LVN 2 stated, Oh, that's high, and continued to administer medications to Resident 24 and to other residents. She did not re-check Resident 24's BP or notify the doctor. The record review of Resident 24's Monthly Vital Signs reflected on 1/9/20, the BP was 127/77. On 2/9/20, the BP was 128/80. In an interview on 2/10/20 at 1:26 p.m., LVN 2 stated she had Forgotten about Resident 24's elevated BP and did not call the doctor. In a subsequent interview, on 2/11/20 at 10:40 a.m., LVN 2 stated she did not call the doctor about Resident 24's high BP because she had administered Pradaxa. According to the food & drug administration (FDA), Pradaxa is a blood-thinning medication used to reduce the risk of stroke and blood clots in patients. In an interview on 2/12/20 at 10:41 a.m., the Director of Nursing (DON) stated it was important for staff to monitor Resident 24's BP because of her history of stroke. Furthermore, DON stated staff should have re-checked the BP and, if still high, notify the doctor. 2. The record review of the document, Face Sheet showed Resident 28 had diagnoses which included a heart attack. Further review of the nursing notes showed the following food intake for Resident 28: 12/11/19: 50% of dinner 12/12/19: refused both breakfast and lunch and, Only drank 2 cups of fluids. 12/12/19: 50% of dinner and, Won't open his mouth. 12/14/19: Did not eat breakfast. Consumed 25% of lunch. 12/15/19: .refused breakfast and lunch. The doctor came to visit and ordered IV (intravenous, into the vein) hydration to replenish fluids and 9-1-1 was called. Resident 28's oxygen saturation (percent of oxygen in the blood) was 63% (normal range 90's). In an interview on 2/13/20 at 12:15 p.m., LVN 1 stated he did not notify the doctor when Resident 28 was refusing his breakfast and lunch on 2/12/20, and had eaten 50% of his dinner the night before. During an interview on 2/13/20 at 12:41 p.m., the Director of Staff Development (DSD) stated there was no I&O (intake and output) or documented weights for Resident 28. (Note: Monitoring I&O during a 24-hour period is an important aspect of fluid balance assessment. Body weight is an important indicator of fluid status, including fluid loss and potential signs of dehydration). During an interview on 2/13/20 at 2:38 p.m., DON stated when a resident is showing signs of dehydration , staff should monitor the vital signs, weights, and notify the doctor. A record review of the facility's document, Transfer and Referral Record dated 12/15/19 showed Resident 28 was sent to the hospital with lethargy and weakness. The record review of the document, ED to Hosp (hospital)-Admission dated 12/27/19 showed Resident 28's diagnoses included, but was not limited to, severe sepsis (bodies response to an infection) and hypernatremia (when sodium is too high for the amount of fluid in the body). 3. A record review of the Face Sheet showed Resident 194 had diagnoses that included cerebrovascular disease. The record review of the Physician Orders dated 3/16/19 showed Resident 194 was to receive Atenolol (BP) medication, 50 milligrams (mg) every day. A record review of Resident 194's, Medication Administration Record showed the following BP's: 2/8/20: 158/86 2/9/20: 166/83 2/10/20: 179/74 In an interview on 2/11/20 at 2:57 p.m., DON stated residents taking BP medications have their BP's checked every day. DON further stated staff are to call the doctor if the readings are outside the established parameters, which are greater than 150/90 or less than 100/50. In a subsequent interview on 2/12/20 at 10:41 a.m., DON confirmed Resident 194 had consistently high BP's and the doctor was not notified. DON further stated the doctor should have been called so the medication dosage could be re-evaluated. During an observation of the medication pass on 2/10/20 at 8:10 a.m., LVN 2 was checking Resident 194's BP and was 179/74. LVN 2 did not recheck the BP. In a subsequent interview, on 2/10/20 at 1:26 p.m., LVN 2 stated she had not rechecked the BP or call the doctor because the resident, . gets BP medication. 4. A record review of the document, Face Sheet showed Resident 297 had diagnoses that included muscle weakness and difficulty swallowing. A review of the nursing notes dated, 10/22/29, 10/23/19, 10/24/19, and 11/4/19, showed no documented vital signs. On 11/4/19, the notes indicated Patient 297 was lethargic and sent to the ED. The record review of the facility's document titled, Transfer and Referral Record dated 11/4/19, reflected the reason for the transfer to the hospital was because Resident 297 was, Lethargic, with signs and symptoms of dehydration. In an interview on 2/13/20 at 2:16 p.m., DSD confirmed there was no vital signs taken before Patient 297 condition changed and was transferred to the hospital's ED on 11/4/19. DSD further stated that tracking (monitoring) Patient 297's BP and heart rate could have shown signs of possible dehydration. The record review of the hospital's, Discharge Summary dated 11/9/19 showed the reason for Resident 297's hospital admission was due to, Lethargy, weakness, poor po (per os, oral) intake. Resident 297 was treated with IV fluids. A record review of the facility's policy and procedure, Change in a Resident's Condition or Status dated 11/'15 indicated, The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: .A significant change in the resident's physical/emotional/mental condition; .A need to alter the resident's medical treatment significantly.

Based on interviews and record reviews, the facility failed to provide education to families regarding food brought in from home for the residents. The facility also failed to have a system for staff to ensure food from home was re-heated to a safe temperature. This had the potential to result in burn injuries from hot food. Findings: During an interview on 2/11/20 at 9:16 AM, registered nurse 1 (RN 1) stated nursing staff reheats food in the microwave in the break room, but was not sure what temperature food is supposed to be heated. During an interview with the Dietician on 2/11/20 at 10:25 AM, the Dietician stated she does not train facility staff on the safety of food brought from home for residents. The Dietician further stated she has no involvement with how staff re-heats outside food brought into the facility for residents. She stated a re-heated food temperature of 165 degrees was too hot to eat directly, but staff was probably thinking of temperatures for other food items, such as poultry. The Dietician stated she does not provide education to families regarding food safety and food brought into the facility from home. During an interview on 2/11/20 at 10:30 AM, the certified nursing assistant 2 (CNA 2) stated time frames for reheating a resident's food depends on what type of food is being heated. CNA 2 indicated the staff use the buttons on the microwave to guide re-heating foods and does not check food temperatures. During an interview on 2/11/20 at 10: 38 AM, the Director of Nursing (DON) confirmed staff does not use thermometers for temperature testing during food re-heating but rely on common sense to know when re-heated food is the appropriate temperature for residents to safely consume. During a record review of the facility's policy and procedure titled, Food Preparation: Leftover Foods dated 2018 indicated, Leftover foods will be stored and served in a safe manner .2) Reheat all leftover foods to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds. During a record review of the facility's policy and procedure titled, Foods Brought by Family/Visitors, (undated)indicated, 1. Family members should inform nursing staff of their desire to bring foods into the facility. The Dietician or a Nurse Supervisor should assure that the food is not in conflict with the resident's prescribed diet plan, and 3. The Dietician will counsel residents or families about requests that conflict with resident's dietary restrictions and whenever diets cannot be liberalized.

Based on observation, interview, and record review, the facility failed to ensure that staff performed hand hygiene after contaminating their hands while passing meal trays. This failure resulted in a certified nursing assistant passing meal trays to residents after contaminating her hands by touching her nose and lips. Findings: During an observation on 2/10/2020 at 12:30 p.m. adjacent to the dining room, Certified Nursing Assistant (CNA) 1 touched the underside of her nose and/or her lips with her hand six times while passing trays to residents in the dining room. CNA 1 did not perform hand hygiene after she touched her nose and/or mouth. During an interview on 2/10/2020 at 2:05 p.m., with CNA 1, CNA 1 stated she did not perform hand hygiene each time after she touched her nose and/or mouth with her hand while passing trays. CNA 1 stated she was supposed to perform hand hygiene after each time she touched her nose and/or mouth. During an interview on 2/11/2020 at 2:07 p.m., with Director of Staff Development (DSD), DSD stated that staff are required to do hand hygiene when passing food trays to residents for infection control. DSD stated that staff touching the end of their nose or lips would contaminate the staff's hands and the staff was therefore, required to do hand hygiene after touching their nose or lips before passing a tray. During a review of the facility's policy and procedure titled, Hand Hygiene Program, (undated), indicated hand hygiene should be done before and after serving food to residents and when hands are likely to be contaminated.

Based on observation, interview, and record review, the facility failed to serve therapeutic diets (diet ordered by a physician for treatment of a disease or clinical condition) as ordered for the Controlled Carbohydrate Diet (CCHO), low sodium, fortified and pureed diets for approximately 25 residents. This failure resulted in under and overserved portions of food and meals not served according to the planned menu. This also had the potential for compromised medical and nutritional status for residents. During an observation of the tray line on 2/10/20 at 11:45 a.m., and review of the winter menu for Monday Week 2, showed the following: 1. The menu indicated for 4 ounce (oz) servings. [NAME] 1 weighed 1 cooked beef patty at 3 oz for the CCHO regular diet. [NAME] 1 served 3 oz of the meat patty for the CCHO regular diets. 2. There were eight CCHO Regular diets, one 3 oz southern style meat patty and 4 oz of mashed potatoes. The menu planned was for 4 oz beef patty and 2 oz of mashed potatoes. 3. For twelve fortified diets, [NAME] 1 served 4 oz of melted butter on mashed potatoes. The menu directions specified the amount was supposed to be one-half oz. 4. One puree double portion diet received one 6 oz scoop, plus a little extra pureed meat, as [NAME] 1 ran out of pureed meat. The Dietary Supervisor Staff (DSS) stated the double should receive two serving of 6 ounces. [NAME] 1 did not prepare adequate quantities of pureed meat to serve all of the portions required. 5. Four No Added Salt (NAS) diets received regular gravy with beef patty. During an observation and taste sample of the test tray on 2/10/20 at 12:48 p.m., DSS tasted the meat and stated it, tastes salty. During an interview on 2/11/20 at 10:25 a.m., with the Registered Dietician (RD), RD read the gravy mix ingredients and stated, This would be an issue for NAS diets.