**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect personal belongings for one resident (Resident 1), when Resident 1's clothes and personal items were missing and were not accounted for.This failure had compromised the right of Resident 1 to retain personal possessions. A review of the admission record for Resident 1 indicated that Resident 1 was admitted on [DATE], and initially admitted [DATE] with diagnoses that included diabetes, hypertension, and end-stage kidney disease on dialysis. Resident 1 was discharged on 10/9/24. During a telephone interview on 8/12/25, at 8:48 a.m. with Resident 1's Responsible Party (RP), RP stated that upon discharge, Resident 1 had missing personal items. RP stated Resident 1's missing personal items were reported to Social Services Director (SSD) 2 during Resident 1's stay in 2024. RP stated there was no inventory of Resident 1's personal items provided to Resident 1 and/or family upon discharge. During an interview on 8/12/25 at 2:55 p.m. with the current Social Services Director (SSD 1), SSD 1 stated they should have a theft and loss form in the log when resident's belongings were reported missing. SSD 1 stated SSD 2 was no longer working in the facility. During a concurrent interview and record review of the facility's 2024 Theft and Loss Log, on 8/12/25 at 4:05 p.m. with SSD 1, SSD 1 stated there was no record of missing clothes/items for Resident 1. During a telephone interview on 8/13/25 at 12:38 p.m. with the Medical Records Director (MRD), a request was made for a record of Resident 1's inventory of personal belongings upon admission and discharge. MRD provided Resident 1's inventory of belongings upon admission, but none was provided for the discharge. MRD stated they did not have the record. During a review of a copy of Resident 1's inventory form upon admission, titled Inventory of Personal Effects signed 11/16/22, the form indicated two coats, two jackets, one shoes [pair], one black shirt, three sweaters, two watches (one brown and one brown) and another inventory form, titled Resident Inventory Form B (Per MRD, it was an added inventory in August 2024). The form indicated one stripe red & white T shirt, but with no date and signature. During a concurrent telephone interview and record review on 8/13/25 at 12:45 p.m. with the Director of Nursing (DON), DON acknowledged the facility did not have Resident 1's Inventoried list of personal belongings upon discharge. DON stated the original would have been given to the Resident and/or RP and they would have a copy of it. DON also stated there was no information on Resident 1's discharge summary note about the resident's inventory of personal belongings. A review of the signed inventory form on admission indicated, Instructions:.Upon discharge, use the columns to indicate that all personal belongings are accounted for. During a review of the facility's policy and procedure (P & P) titled, Personal Property, dated 7/14/17, the P&P indicated, To ensure the facility takes reasonable steps to protect resident's property.the facility will return inventoried personal items to residents or their representative upon discharge. the resident/resident representative will review the Resident inventory to ensure all personal items are taken. The resident/resident representative will sign the inventory indicating that all personal property is released to them. If an item(s) is missing, the staff will initial a search and notify Social Services/ designee in accordance with the Theft and Loss policy for resolution. During a review of the facility's P&P titled, Theft and Loss, dated 7/11/17, the P&P indicated, To assist residents in safeguarding their personal property. At the time of admission and discharge, Facility staff complete a Resident Inventory. Social Services staff documents report of lost and stolen resident property on .Theft and Loss Log.

Based on interview and record review, the facility failed to protect one of five sampled residents (Resident 4) from physical abuse, when Resident 5, with a known of history of aggressive behavior, hit Resident 4 with a bed power cord (a thick electrical cord that connects the hospital bed with a power outlet). The failure resulted in Resident 4 suffering from a bleeding facial/scalp wound and received and hospitalization for further care. Findings: During a review of Resident 4's admission Record (a document that records a patient's information when they are admitted to a hospital or other healthcare facility), printed on 2/6/25, the record indicated Resident 4 was admitted to the facility in November 2023 with vascular dementia (a loss of brain function, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a review of Resident 4's Minimum Data Set (MDS, an assessment used to guide care), dated 9/5/24, the MDS indicated Resident 4's Brief Interview of Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status) score of eight (8) out of 15, indicating Resident 4 was moderately cognitively impaired. During a review of Resident 5's admission Record, printed on 2/6/25, the record indicated Resident 5 was admitted to the facility in November 2022 with diagnoses of unspecific dementia, unspecific psychosis (a mental health condition characterized by a loss of contact with reality that can cause significant distress and impairment in daily functioning) and anxiety (feeling of unease, worry, fear, and apprehension) During a review of Resident 5's MDS assessment, dated 10/5/24, the MDS indicated Resident 5's BIMS score was14 out of 15, indicating Resident 5 was cognitively intact. During a concurrent interview and record review on 2/6/24 at 11:30 a.m. with MDS Coordinator (MDSC), Resident 4's Nursing Progress Notes, dated 9/24/24, were reviewed. Licensed Vocation Nurse (LVN) 4 documented, at 0015, [LVN] [heard] a shout from the room, help rushed in to see [Resident 4] bleeding profusely from the head .[Resident 5] hit [Resident 4] with bed control cord on her head .called 911 immediately, and she was transferred to [Acute care Hospital] by paramedic for further evaluation . MDSC stated Resident 4 did not come back to the facility after this hospitalization. During a concurrent interview and record review on 2/6/25 at 11:40 a.m. with MDSC, Resident 5's Nursing Progress Notes, dated 9/24/24 and Behavior Care Plans, dated 8/26/24, were reviewed. LVN 4 documented [Resident 5] hit [Resident 4] with her bed control cord on her head, to the face . MDSC stated Behavior Care Plan indicated Resident 5 is/has potential to be physically aggressive, threatening to hit roommate with a hanger, related to anger. The MDSC stated Resident 5 had a few room-changes in the past because of conflict with prior roommates. During an interview on 2/6/25 at 12:30 p.m. with Director of Nursing (DON), DON stated she was aware of the incident between Resident 4 and Resident 5. The DON stated the staff involved in the incident did not work at the facility anymore. The DON stated the involved staff told her, on 9/24/24 when they rushed to Resident 4 and 5's shared room, they saw Resident 5 was sitting on the floor, swinging the bed power cord in her hand, and Resident 4 was bleeding heavily. During a phone interview on 2/6/25 at 4:57 p.m. with LVN 4, LVN 4 stated she heard one of the staff members was shouting that Resident 4 was bleeding, and she rushed to Resident 4's room. LVN 4 stated Oh, my gosh, there was a lot of blood on [Resident 4's] face and head. LVN 4 stated she had to put pressure on Resident 4's head to stop the bleeding and called 911 for further care. During a review of the facility's policy and procedure (P&P) titled Abuse-Prevention, Screening, and Training Program, revised 7/2018, the P&P indicated the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, and/or mistreatment and develops facility policies, procedures, training programs, and screening and prevention system to promote an environment free from abuse, neglect, misappropriation of resident property, exploitation, and mistreatment.

Based on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 2 did not have access to facility residents and their personal care, after one of five sampled residents (Resident 3) alleged that CNA 2 hit him. CNA 2 continued to provide care to Resident 3 and at least 18 other residents for 12 more hours after the allegation was made. This failure placed Resident 3 and other residents at the facility at risk for abuse and further complications. Findings: During a record review of Resident 3's undated admission Record (a document with patient's basic personal information), the record indicated Resident 3 was admitted to the facility in April 2022. During a review of Resident 3's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/11/24, showed Resident 3's short-term memory was intact. A record review of Resident 3's Nursing Progress Notes, dated 9/14/24, the notes indicated Licensed Vocational Nurse (LVN) 3 documented, on 9/14/24 around 7:30 pm resident called 911. Paramedic is here to [check] him. Resident stated he is physically hurt by CNA [with CNA 2's full name] .they recommended to us to keep monitoring him . During a concurrent phone interview and record review with Director of Nursing (DON) on 2/7/25 at 4:10 p.m., the facility's documents titled Nursing Staffing Assignment and Sign- in Sheet, dated 9/14/25, were reviewed. The DON stated the Sign- In Sheet indicated CNA 2 worked Shift 2 and Shift 3. The Sign- in Sheet indicated CNA 2 started working on 9/14/24 at 3:40 p.m. and did not leave the facility until 7:37 a.m. on 9/15/24. The DON stated she was under the impression that CNA 2 was sent home after Resident 3 made an allegation of abuse against CNA 2 but was unable to state why Sign-in Sheet indicated that CNA 2 continued to work for 12 more hours in the resident care areas even after the abuse allegation was still under investigation. During a phone interview on 2/7/25 at 8:45 a.m. with CNA 2, he stated he recalled Resident 3 becoming upset at him, and then police came to the facility on the evening of 9/14/24. CNA 2 stated police talked to him about Resident 3. CNA 3 stated however, nobody, including facility staff told him that Resident 3 had alleged that he had abused Resident 3. CNA 3 stated he did not hit Resident 3, but he kept his distance from Resident 3 after the police left the facility and continued working for rest of the evening and night shift, until the morning of 9/15/24. CNA 3 stated he continued to provide care to all his assigned residents. During a phone interview on 2/7/25 at 12:42 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated she was the nurse assigned to Resident 3 on 9/14/24. LVN 3 stated she had started one week prior to incident. LVN 3 stated Resident 3 alleged CNA 2 kicked him, but it was an unwitnessed event. LVN 3 stated Resident 3 called the police by himself. LVN 3 stated she interviewed CNA 2, he denied the allegation and indicated nothing happened. During a phone Interview with LVN 3 on 2/7/25 at 1:46 p.m. LVN 3 stated she was not aware of the incident until the police arrived at the building. LVN 3 stated she was not sure if CNA 2 was removed from resident care areas and or sent home. During a phone interview on 2/11/25 at 1:39 p.m. with DON, DON stated CNA 2 provided direct personal care to at least 11-12 residents during evening shift and up to 18 residents during the night shift on 9/14/24. DON stated CNA 2 worked for at least 12 more hours after Resident 3 had alleged that CNA 2 hit him around 7:30 p.m. on 9/14/24. During a review of facility's Policy and Procedure (P&P) titled Abuse & Neglect- Reporting and Investigations, dated 1/1/24, the P&P indicated, 2. Immediate Action a. The Administrator or designated representative will provide for a safe environment for the resident as indicated by the situation . ii. If the suspected perpetrator is an employee, remove the employee immediately from the care of the resident (s) and immediately suspend the employee pending the outcome of the investigation in accordance with facility policies.

Based on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 30) was treated with dignity and respect when Resident 30 attended activity wearing facility gown and disposable undergarment was soaking wet with urine. This failure had the potential to negatively impact Resident 30's sense of self-worth and self-esteem. Findings: During an observation on 9/9/24 at 12:38 p.m. in the activity room, Resident 30 was sitting on the wheelchair wearing facility gown and liquid was dripping from the wheelchair onto the floor. Other residents in the room were wearing personal clothes. During a concurrent observation and interview on 9/9/24 at 12:40 p.m. with the Activity Director (AD) in the activity room, the AD pulled up Resident 30's gown to check the disposable undergarment. The AD stated Resident 30's diaper was soaking wet with urine. The AD stated Resident 30 wearing gown and soaking wet affected their dignity. During a review of the facility's policy and procedure titled, Resident Rights, dated 1/1/12, indicated, Employees are to treat all residents with kindness, respect, and dignity and honor the exercises of resident's rights.

Based on observation, interview, and record review, the facility failed to ensure one of 4 sampled residents (Resident 11), had a Doctor's Order for supplemental oxygen before they received the supplemental oxygen. This failure had the potential for Resident 11 to receive supplemental oxygen inappropriately and in an unsafe manner. Findings: A review of Resident 11's admission Record printed 9/12/24, indicated Resident 11 was admitted to the facility in 2024 with multiple diagnoses including a primary admitting diagnosis of Acute and Chronic Respiratory Failure (a condition that occurs when the lungs are unable to get enough oxygen into the blood or remove enough carbon dioxide from the blood) with Hypoxia (a condition that occurs when the body's tissues, blood, or cells don't have enough oxygen to function normally). During a concurrent observation and interview on 9/09/24, at 10:48 a.m., Resident 11 was observed as they used an oxygen concentrator (a medical device that gives you extra oxygen) via nasal canula (a thin, flexible tube with two prongs that sit inside the nostrils and delivers oxygen) at a rate of 2L (liters). During a concurrent interview and record review on 9/11/24, at 1:30 p.m., with Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) Coordinator (MDSC), Resident 11's Doctor's orders, were reviewed. MDSC stated Resident 11 did not have a Doctor's Order for an oxygen concentrator. During a concurrent interview and record review on 9/12/24, at 11:07 a.m. with Assistant Director of Nursing (ADON), Resident 11's Doctor's Orders, were reviewed. The orders indicated Resident 11 had a Doctor's Order dated 9/11/24, at 14:39 p.m., for Oxygen 2 liters as needed for SOB (shortness of breath), to keep O 2 (oxygen) above 90% Via N/C (Nasal Cannula). ADON confirmed Resident 11 did not previously have a Doctor's Order for O2. ADON stated Residents needed a Doctor's Order for O2 because it can harm the resident. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, revised November 2017, the P&P indicated, To ensure the safe storage and administration of oxygen in the Facility. The P&P indicated Licensed Nursing staff will administer oxygen as prescribed. The P&P indicated Administer oxygen per physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her need for assistance) was within reach for one of three sampled Residents (Resident 56). This deficient practice resulted in the delay of care and services. Findings: During a review of Resident 56's face sheet dated, 9/10/24, indicated Resident 56 was admitted to the facility on [DATE]. During a review of Resident 56 Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan) dated 8/13/24, the MDS indicated, Resident 56 had multiple diagnoses that included, muscle weakness, polyneuropathy (nerve damage causing problems with sensation, coordination, or other body functions). The MDS also indicated Resident 56 had a Brief Interview for Mental Status (BIMS - is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) Score of 13, meaning Resident 56 had intact cognition. During a concurrent observation and interview on 9/9/24 at 10:18 a.m. Resident 56's call light was on the floor behind the bed. Resident 56's urinary collection bag measured 1600 cubic centimeter (cc - measure of volume). Resident 56 stated, staff did not empty drainage bag and it felt heavy. Resident 56 also stated, he could not ask for help because staff took his call light from within reach. During a concurrent observation and interview on 9/10/24 at 10:23 a.m. with Certified Nursing Assistant (CNA) 8, CNA 8 stated, she was not aware Resident 56 needed assistant. CNA 8 then picked up the call light from the floor behind Resident 56's bed and stated, I should have checked call light when I came this morning. During an interview on 9/12/24, at 11:22 a.m., with the Director of Nursing (DON), DON stated the expectation for the nursing staff was to ensure call light for Resident was within reach. DON further added, especially for Resident 56 who required extensive assistance. During a review of Resident 56's care plan dated 8/6/24, indicated Resident 56 was at risk for fall related to diabetes, polyarthritis (swelling of one or more joints), chronic pain, CKD (chronic kidney disease - gradual loss of kidney function) . One of the interventions is: Be sure the Resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. During a review of facility's policy and procedure, titled Communication-Call System, dated 1/1/12, indicated, Under Purpose: To provide a mechanism for residents to promptly communicate with Nursing Staff. Under Policy: The facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities.Under Procedure II. Call cords will be placed within the resident's reach in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist four out of eight sampled residents (Resident 30, 46, 48, 52) with personal hygiene when: 1. Resident 30 and Resident 46's long facial hair was not shaved. 2. Resident 48 and Resident 52's fingernails were not clean and trimmed. These failures resulted in Resident 30 feeling yuck, Resident 46 feeling crutty and unkept and placed Resident 48 and Resident 52 at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails. Findings: 1.a. During a concurrent observation and interview, on 9/9/24 at 10:14 a.m. with Resident 30 in Resident 30's room, Resident 30's beard was approximately 1 centimeter (cm) long. Resident 30 stated he preferred to keep his mustache long, but his beard shaved. Resident 30 stated staff doesn't offer to help him shave. Resident 30 stated feeling yuck with the long beard. During a concurrent observation and interview, on 9/12/24 at 11:00 a.m. with Licensed Vocational Nurse (LVN) 2 in the activity room, Resident 30 was sitting on the wheelchair with long beard. LVN 2 stated Resident 30's beard looked long and needed to be shaved. During a record 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 7/11/24, indicated, Resident 30 required Partial/moderate assistance from staff with personal hygiene. b. During a concurrent observation and interview, on 9/9/24 at 9:45 a.m. with Resident 46 in Resident 46's room, Resident 46's beard was approximately 2 centimeters long. Resident 46 stated he doesn't remember when he was last shaved. Resident 46 stated staff doesn't offer to help him shave. Resident 46 stated feeling crutty and unkept with the long beard. During a concurrent observation and interview, on 9/9/24 at 9:52 a.m. with Certified Nursing Assistant (CNA) 5 in Resident 46's room, Resident 46's beard was long. CNA 5 stated Resident 46's beard was long and would assist Resident 46 with shaving. During a record review of Resident 46's MDS dated [DATE], indicated Resident 46 required Partial/moderate assistance from staff with personal hygiene. During an interview on 9/12/24 at 11:07 a.m. with CNA 9, CNA 9 stated there was no option in the Electronic Health Record (EHR) to document staff assistance of resident with shaving. CNA 9 stated a paper documentation of shaving was available at the nursing station one. During a concurrent interview and record review, on 9/12/24 at 11:20 a.m. with LVN 4 at the nursing station one, Resident Skin & Body Check form inside the white Shower Schedule binder was reviewed. The form indicated, date on when the resident was shaved. LVN 4 stated Resident Skin & Body Check form was the only place the staff documented assisting residents with shaving. LVN 4 stated she was unable to find documentation in the shower schedule binder when Resident 30 and Resident 46 was last shaved. LVN 4 stated there was only one shower schedule binder. LVN 4 stated the Director of Staff Development (DSD) kept the old Resident Skin & Body Check forms. During a concurrent interview and record review on 9/12/24 at 1:39 p.m. with the DSD in the DSD office, Resident Skin & Body Check form in a black Completed Shower Sheet Forms 2024 binder was reviewed, the binder indicated the months of June, July, August and September did not have any Resident Skin & Body Check forms. The DSD stated she had to check the completed forms in the DSD box located in the nursing station one. During a concurrent observation and interview on 9/12/24 at 1:46 p.m. with the DSD in the nursing station one, the DSD checked the completed Resident Skin & Body Check forms at the DSD box attached to the wall and inside the cabinet. The DSD stated the completed forms was not in the box nor the cabinet. During a concurrent interview and record review, on 9/12/24 at 1:50 p.m. with the DSD at the nursing station two, Resident 46's Resident Skin & Body Check form dated 8/13/24 in a black shower schedule binder was reviewed, the form indicated, Resident 46 had a bed bath and resident shaved was unmarked. The DSD stated no other documentation of Resident 30 and Resident 46 was in the shower schedule binder. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 1/1/2012, indicated, Each resident is allowed to choose activities, schedule, and health care that are consistent with his or her interests, assessments and plans of care, including: Personal care needs such as grooming styles. During a review of the facility's (P&P) titled, Grooming, dated 1/1/12, indicated, The facility will work with residents to improve their ability to groom him/herself to promote independence, hygiene, comfort, self-esteem and dignity. 2a. During a review of Resident 48's admission record dated, 9/12/24, indicated Resident 48 was admitted to the facility on [DATE] with multiple diagnoses that included, surgical after care (treatment and care to ensure healing and prevent infection) following surgery on the digestive system and muscle weakness. During a review of Resident 48's Minimum Data Set (MDS- an assessment tool used to guide care) dated, 8/30/24, indicated Resident 48 had a Brief Interview for Mental Status (BIMS -a tool used to assess mental function) Score of 15. Meaning, Resident 48 was cognitively intact. The MDS also indicated, Resident 48 required substantial / maximal assistance with personal hygiene. During a concurrent observation and interview on 9/10/24 at 1:05 p.m. with Resident 48, Resident 48's toenails were overgrown, thick, and dirty with black matter underneath. Resident 48's fingernails were also long and dirty with brown matter underneath. Resident 48 stated, her toenails hurt, heavy and very uncomfortable. Resident 48 also stated, staff did do anything to clean and/or trim her toenails and fingernails. During a concurrent interview and observation, on 9/10/24 at 1:10 p.m. with Certified Nursing Assistant (CNA) 7, in the presence of Resident 48, CNA 7 acknowledged Resident 48 had thick, long, dirty toenails and dirty fingernails. CNA 7 stated, she did not include toenails and fingernails when she provided Activities of Daily Living (ADL) to Resident 48 because no one asked her to. CNA 7 added, Resident 48 can get infection if dirt from nails got in Resident 48's wound. During a concurrent interview and observation, on 9/10/24 at 1:18 p.m. with Licensed Vocational Nurse (LVN) 1, in the presence of Resident 48, LVN 1 agreed Resident 48 had overgrown, thick, dirty toenails and long and dirty fingernails. LVN 1 stated, it was everyone's responsibility to make sure Resident 48's nails are clean to avoid infection. 2b. During a review of Resident 52's admission record dated, 9/12/24, indicated Resident 52 was admitted to the facility on [DATE] with multiple diagnoses that included muscle weakness, reduced mobility, aphasia (difficulty speaking) following Cerebral Infarction (stroke), and need for assistance with personal care. During a review of Resident 52's MDS, dated [DATE], indicated Resident 52 was unable to make self-understood/unable to express ideas and wants. The MDS also indicated, Resident 52 was dependent on helper with personal hygiene. During a concurrent observation and interview on 9/10/24 at 1:30 p.m., with Registered Nurse Regional Consultant (RNRC), Resident 52 had overgrown toenails and fingernails with black matter underneath. RNRC stated, direct care staff should have ensured Resident 52's nails are cleaned. During a concurrent interview and record review on 9/12/24 at 12:05 p.m., with the Director of Nursing (DON), DON confirmed Resident 48 did not have diagnosis of Diabetes Mellitus (DM). DON added, there was no documentation nail care was done for Resident 48. DON stated, the expectation was for staff to ensure Resident 48 and Resident 52 had clean and trimmed nails. DON added, there was no excuse for staff not to keep residents overgrown and dirty nails as there was risk for infection.

Based on interview and record review the facility failed to ensure 4 Certified Nursing Assistants (CNAs) and 1 Licensed Vocational Nurse (LVN) had the appropriate competencies to care for residents when the facility did not complete Orientation Evaluation Checklists for LVN 1 and CNA 3, and Annual Performance Evaluations for CNAs 1, 2 and 4. This failure had the potential for resident care to be provided in an unsafe and incompetent manner. Findings: During a concurrent interview and record review on 9/12/24, at 11:59 a.m., with Director of Staffing Development (DSD), CNAs 1, 2, and 3 and LVN 1's personnel folders were reviewed. DSD stated CNA 1's personnel folder indicated CNA 1 was hired on 8/17/23 and did not have an Annual Performance Evaluation. DSD stated CNA 2's personnel folder indicated CNA 2 was hired on 5/17/23 and did not have an Annual Performance Evaluation. DSD stated Annual Performance Evaluations had to be done annually and were important to evaluate CNA's competency. DSD stated CNA 3's personnel folder indicated CNA 3 was hired on 5/23/24 and did not have an Orientation Evaluation Checklist. DSD stated Orientation Evaluation Checklists had to be done when staff were hired and were important to evaluate their competency. During an interview on 9/12/24, at 2:20 p.m., with CNA 4, CNA 4 stated they had not done an Annual Performance Evaluation in over a year. During a concurrent interview and record review on 9/12/24, at 2:36 p.m., with DSD, CNA 4's personnel folder was reviewed. DSD stated CNA 4's personnel record indicated her last Annual Performance Evaluation was on 8/4/22. During a concurrent interview and record review on 9/12/24, at 2:51 p.m., with DSD, LVN 1's personnel folder was reviewed. DSD stated LVN 1's personnel folder indicated they were hired on 1/31/24 and did not have an Orientation Evaluation Checklist. During an interview on 9/12/24, at 3:05 p.m., with CNA 1, CNA 1 stated they had not done an Annual Performance Evaluation in over a year. During an interview on 9/12/24, at 3:18 p.m. with Director of Nursing (DON), DON stated DSD was supposed to complete CNA Annual Performance Evaluations for each CNA every year from the date of hire and more often if there were any resident concerns. DON stated during Annual Performance Evaluations DSD was supposed to watch CNAs perform their skills and verify their competency and was important to identify any areas where they needed training. DON stated CNA and LVN Orientation Evaluation Checklists were supposed to be done before they work on the floor. DON stated Orientation Evaluation Checklists were important so staff know their scope of practice, to assess how safe they are practicing and to find any areas where the needed training. During an interview on 9/13/24, at 11:43 a.m., DON stated they did not have a Policy and Procedure on Annual Performance Evaluations or Orientation Evaluation Checklists.

Based on observation, interview, and record review the facility failed to ensure proper storage and labeling of medication and biologicals (made from a variety of natural sources human, animal, or microorganisms and are used to treat, prevent, or diagnose diseases and medical conditions) for one of one sample medication room and two of two medication carts when: 1. Three opened vials of Tuberculin Purified Protein Derivative (PPD- indicated to aid diagnosis of tuberculosis infection (TB) in persons at increased risk of developing active disease) was unlabeled and undated with an open date. 2. Two activase (a clot-busting medication. It helps the body to produce a substance that dissolves unwanted blood clots.) vials for a discharged resident (Resident 222) were stored in the refrigerator. 3. Thirteen expired Influenza (common respiratory illness. Symptoms often include fever, head, and body aches, coughing and a stuffy or runny nose.) vaccine vials were stored in the refrigerator. 4. Expired medications for Resident 13, 14 and 52 was stored in the medication cart. 5. Two opened fluticasone furoate-vilanterol inhalation powder (medication used to control wheezing, shortness of breath, coughing, and chest tightness caused by asthma and chronic obstructive pulmonary (COPD- a group of diseases that affect the lungs and airways, that includes chronic bronchitis and emphysema)) inhaler for Resident 59's was unlabeled and undated with an open date. These failures had the potential to result in unsafe medication administration and storage practices. Findings: 1. During a concurrent observation and interview on 9/9/24 at 3:24 p.m. with the Director of Nursing (DON) in the medication room, three 1 milliliter (mL) multi-dose vial of PPD was in the refrigerator without a vial cap and a label of the open date. The DON stated the nurse who opened the vial should label it with the open date because it expires in 30 days. During a review of the facility's policy and procedure (P&P) titled Storage of Medication, dated 4/2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. During a review of the Tuberculin PPD product information from www.fda.gov/media/74862/download?attachment, dated 11/2013, indicated, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. 2. During a concurrent observation and interview, on 9/9/24 at 3:28 p.m. with the DON, Resident 222's two 2 mL activase vials with an expiration date of 12/2025 was inside the medication refrigerator. The DON stated Resident 222 had been discharge. The DON stated the vials doesn't need to be stored in the medication destruction container because it was not expired. During a review of Order Summary, dated 4/9/24, the Order Summary indicated, Resident 222 had an order for activase to declog the peripherally inserted central catheter (PICC- a long, thin tube that goes through a vein in the upper arm. The end of this catheter goes into a large vein near the heart to help carry nutrients and medicines into the body.) line. During a review of undated admission Record, printed on 9/11/24, the admission Record indicated Resident 222 was discharged on 5/14/24. During a review of the facility's (P&P) titled Medication Destruction, dated 12/2017, indicated Discontinued medication and medications left in the facility after a resident's discharge are destroyed . Medication is destroyed within 90 days from the date the medication was discontinued. 3. During a concurrent observation and interview on 9/9/24 at 3:35 p.m. with the DON in the medication room, thirteen unopened 5 mL multi-dose vials of Influenza vaccine with an expiration date of 6/30/24 was in the medication refrigerator. The DON stated the Influenza vaccines should have been stored in the medication destruction container and destructed. During a review of the facility's (P&P) titled Disposal of Medications and Medication-Related Supplies, dated 12/2018, indicated When medications are expired . the medications are stored in a separate location and later destroyed. 4. During a concurrent observation and interview on 9/10/24 at 10:47 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 13's 18 tablets of Sertraline (medication used to treat depression) 25 milligrams (mg) medication bubble pack with an expiration date of 7/1/24, Resident 14's 30 tablets of Metformin (medication that help lower blood sugar levels in people with type 2 diabetes.) 1,000 mg medication bubble pack with an expiration date of 9/8/24 and Resident 52's one uncapped 3 mL vial of Humulin R 100 unit insulin (an essential hormone. It helps the body turn food into energy and manages blood sugar levels.) with an open date of 8/7/24 was in the medication cart 2. LVN 2 stated Residents 13, 14 and 52 were active residents in the facility. LVN 2 stated medication cart was checked for expired medications once a month by the nurses, Assistant DON, and DON. During a review of Order Summary, dated 8/9/24, the Order Summary indicated, Resident 13 had an order for Sertraline 25mg one time a day. During a review of Order Summary, dated 7/24/24, the Order Summary indicated Resident 14 had an order for Metformin 1,000mg two times a day. During a review of Order Summary, dated 4/30/24, the Order Summary indicated Resident 52 had an order for Humulin R 100-unit insulin two times a day. During a review of the Humulin R product information from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/018780s180lbl.pdf, revised 6/2022, indicated, Throw away all opened vials after 31 days, even if there is still insulin left in the vial. During a review of the facility's policy and procedure (P&P) titled Storage of Medication, dated 4/2008, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. During a review of the facility's (P&P) titled Disposal of Medications and Medication-Related Supplies, dated 12/2018, indicated When medications are expired . the medications are stored in a separate location and later destroyed . Medications are removed from the medication cart or storage area prior to expiration. 5. During a concurrent observation and interview, on 9/10/24 at 11:56 p.m. with LVN 1, Resident 59 had two opened fluticasone furoate-vilanterol inhalation powder 200 mcg/25 mcg inhaler was undated and unlabeled with open date. LVN 1 stated the two inhalers did not have an open date. During a review of Order Summary, dated 7/24/24, the Order Summary indicated Resident 59 had an order for fluticasone furoate-vilanterol inhalation powder 200 mcg/25 mcg inhaler one puff orally one time a day. During a review of the facility's policy and procedure (P&P) titled Storage of Medication, dated 4/2008, indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. During a review of the fluticasone furoate-vilanterol inhalation powder inhaler product information from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/204275s012lbl.pdf, revised 5/2017, indicated, Safely throw away the inhaler in the trash 6 weeks after you open the foil tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain and observe infection control practices when: 1. Certified Nursing Assistant (CNA) 6 picked up a soiled linen on the floor of Resident 37 and Resident 58's room and disposed the soiled linen in the cart across Resident 37 and Resident 58's room. 2. Licensed Vocational Nurse (LVN) 3 did not perform hand hygiene and did not put on a new pair of gloves prior to administering eye drops to Resident 51. 3. LVN 3 did not remove gloves after applying topical medication (a medication that is applied to a particular place on or in the body.) to Resident 20. 4. Resident 17, 22 and 44's nasal cannula tubing was undated, unlabeled and was touching the floor. These failures had the potential for cross contamination and spread of infections among residents at the facility. Findings: 1. During an observation on 9/9/24 at 12:32 p.m. in Resident 37 and Resident 58's room, CNA 6 picked up a white linen on the floor with a gloved hand and proceeded to walk out of the room. During a concurrent observation and interview, on 9/9/24 at 12:33 p.m. with CNA 6, CNA 6 walked out of Resident 37 and Resident 58's room holding the white linen and threw the linen in the cart labeled soiled linen across Resident 37 and Resident 58's room. CNA 6 stated the linen was dirty. CNA 6 stated the dirty linen should be placed inside a plastic bag during transport or the soiled linen cart should be placed in front of the resident's room door to prevent the spread of infection. During a review of the facility's policy and procedure (P&P) titled Soiled Laundry & Bedding, dated 9/2016, indicated Facility staff handle soiled laundry and bedding in a manner that prevent gross microbial contamination of the air and those handling the linen . Contaminated laundry is placed in a bag or container at the location where it is used to prevent contamination during transport. 2. During medication administration observation on 9/10/24 at 8:19 a.m. with LVN 3 in Resident 51's room, LVN 3 moved Resident 51's bedside table away from Resident 51's bed and pulled the privacy curtain with her left gloved hand. LVN 3 informed Resident 51 that she would give the eye drops. LVN 3 proceeded to pull Resident 51's left lower eyelid with the same left gloved hand to administer the Dorzolamide HCl Solution (used to treat glaucoma, a condition in which increased pressure in the eye can lead to gradual loss of vision.) 2% eye drop. Resident 51 stated he did not want the eye drop. During an interview on 9/10/24 at 8:50 a.m. with LVN 3, LVN 3 stated a new pair of gloves should have been worn before giving the eye drops to prevent spread of infection. During an interview on 9/11/24 at 2:10 p.m. with the DON, the DON stated the staff should perform hand hygiene before wearing clean gloves and not touch resident's surroundings. The DON stated administering eye drops was a clean procedure and a clean glove should be used to prevent infection. During a review of facility's P&P titled Eye Drops, dated 1/1/12, indicated Gloves are worn when contact with body fluids or secretions are expected . Wash hands before and after administration of eye drops. During a review of facility's P&P titled Hand Hygiene, dated 9/1/20, indicated, The facility considers hand hygiene as the primary means to prevent the spread of infections . Wearing gloves does not replace the need for hand hygiene. 3. During medication administration observation on 9/10/24 at 8:42 a.m. with LVN 3 in Resident 20's room, LVN 3 used her gloved left hand to open Resident 20's right and left lower abdominal fold and shook the Nystatin (treats fungal or yeast infections of the skin) powder bottle with her right gloved hand to apply the powder. LVN 3 proceeded to move Resident 20's bedside table closer to the resident with the same gloved hands. During an interview on 9/10/24 at 8:50 a.m. with LVN 3, LVN 3 stated gloves should be removed after the Nystatin powder was applied. During an interview on 9/11/24 at 2:13 p.m. with the DON, the DON stated gloves should be removed after applying the powder, perform hand hygiene and not touch anything in between. During a review of facility's P&P titled Medication Administration-General Guidelines, dated 10/17, indicated Hands are washed before and after administration of topical medications. During a review of facility's P&P titled Personal Protective Equipment, dated 1/1/12, indicated Hands are washed before and after removing gloves. 4. During a review of Resident 22's admission record, dated 9/13/24, indicated Resident 22 was admitted to the facility on [DATE], with multiple diagnoses that included Chronic Respiratory Failure (a condition that occurs when the lungs are unable to get enough oxygen into the blood or remove enough carbon dioxide from the blood) with Hypoxia (a condition that occurs when the body's tissues, blood, or cells don't have enough oxygen to function normally) During a review of Resident 44's admission record, dated 9/10/24, indicated Resident 44 was admitted to the facility on [DATE], with multiple diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - ongoing lung condition caused by damage to lungs), Chronic Respiratory Failure with Hypoxia. During a review of Resident 17's admission record, dated 9/10/24, indicated Resident 17 was admitted to the facility on [DATE] with multiple diagnoses that included COPD, wheezing, dependence on supplemental oxygen. During a concurrent observation and interview on 9/10/24, at 12:46 p.m. with Licensed Vocational Nurse (LVN) 2, in Resident 22's room. Resident 22's oxygen tubing was on the floor, kinked and stuck under wheel of Resident 22's wheelchair. LVN 2 acknowledged the oxygen tubing was not labeled and removed the tubing from the floor. LVN 2 stated, it was infection control issue. During a concurrent observation and interview on 9/10/24, at 12:50 p.m. with LVN 2, in Resident 44's presence, LVN 2 picked up oxygen tubing from the floor and stated the tubing was too long that's why it was easy to fall on the floor. LVN 2 stated, Resident 44's oxygen tubing was not labeled. During a concurrent observation and interviews on 9/10/24, at 12:55 p.m. with LVN 2, in Resident 17's presence, Resident 17's oxygen was not labeled. LVN 2 stated, if oxygen tubing are not labeled it was unknown when the tubing was changed, and when it was due to be changed. LVN 2 further added, this was infection control issue. During an interview on 9/12/24 11:22 p.m. with the Director of Nursing (DON), DON stated oxygen tubing must be labeled with date when changed. DON also stated, if tubing was not dated, nursing staff will not know when it will be due to be changed. DON added, oxygen tubing should not be touching the floor, must be secured to head of bed. DON further added, it was both infection control issue when the oxygen tubing is touching the floor and/or if unlabeled. During a review of facility's policy and procedure (P&P), titled Oxygen Therapy, dated November 2017, indicated, Oxygen is administered under safe and sanitary conditions to meet resident needs. The P&P also indicated, under Procedure I.E. The humidifier and tubing should be changed no more than every 7 days and labeled with the date of change. II.C. Oxygen tubing, mask, and cannulas will be changed no more than every seven (7) days and as needed. The supplies will be dated each time they are changed.

Based on observation, interview and document review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. Cook failed to thaw fish safely in a sink. 2. Cook failed to report out of range temperatures on 9/9/24. 3. Dietary Manager was not able to state appropriate thawing procedures. 4. Dietary Manager was not able to state the importance of keeping freezer at proper temperature. These failures had the potential to result in food borne illness. Findings: During an interview on 9/9/24, at 10:26 a.m., with Dietary Manager (DM) and [NAME] (CK) 1, DM stated, the fish fillet inside 3-compartment dishwashing sink was going to be served for lunch. CK 1, then stated the fish fillet was taken out of the freezer at around 8:00 a.m. When asked which freezer did the fish fillet came from, CK 1 pointed to the freezer with temperature reading of 30 degrees F. During a concurrent observation and interview on 9/9/24 at 10:46 a.m. with DM, in the presence of Registered Dietician (RD) 1 and Senior [NAME] President of Operations (SVPO). DM stated, if corn on cob was covered in ice it meant freezer was working and everything inside was still good and safe to cook. RD 1 stated, freezer should be at zero degrees Fahrenheit (F) for safe storage of frozen food. RD 1 added, fish especially was a high risk for bacterial growth and could cause serious illness. RD 1 also added, fish prepared for today's lunch was not safe to be served to residents. RD 1 further added, produce that has been crystallized (with freezer burns) like corn on cob, meant it was thawed and re-frozen and should no longer be used for safety. During a concurrent observation and interview on 9/9/24, at 11:03 a.m., with CK 1, CK 1 pointed to freezer 2 and confirmed she retrieved the fish being prepared from this freezer. CK 1 further added, freezer 2's temperature was at 30 degrees F when she removed the fish at 8:00 a.m. CK 1 stated, she did not thaw fish under running water. CK 1 added, she washed and left the fish in colander then let it sit to drain. During a concurrent observation and interview, on 9/9/24 at 11:45 a.m., with CK 1 and RD 1, CK 1 was seen frying fish fillet. CK 1 stated, these were the fish that she prepared since 8:00 a.m., and will be served for lunch. RD 1 then stated, fish had to be continuously under running water before cooking. RD 1 further added, there was chance of bacterial growth and the fish may not be safe to serve to residents. During an interview on 9/10/24, at 12:35 p.m., with CK 1, CK 1 stated, she did not have competency evaluation with DM since he started employment. CK 1 further added, she has not been evaluated by a supervisor even prior to current DM. During an interview on 9/10/24, at 10:37 a.m., with the DM, DM stated, he was not evaluated by a Registered Dietician when he began his employment. DM also stated, he did not conduct nor completed competency skills check for the dietary staff. During an interview on 9/11/24, at 1:55 p.m., with Dietary Aide (DA) 1, DA 1 stated, she only had competency check done by previous supervisor three years go. DA 1 added, there was no ongoing or annual competency evaluation given by the DM. During an interview on 9/12/24, at 1:21 p.m., with the RD 1, stated she had never performed skills competency performance evaluation for the DM. RD 1, further stated, she has never been asked to do it. During an interview on 9/12/24, at 1:30 p.m., with CK 2, CK 2 stated she worked here for a long time and has not done any competency skills training for many years. During an interview on 9/13/24, at 12:42 p.m., with the Administrator (ADM), ADM stated, the DM was supposed monitor all kitchen staff performance to ensure competency. During a review of the facility's policy and procedure (P&P) titled, Meat Cookery and Storage, dated 7/1/14, indicated, under procedure I. Meat will be stored in a freezer of 0 degrees F or less until pulled for defrosting. II. Meat to be defrosted will be pulled three days prior to service and defrosted in a dry, cool area 41 degrees F or lower.B. If meat is frozen and needs a quick defrost, it may be defrosted in a pan or sink with constant running cold water until adequately defrosted for preparation. During a concurrent interview and record review on 9/11/24 at 10:37 a.m., with the DM, DM stated he did not complete staff competency for kitchen staff since he started employment in March 2024. DM also stated, he was unaware of the policy dietary staff competency. During a review of the facility's job description: Titled, Dietary Services Supervisor/Certified Dietary Manager, (undated) indicated under Administrative: Maintains all records and documentation according to Federal, State and Company requirements. Under Supervisory: .Monitors staff performance and addresses any needs. Evaluates quality of service accomplished by staff. During a review of the facility's P&P titled, Staff Competency Assessment, dated 3/17/22, indicated, Competency assessments will be performed upon hire during the employee's 90-day employment period, annually, or anytime new equipment or a procedure is introduced and as needed.II. All staff are required to have competency assessments by the Director of Staff Development or department manager based on their job description or assigned duties within the first 90 days of employment. III. The competency evaluations or sills checks will be done by an individual who has the licensure education and experience qualifying them to perform the competency assessment. IV. The annual evaluation of an employee will include review of completed competency assessments which may have been done throughout the year. During a review of facility's document titled, Dietary Quality Control Review, dated, 9/4/24, indicated under Clinical/Staffing J. Are all staff and Dietary Manager competencies in place at orientation and reevaluated at least annually - NOT MET. Under Observation indicated, Need competencies on new employees to be completed by the CDM (Certified Dietary Manager).

Based on observation, interview, and record review, the facility failed to ensure one of two sampled Residents (Resident 1) had staff identify themselves with name badges while they received care. This failure had the potential to cause Resident 1 emotional distress and anxiety. Findings: During a review of Resident 1's face sheet, dated 4/12/24, face sheet revealed Resident 1 was admitted to the facility in 1/2024. During a review of Resident 1's Minimum Data Set (MDS- an assessment tool used to guide care) dated 2/1/24, the MDS indicated Resident 1 had multiple diagnoses that included arthritis (swelling and tenderness of one or more joints) and anxiety disorder. The MDS also revealed Resident 1 had a Brief Interview for Mental Status (BIMS -a screening tool used to assess cognition) score of 15/15. Meaning, Resident 15 was able to understand and understood others. During a telephone interview on 4/12/24, at 8:26 a.m. with the Responsible Party (RP), RP stated there were multiple issues with staff members that included leaving Resident 1 in bloody bed sheets. RP further stated, she did not know name of staff assigned because they do not wear name badges. RP also stated, staff members did not identify themselves when asked. During an interview on 4/12/24 at 10:47 a.m. in Resident 1's room, Resident 1 stated, there were several issues with staff member that included neglecting his request to shower. When asked which staff in particular, Resident 1 stated, it was hard to remember staff members assigned to him because they do not wear identification (ID) badges. During a concurrent observation and interview on 4/12/24 at 11:07 a.m., CNA 1 entered Resident 1's room, and was observed without a name badge. CNA 1 stated, he was a registry staff assigned to Resident 1. CNA 1 further added, the facility did not provide registry staff ID badge. CNA 1 also stated, Resident 1 had the right to know who was taking care of him. During a concurrent observation and interview on 4/12/24 at 11:58 a.m., CNA 2 was seen in the hallway entering communal dining room. CNA 2 did not have ID name badge. CNA 2 stated, she was registry assigned to help residents in the dining room. CNA 2 also stated, the facility did not supply ID name badge. CNA 2 further added, it was important to wear name badge, so residents know who they are working with. Residents have the right to know who's caring for them. During an interview on 4/12/24 at 12:00 p.m. with Facility Staff (FS), FS 1 stated, he was responsible for scheduling staff including registry. FS 1 also stated, it was important for residents to be able to identify staff taking care of them. FS 1 further added, registry staff were not required to wear ID name badge. During an interview on 4/12/24 at 12:27 p.m. with the facility Administrator (ADM), ADM stated, the facility received deficiency in the past related to staff not wearing ID name badges. ADM also stated, all facility staff, regular and registry are supposed to wear name badge at all times. ADM further added, name badges are to be worn for residents to be able to identify employee and their designated role. During a review of facility schedule dated 4/12/24, revealed CNA 1 was employed as Registry (R) and was assigned to Resident 1. The facility schedule also showed, CNA 2 (R) was assigned to social dining.

Based on observation, interview, and record review, the facility failed to implement their Policy and Procedure (P&P) for one of four sampled residents when Resident 1's social security card, a watch, and other personal items reported missing were not investigated thoroughly and documented. This failure placed resident 1 at risk for emotional distress, potential financial hardship and affected Resident 1's sense of security and well-being. Findings: During a review of Resident 1's admission Record , printed on 9/29/23, the admission Record indicated Resident 1 was originally admitted to the facility on admitted to the facility in December 2019. The admission records also indicated that Resident 1 had a medical diagnosis including unspecified dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior). During a record review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 7/10/23, the MDS assessment section C indicated Resident 1's Brief Interview of Mental Status (BIMS- an assessment for cognition status) score was 11 out of 15 which indicates moderately impaired mental status. During a review of Resident 1's Discharge Evaluation 1.0 – V 2 , printed on 9/29/23, the Discharge Evaluation indicated Resident 1 was discharged on 9/8/23 from the facility. During an interview on 9/29/23 at 12:43 p.m., with the administrator, the administrator stated when a resident reports any missing items in the facility, they would initiate a search and start a theft and loss form and do an investigation for 3 days. The administrator also stated, if the item was in the inventory, they would replace it or estimate the value and re-imburse them. During a concurrent interview and record review on 9/29/23 at 1:55 p.m., with the administrator, Resident 1's Inventory of personal effects dated 12/18/2020 were reviewed. The inventory of personal effects indicated Resident 1 owned a Gold colored Timex watch with Matching Gold Band . The administrator stated few days prior to discharge (9/8/23), Resident Representative (RR) for Resident 1 reported to him that Resident 1 s watch, his original social security card and few other documents were missing. The administrator also stated, the RR reported that the social security card and other documents were given to the Social Worker (SW) in January 2023 and the social worker reported she cannot produce them when the RR requested them back prior to discharge. The administrator stated when he inquired about the documents to SW, she told him she looked everywhere, and she cannot find them. During a concurrent interview and record review on 9/29/23 at 2:00 p.m., with the administrator, the facility's loss and theft binder was reviewed. The administrator stated he had asked the social worker to initiate a theft and loss form for Resident 1 but cannot find a loss and theft form for Resident 1's reported missing items in the binder. The administrator stated he did not report the loss of social security card to police yet as he was hoping the social worker would be able to locate them. During an interview and record review on 9/29/23 at 2:08 pm., with the administrator, the administrator stated Resident 1 is a Canadian Citizen and it's going to be a while to replace these crucial documents and it is going to be a hardship and would need assistance to get them replaced. The administrator also stated Resident 1 is in a new environment and must be feeling frustrated and upset. During a concurrent interview and record review on 10/2/23 at 10:40 p.m., with the administrator, the administrator stated he reported the missing social security card for Resident 1 to Oakland police department on 9/28/23 at 4 pm and the incident number was 2309001038. During a concurrent interview on 10/2/23 at 11:21 a.m. with SW and the administrator, SW stated she has not completed a loss and theft form for the reported missing items for Resident 1. SW also stated she did not document about the missing items reported to her in any of Residents or facility records. SW was unable to provide any documentation of an investigation done to locate the missing items reported on or before 9/8/23. During a review of the facility's P&P titled, Theft and Loss , revised 07/11/2017, the P&P indicated, Policy- The Facility is committed to preventing the misappropriation of resident property. The facility investigates all reports of stolen items, reports to authorities as required by law, and maintains documentation of all reports of lost or stolen property .Procedure. IV. Social service staff documents reports of lost and stolen resident property on AP-11-Form C-Theft and Loss Log .B. The document includes, but is not limited to, the following: i. A description of the article; ii. Its estimated value; iii. The date and time the theft or loss was discovered; iv. If determinable, the date and time of loss or theft; and V. the action taken.

Based on observation, interview, record review, the facility failed to ensure one of 3 sampled residents (Resident 1) had staff identify themselves with name badges while they received care. This failure had the potential to cause Resident 1 confusion and emotional distress. Findings: During a concurrent observation and interview on 7/11/23, at 1:16 p.m., Resident 1 stated he could not identify most of the staff that were assigned to him. Resident 1 stated staff didn't wear name badges and didn't say their name when they provided care. Resident 1 stated it made him upset and confused. During a concurrent observation and interview on 7/11/23, at 2:00 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 was observed without a name badge. CNA 1 stated they were assigned to resident 1 and gave Resident 1 a bed bath, back rub and applied A&D ointment (Vitamins A & D - a skin protectant) to Resident 1's lower legs and feet earlier that morning. CNA 1 stated they should have worn a name badge with their name and title, and they did not have one. CNA 1 stated they never got one and it was their first day working on the floor. CNA 1 stated it was a risk to the resident because they wouldn't be able to identify staff. During an observation on 7/11/23, at 2:15 p.m., CNA 2 talked to Resident 1 in the front lobby. During a concurrent observation and interview on 7/11/23, at 2:21 p.m., with CNA 2, CNA 2 was observed without a name badge. CNA 2 stated they should have worn a name badge with their name and title, and they did not have one. CNA 2 stated they never got one and it was their first day working on the floor. CNA 2 stated it was a risk to the residents because they would not know who they were. During a concurrent observation and interview on 7/11/23, at 2:55 p.m., with Director of Nursing (DON), DON was observed without a name badge. DON stated it was the facility's policy that all staff always wore name badges with their name and title while in they were in the facility. DON stated that included new staff. DON stated it was a risk to the resident because residents should know who was caring for them. During a review of Resident 1's Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition), dated 3/16/23, the BIMS indicated, Resident 1 had intact cognition. During a review of the facility's policy and procedure (P&P) titled, Identification of a Resident & Staff, revised January 1, 2012, the P&P indicated, The Facility provides each Facility Staff member with a name badge upon hire, which must be worn at all times while in the Facility or on the grounds. The P&P indicated The approved name badge will consist of the employee's name and job title legibly printed. The P&P indicated Each Facility Staff member must wear the approved name badge above the waist in an area readily visible to residents, family, surrogates and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide a comfortable, home-like environment for two (Resident's 1 and 2) of three sampled residents when staff were yelling at each other during the night. This deficient practice resulted in Resident 1 feeling angry and Resident 2 feeling upset. Findings: A review of Resident 1's admission Record dated 12/13/22, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of atherosclerosis of aorta (gradual buildup of plaque in your aorta- main artery that carries blood away from your heart to the rest of your body). A review of Resident 1's Minimum Data Set (MDS- a resident assessment and care screening tool) dated 10/5/22, indicated Resident 1 was cognitively intact. During an interview on 12/13/22 at 9:43 a.m. with Resident 1, Resident 1 stated it is loud at the facility at times. Resident 1 stated there was a time when staff were yelling at each other at night and it made him feel angry because he was trying to sleep. A review of Resident 2's admission Record dated 12/13/22, indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of Arnold Chiari Syndrome (a condition in which brain tissue extends into the spinal canal). A review of Resident 2's MDS dated [DATE] indicated Resident 2 is cognitively intact. During an interview on 12/13/22 at 9:50 a.m. with Resident 2, Resident 2 stated there was a time when two female staff were yelling at each other during the night and kept her awake. Resident 2 stated it upset her because she wanted to rest. Resident 2 further stated when staff were yelling at each other, it did not feel home-like. During an interview on 12/9/22 at 9:25 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she witnessed staff yelling at each other at the facility during the evening shift. CNA 1 stated Resident 1 complained to her about the yelling of the staff because he could not sleep. A review of the facility document titled, Resident Rooms and Environment , revised January 2012, indicated, Procedure 1. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: G. Comfortable noise levels.

Based on observation, interview, and record review, the facility failed to provide personal care and grooming for four of 24 residents (Residents 165, 265, 6, and 12) who were unable to perform activities of daily living when: 1. Resident 165's fingernails and toenails were long, jagged, with brown substances underneath them; 2. Resident 265's fingernails were long with dark brown substances underneath them, and Resident 265 had dried food crumbs around his mouth and clothes; 3. Resident 6's fingernails were very long, with dark brown substance underneath his nails; and 4. Resident 12's fingernails were long with thick black matter underneath and Resident 12's legs were dry, cracked, and scaly. These deficient practices had the potential for unmet personal care needs for Residents 165, 265, 6, and 12. Findings: 1. A review of Resident 165's admission Record indicated Resident 165's diagnoses included need for assistance with personal care. During a concurrent interview and observation on 7/25/22, at 10:15 a.m., at Resident 165's bedside, Resident 165's fingernails were long, jagged with dark brown substances underneath them. Resident 165's toenails were also long, jagged and with brown substances underneath them. Resident 165 removed his socks to reveal both his feet were covered with thick, dark, dry scales shedding off his feet. Resident 165 stated he has not had a shower for almost two months. 2. A review of Resident 265's admission Record indicated resident 265's diagnoses included need for assistance with personal care. During an observation on 7/25/22, at 10:50 a.m., Resident 265 was observed lying down in bed with his hands over his linens. Resident 265's fingernails were long with dark brown substance underneath his nails. Resident 265's clothes was observed covered with food crumbs. Resident 265's had dried crusts of food around his mouth. 3. Review of Resident 6's medical record indicated Resident 6's diagnoses included hemiplegia and hemiparesis (weakness or loss of strength on one side of the body). Resident 6's Minimum Data Set (an assessment tool to guide care) indicated Resident 6 was totally dependent on staff for personal hygiene. During an observation on 7/25/22, at 11:00 a.m., at Resident 6's bedside, Resident 6's fingernails were observed being very long, with dark brown substance underneath his nails. During an interview on 7/25/22, at 12:40 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Residents 165, 265 and 6 had very long nails and need their fingernails to be trimmed and cleaned. During an interview on 7/26/22, at 8:45 a.m., with Acting Director of Nursing (ADON), ADON stated the CNAs were supposed to trim non-diabetic residents' fingernails and toenails during their shower days and report their skin condition to the charge nurse. During a concurrent interview and record review on 7/26/22, at 11:00 a.m., with Case Manager (CM), CM was unable to provide the shower records for Residents 165, 265 and 6. 4. A review of Resident 12's medical record indicated Resident 12's diagnoses included paralysis to the right side of his body and needed assistance with personal care. Resident 12's Brief Interview for Mental Status (BIMS, an assessment tool to measure mental status) score of 4, indicated severe mental impairment. Resident 12's Minimum Data Set (MDS- an assessment tool to guide care) for activities of daily living (ADL) indicated Resident 12 was dependent on staff to perform his personal hygiene. A review of Resident 12's care plan titled, Potential for Impaired Skin Integrity, dated 4/25/22, indicated staff education on the importance of keeping Resident 12's skin clean and moisturized. During an observation on 7/26/22, at 10:13 a.m., at Resident 12's bedside with CNA 4, Resident 12's fingernails were long with thick black matter underneath. Resident 12's lower extremities were inspected. Above the ankles, Resident 12's skin was dry, cracked, and scaly. When CNA 4 removed resident's socks, flakes of skin scattered into the air and onto Resident 12's bed. Resident 12's heels were covered in a thick layer of dry and cracked skin. During an interview on 7/26/22, at 10:15 a.m., with CNA 4, CNA 4 stated she did not clean Resident 12's fingernails. CNA 4 further stated it was best to clean Resident 12's skin during a shower. CNA 4 stated she had not given Resident 12 a shower or a bed bath. CNA 4 stated did not know when Resident 12's shower days were scheduled. A review of the Resident Daily Shower Schedule indicated Resident 12's shower days were Monday mornings. During an interview on 7/28/22, at 10:48 a.m., with Director of Staff Development (DSD), DSD stated inspection of the skin was completed on shower days and documented by the CNAs and licensed nurses. DSD stated she would review the skin assessments for accuracy. The DSD stated she was unable to locate Resident 12's shower sheet form. DSD stated if it was not documented, it was not done. A review of the facility's policy and procedure on Grooming, dated 1/1/12, outlined the process of performing Nail Care and indicated a nail brush can be used to gently remove any particles under the nails.

Based on interview and record review, the facility failed to conduct a timely performance review and in-service training program for two of three sampled Certified Nursing Assistants (CNA 1 and 4) when CNA 1 and 4 did not complete their CNA skills observation checklist and 12-hour mandatory in-services within the past 12 months. This failure had the potential for residents to receive incompetent care from CNA 1 and 4. Findings: During a record review of CNA 1's employee file, CNA 1 did not have a completed CNA skills observation checklist and the 12-hour mandatory in-services within the past 12 months. CNA 1's file indicated CNA 1 was hired on 12/2/05. During a review of CNA 4's employee file, CNA 4 did not have a completed CNA skills observation checklist and the 12-hour mandatory in-services within the past 12 months. CNA 4's file indicated CNA 4 was hired 4/21/20. During an interview on 7/27/22, at 1:05 p.m., with Quality Regional Management Consultant (QRMC) 2, QRMC 2 confirmed there were no CNA skills observation checklists completed within the past 12 months for CNA 1 and CNA 4. During a review of the facility's policy and procedure (P&P) titled, In-Service and Record Keeping, dated 2/20/20, indicated I. An in-service training program shall be developed, implemented, and maintained by the facility to ensure the continuing competency of all CNAs. The P&P further indicated a. Training program shall address specific needs of the facility's resident population, address areas for improvement determined through annual nurse performance reviews, facility deficiencies and annual facility assessment.

Based on interview and record review, the facility failed to provide dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes and impaired reasoning) training to three of three sampled certified nursing assistants (CNA 1, 4 and 5) when mandatory dementia training was not completed by CNA 1, 4, and 5 in the last 12 months. This failure had the potential for unmet care needs of residents with dementia by CNA 1, 4 and 5. Findings: During a record review of the employee files CNA 1, 4, and 5, on 7/27/22, at 9:05 a.m., all three employee files did not have in-service records of the mandatory dementia training completed in the last 12 months. During an interview with the Director of Staff Development (DSD) on 7/27/22, at 10:30 a.m., DSD stated she was new and did not know where the training records were in the facility. The facility's policy and procedure titled, In-Service Training and Record Keeping, dated 2/20/20, indicated, The purpose of the policy and procedure was to establish guidelines for the facility staff to complete required in-service education in accordance with Federal and State regulations .Five (5) hours of instruction on dementia-specific in-service training is required every year per California Health and Safety Code 1263.

Based on observation, interview, and record review the facility failed to store refrigerated medications, in accordance to facility policy which requires storage of medications between 36-46 degrees Fahrenheit (F). The medications were stored at temperatures that were too cold. This failure exposed patients to compromised medications. Findings: A review on 07/26/22 of the facility policy titled, STORAGE OF MEDICATIONS, dated April 2008, indicated, Medications requiring refrigeration or temperatures between 2 C (36F) and 8 C(46 F) are kept in a refrigerator. During an observation on 07/26/22 at 1:15 PM in the nursing station, two-medication room refrigerator was 30 F. There were multiple medication storage within the refrigerator. The manufacturer required all these medications (Tuberculin test, Humalog, Flu vaccine, etc.) were to be stored between 36-46 F. A review on 7/26/22 of the Medication Refrigerator Log, a log that had documented daily refrigerator temperatures, indicated for 7/26/22 that the refrigerator was at 30 F. During an interview on 7/26/22 at 2:15 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she did not know the refrigerator was too cold. LVN 2 stated she was not aware of anyone working on the refrigerator to raise the temperature of the refrigerator. LVN 2 acknowledged the importance of maintaining appropriate temperatures to prevent reducing the potency of drugs due to excess cold.

During a review of Resident 37's admission Record, dated 7/29/22, the admission Record indicated, Resident 37 had a diagnosis of Benign Prostatic Hyperplasia (prostate gland enlargement) without Lower Urinary Tract Symptoms During a review of the facility's MRR binder, MRR was done for Resident 37 on 3/25/22 with the recommendation: Resident take [tamsulosin] (drug used to treat symptoms of an enlarged prostate) 0.4 mg BID (twice a day) which is more frequent than recommended by the manufacturer. Please give consider administering total dose of 0.8 mg daily 30 minutes after same meal every day or at bedtime. The same recommendation was given during the MRR on 4/12/22. During a review of Resident 37's Order Summary Report, for July 2022, the Order Summary Report indicated, the order for tamsulosin 0.4 mg cap give 1 capsule orally two times a day related to Benign Prostatic Hyperplasia (enlarged prostate) Without Lower Urinary Tract Symptoms was still active. During an interview on 7/28/22, at 1:45 p.m., with Case Manager (CM), CM stated MRR recommendations are given to the doctor for them to sign if they agree or disagree with the recommendation given. CM stated a copy of the signed recommendation should be placed in a binder and the original goes to the chart to be carried out. During an interview on 7/29/22, at 8:03 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, MRR recommendations are reviewed with the Director of Nursing before communicated to the doctors and once the doctors have reviewed the recommendations, orders are carried out in the chart or documented. During a review of the facility's policy and procedure (P&P) titled, Pharmacy Services Committee-Composition and Duties, dated January 01, 2012, the P&P indicated, Duties and Responsibilities may consist of, but are not limited to the following: Monthly review of each resident's drug regimen, including irregularities, and update previously noted irregularities. Based on interview and record review, the facility failed to ensure the Pharmacy Consultant (PC)'s monthly recommendations were acted upon for five of 24 sampled residents (Resident 12, 13, 19, 22 and 37) when the PC's recommendations were not reviewed for Resident 12, 13, 19, 22 and 37 who were prescribed psychotropic drugs (medications used to stabilize or improve mood, mental status or behavior) for five consecutive months, from March through July 2022. This failure had the potential for unnecessary medications to be given to Resident 12, 13, 19, 22, and 37. Findings: During a review of the Consultant Pharmacist's Medication Regimen Review, dated 6/14/22, for Resident 12, it indicated, to monitor appropriate behavior and side effects of the medication sertraline (medication for depression) for depression on the Medication Administration Record (MAR). Resident 12's MAR indicated the monitoring of Resident 12's behaviors and medication side effects started 42 days later, on July 26, 2022. During a review of the Consultant Pharmacist's Medication Regimen Review, dated 6/14/22, For Resident 13, it indicated to monitor for a behavior and side effect of the medication mirtazapine (medication for depression) for depression and trazadone (medication for depression or aids in sleep) for sleep. Review of the MAR did not indicate to observe behavior(s)for the use of the antidepressant (medication to help depression). Also, no side effects were monitored for the use of sleep aid. Review of the Note to Attending Physician/Prescriber, dated 6/14/22, indicated Resident 19 had a medication order for metformin (medication to help control blood sugar) to treat elevated blood sugar levels. The use of metformin cautions against its use for impaired kidneys (defined as serum creatinine [SCr] >/or =1.5 in males, >/or = 1.4 in females, or creatinine clearance less than 60 ml/min.). The pharmacist noted Resident 19's most recent SCr level was high at 1.7 mg/dL and the estimated creatinine clearance was 17 ml/min. The pharmacist's recommendation indicated to re-evaluate continuous use of metformin, discontinue and initiate [linagliptin, medication to help control blood sugar] 5 mg everyday if appropriate for resident. A section of the form for Physician/Prescriber Response was not completed to agree, disagree, or other comments and did not include a signature or a date that it was reviewed by the physician. Review of the Note to Attending Physician/Prescriber dated 5/10 22, indicated Resident 22 was prescribed quetiapine (antipsychotic medication) and there were no recent laboratory results (there is an association of increase of clogged arteries with the use of quetiapine). The pharmacist recommended to monitor Resident 22's lipids (fat levels) and glucose (sugar level) the next lab day. A section of the form for Physician/Prescriber Response was not completed to agree, disagree, or other comments and did not include a signature date it was reviewed by the physician. During an interview on 7/29/22 at 9:50 a.m., with the Assistant Director of Nursing (ADON), the ADON stated when the pharmacist completes the medication regimen review (MRR, a review of all medications the resident was currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy), it is reviewed by the physician. The ADON stated the physician did not verify the pharmacist's recommendations for Resident's 12, 13, and 19 because there were no signatures and dates.

Based on observations, interviews, and document reviews the facility failed to be free of medication error rates of five percent or greater when two medication errors were observed out of 32 opportunities. The medication error rate was calculated as followed: two divided by 32 then multiplied by 100, which was equal to 6.2 percent. This failure resulted in multiple medication errors. Findings: 1. A review on 07/26/22 of the facility policy dated October 2017 entitled Medication Administration-General Guidelines indicated Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicated a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. During an observation on 07/26/22 at 9:20 AM LVN 1 was preparing Resident 43's Metoprolol for oral administration. LVN 1 did not compare the MAR with the medication label. LVN 1 did not check the physician's orders for a correct dosage. LVN 1 prepared three 75 mg tablets for administration. During an interview on 07/26/22 at 9:24 AM LVN 1 was asked why she had prepared three 75 mg tablets for administration. LVN 1 said my bad, after reviewing the MAR, LVN 1 was supposed to prepare three 25 mg tablets for 75 mg instead of three 75 mg tablets which would be three times the prescribed dose. She stated the physician orders were for Metoprolol 75 mg twice daily. If she had not be questioned, she would have given 225mg. During an interview on 7/26/22 at 11:05 AM LVN 1 stated that she primarily looked at the MAR when preparing the Metoprolol. The MAR showed that three tablets needed to be prepared so she prepared three 75 mg tablets because she did not look at the medication label which indicated 75 mg tablets instead of 25 mg tablets. She said she would be more careful in the future. 2. A review on 07/26/22 of the Fluticasone Propionate Nasal Spray manufacturers insert dated indicated USING FLUTICASONE PROPIONATE NASAL SPRAY Step 1. Blow your nose to clear your nostrils Step 2 Close one nostril. Tilt your head forward slightly and, keeping the bottle upright, carefully insert the nasal applicator .Step 3 Start to breath in through your nose and WHILE BREATHING IN press firmly and quickly down on the applicator Step 4 Breath out through your mouth .Step 7 Wipe the nasal applicator with a clean tissue . During an observation on 07/26/22 at 9:20 AM LVN 1 administered Fluticasone Propionate Nasal to Resident 43. LVN 1 inserted the medication and did not follow any of the steps listed above. LVN X sprayed in each nostril and did not instruct Resident 43 to follow only of the directions listed above. During an interview on 7/26/22 at 11:05 AM LVN 1 stated she did not follow the manufacturers insert guidelines when administering the Fluticasone Propionate Nasal. She said she was not aware of the appropriate technique required by manufacturer. She stated in the future she would follow the manufacturers steps to appropriately administer the Fluticasone Propionate Nasal.

Based on interview and medical record review, the facility failed to ensure 37 of 74 sampled residents received or were offered the pneumococcal vaccine when 37 of 74 residents did not have a record of the pneumococcal vaccine in their records. This failure had the potential risks of spreading bacterial infection and causing respiratory complications to residents. Findings: During a review of the facility's undated pneumonia vaccination log, the log indicated 37 of 74 residents did not have a record of pneumonia vaccine administration. During an interview on 7/28/22, at 9:25 a.m., with Infection Preventionist (IP), IP stated he has been the IP for a month. IP stated he picked up where the previous IP last recorded pneumonia vaccines. IP state he was still reviewing patient charts to verify if residents had their pneumonia vaccine and was working to update the incomplete pneumonia vaccine list. Review of the facility's policy and procedure (P&P), titled, Policy for Pneumonia Vaccine (New), dated 10/2014, indicated, on admission, all residents will be evaluated for pneumococcal vaccination needs. The pneumonia vaccination status of the resident will be determined and vaccines will be offered based on a criteria established by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

Based of observation, interview, and facility document review, the facility failed to ensure: 1. There was adequate supervisory oversight for the Food and Nutrition Department; 2. Food was ordered in the right quantity for the planned menu; and 3. The RD inspected the resident food refrigerator located in the nursing station. These failures had the potential to result in unsafe and unsanitary practices in regard to food storage, food preparation, and food service, as well as result in an inadequate supply of food for the planned menu to meet the nutritional needs of the residents all of which could in turn affect the safety and wellbeing of 52 residents who ate food by mouth out of a facility census of 54. Findings: Review of the undated job description titled Director of Nutrition Services (DNS), indicated this position was responsible overseeing the day-to-day operation of the Food and Nutrition Services department. An example of areas the DNS was responsible for according to the job description included ensuring nutritious meals to all residents, maintaining a safe and sanitary working environment, maintaining inventory of food and supplies to meet resident needs and according to the planned menus, monitoring staff performance through coaching and takes direct corrective action after coaching if needed, evaluating quality and quantity of services accomplished by staff. Review of the job description titled Registered Dietitian dated 11/27/17, indicated the Registered Dietitian (RD) was to work with the DNS to ensure that quality food, service and nutritional care was provided to residents. 1. During the recertification survey from 7/25/22 - 7/29/22 it was noted there was no full-time supervisory guidance by either a Registered Dietitian or a Director of Nutrition Services resulting in identification of issues related to: food safety and sanitation in the kitchen (Cross-reference F812), lack of ingredient availability for the approved menu, ensuring the dish machine was in safe operating condition (Cross-reference F908), and staff competency regarding their job functions (Cross-reference F802). On 7/25/22 at 10:12 a.m., during the initial tour of the kitchen the Assistant Dietary Manager (Asst DM) introduced herself and stated she was new to this facility, started just over a week ago, and functioned as both the Assistant Dietary Manager and a daily cook. She confirmed there was currently no Dietary Manager at the facility. In an interview with the Regional Dietary Manager (RDM) and a concurrent observation on 7/26/22 at 8:50 a.m., RDM stated there was no Supervisor at the facility yet today and did not know who was in charge. In an interview with Director of Nutrition Services 1 (DNS 1) on 7/26/22 at 1 p.m., DNS 1 stated he came into the facility 4-5 times a week when he could, but he was also going to school. DNS 1 stated he came into the facility yesterday evening. DNS 1 stated he would try to come into the facility the next day for an interview. DNS 1 was not on site when the surveyors were present for the remainder of the survey. In an interview with the RD and a concurrent observation on 7/27/22 at 9:30 a.m., RD stated she started working for the facility in June and she came into the facility once a week. It was identified that ceiling fans and the floor around the stove were not clean (Cross-reference F812). RD stated the DNS was supposed to report or request help for cleaning from maintenance when there were things that could not be cleaned by kitchen staff. She confirmed she reported the dirty fans and the floor on her monthly inspection report. She said her reports were available to the DNS and the Administrator. In an interview with the Administrator (ADM) on 7/27/22 at 10:30 a.m., ADM stated DNS 1 was still in charge of the department and he came in almost every day. She stated he was usually at the facility in the morning and sometimes in the afternoon if he was able to make it. She said he put in his resignation a month ago and she put out a general add for the DNS position. She said the Asst DM was not a kitchen manager and she just started working for this facility On 7/28/22 at 11:39 a.m., review of staff time records showed the DNS 1 was at the facility from 7/3/22 - 7/10/22 for a total of 10.25 hours, from 7/11/22 - 7/17/22 for a total of 6 hours, from 7/18/22 - 7/24/22 a total of 5 hours. Centers for Medicare/Medicaid Services, State Operations Manual, Guidance to Surveyors, Section 483.60(a)(1)-(2) defines full time as 35 or more hours per week. In an interview with [NAME] 2 on 7/28/22 at 9:16 a.m., she stated her job was frustrating and hard right now. She said with no supervisor she felt like she was in charge, but she did not want to be in charge because she did not want to tell people what to do. She said it was hard to get everything done and it was a big help when there was a supervisor around to help if needed. She said right now it was complicated because food deliveries came in on Tuesdays and Thursdays and she did not know who was in charge to help. She stated DNS 1 left as a manager the first week of June and now he came in twice a week just to do the food ordering, but he did not do anything else in the kitchen. In an interview with Dietary Aide 1 (DA 1) on 7/28/22 at 10:13 a.m., she stated she had to stay extra hours to clean every shift and that sometimes she did not have time to take a break. She said there was no supervisor. In an interview with [NAME] 1 on 7/28/22 at 10:25 a.m., she stated there was not enough food to be able to follow recipes for the menu all the time. She stated when DNS 1 was supervising, she told him she did not have the right ingredients to follow recipes, and he told her to just cook something anyway. She said often times food was either not available because it was not ordered, or it was expired. She said she did not have the all the bananas to make the dessert tonight. She stated DNS 1 still ordered the food. She confirmed there was no supervisor for about a month. In an interview with the Asst DM on 7/28/22 at 11:55 a.m., she stated she did not have a regular schedule at the facility yet. She said she felt like staffing was extremely short. She stated that food was not always available to follow recipes. She said in the last 48 hours she had to go to the store to buy ingredients. She said she did not have all the ingredients for dinner last night, for dessert for lunch today, and for the dessert tomorrow. She stated DNS 1 ordered the food and either missed ordering some food or ordered too much of some food. She stated there was too much work and it would be a lot easier if there was a supervisor. She said there had to be a supervisor because when she cooked, she could not focus on cooking if she also had to do supervisor work. She said there are some tasks she did that she thought was the supervisor's job, such as printing the tray tickets and was also responsible for the diet changes. She said she had to contact DNS 1 for his password to make diet changes or they would not be made until he came in. She stated she did not know about therapeutic diets and needed more training. In an interview with the RD on 7/28/22 at 12:35 p.m., she stated she put her monthly inspection reports into the computer system and the DNS and the Administrator had access to them. She stated she still delegated tasks to the DNS position on her reports even though there was not anyone in that position. For instance, she stated she delegated in-services for kitchen staff to the DNS position when she identified training was needed. The RD stated she did not think the cleaning schedule was being followed in the kitchen because there was no supervisor. In an interview with the RDM on 7/28/22 at 2:40 p.m., she stated she was not aware the facility did not have a full-time DNS before arriving to the facility to help support staff during the survey. She stated she was not asked by the Administrator to help with ideas for recruiting a full-time DNS. She stated she would have helped if she was asked. 2. During a concurrent observation and interview on 7/26/22 at 9 :30 a.m., with RDM, a hotel pan of apricot dessert was in freezer for cool down. RDM stated the apricot dessert was for lunch that day. Review of facilities cook spreadsheet, titled, SUMMER MENUS, for week 4, Tuesday 7/26/22 indicated glazed Apple square on the lunch menu. During an observation on 7/26/22 at 12:17 p.m., [NAME] 2 served mixed vegetables during the lunch trayline. Review of the cook spreadsheet, titled, SUMMER MENUS, for week 4, Tuesday 7/26/22 indicated Broccoli with Garlic was on the menu for lunch. During an interview on 7/27/22 at 2:55 p.m., RDM the said the DNS was responsible for ordering the food for the menu including the vegetables. She also said stated there were no canned apples available to prepare the glazed apple squares on 7/26/22, so she used apricots to prepare the dessert. During an interview on 7/28/22 at 9:16 a.m., [NAME] 2 stated on 7/26/22, she did not have enough Broccoli for lunch, so she substituted Broccoli with Garlic indicated on the menu with mixed vegetables. During an interview on 7/28/22 at 10:25 a.m., [NAME] 1 stated she did not follow the recipe /menu sometimes because the ingredients were not available or were expired. During an interview on 7/28/22 at 11:55 a.m., Assistant. Dietary Manager/Lead cook (Asst. DM) stated she did not have ingredients for dinner on 7/27/22, dessert for lunch for 7/28/22, dessert for dinner on 7/28/22 and dessert for 7/29/22. Some of the ingredients she did not have included egg noodles, tomato sauce, whipping topping, cottage cheese, and watermelon. She stated the DNS missed ingredients for the planned menu when he ordered food. 3. During a concurrent observation and interview on 7/25/22 at 1:10 p.m., it was found that staff were not following the facility policy and procedure for safely storing food in the resident refrigerator brought into the facility by visitors and/or family when food was not labeled with resident names, food was not dated when it came into the facility or opened, and items were not discarded when expired or in the refrigerator longer than what the policy and procedure stated. There was a total of 2 resident refrigerators designated for resident food. One in nursing station 1 and one in nursing station 2. Only the refrigerator in nursing station 1 contained food. (Cross-reference F813), Review of 2 of the RD's monthly inspection reports titled Dietary Quality Control Review dated 6/27/2022 and 7/25/2022 indicated under section Resident Living G. Nursing Station and Staff Room Refrigerators are clean, with logs in place and up to date Any Patient food is dated and labeled. None is open and more than 72 hours, her note under observation on the 6/27/22 report read No refrigerators in nursing stations Staff room refrigerator is strictly for employee food - NO patient food. In this section on the 7/25/22 report, the RD's note read NA [not applicable] - no refrigerators in nursing stations. Staff room refrigerator is strictly for employees only - NO patient food storage. In an interview on 7/27/22 at 9:40 a.m., with RD, RD stated she worked at the facility 1 day a week and started in June. In an interview on 7/28/22 at 12:35 p.m., with RD, RD stated she just found out today there was a resident refrigerator located in the nursing station. She said she did not know who monitored it and guessed it was nursing. RD stated the Food and Nutrition services department would be responsible for training nursing regarding safe food storage for the residents and she did not know if nursing was trained.

Based on observation, interview, and facility record, the facility failed to ensure kitchen staff were competent for job duties performed when Certified Nursing Assistant/Diet Aide 1 (CNA 1) washed dishes in the kitchen and did not know the appropriate sanitizer strength and did not ensure appropriate wash water temperature for the dish machine (Cross-reference F812). This failure had the potential to result in contamination of dishware, utensils, and food leading to illness for 52 residents who received food from the kitchen out of a facility census of 54. Findings: Review of the job description titled, Dietary Aide, published March 2012, indicated the Dietary Aide position was responsible for maintaining daily care of the dishwasher and washing dishes. In an interview with CNA 1 and a concurrent observation of the dish machine on 7/26/22 at 9:10 a.m., indicated CNA 1 washed dishes using the dish machine. CNA 1 stated she was usually a CNA but washed dishes today because the diet aide went home, so she helped out. CNA 1 stated she was responsible for testing the sanitizer of the dish machine before washing dishes. CNA 1 demonstrated how she tested the sanitizer. CNA 1 removed a chlorine sanitizer test strip from the container and placed it on a dish that just went through a wash/rinse cycle in the dish machine. The test strip turned dark purple. She compared the test strip to the color chart inside the test strip container and said it was 200 parts per million (ppm). She stated the sanitizer had to be at least 200 ppm and 100 ppm would not be okay. Then she stated she also looked at the water temperature dial of the dish machine to make sure the wash and rinse cycle temperature was appropriate when washing dishes. She stated the temperature for both rinse and wash had to be 120 degrees Fahrenheit (F). CNA 1 ran the dish machine to show how she checked the dish machine water temperature. The dial showed the was cycle was 100 degrees F and the rinse cycle was 110 degrees F. CNA 1 ran the dish machine again because she said the water temperature was too low. The second time the dial showed the wash cycle water was 110 degrees F and the rinse water cycle was 120 degrees F. CNA 1 stated the water temperatures were okay. The information plate attached to the front of the dish machine showed the wash temperature was to be a minimum of 120 degrees F, the rinse temperature was to be a minimum of 120 degrees F, and the chlorine sanitizer was to be at least 50 ppm. Review of the facility's policy and procedure (P&P) titled, Dish Machine Operation and Cleaning, dated October 1, 2014, indicated the dish machine when operating the equipment the water temperature gauge needed to be checked and proper temperatures had to be reached upon startup. The wash water temperature had to be between 120 degrees and 160 degrees F. The P&P also indicated if the temperature of the machine failed to reach these temperatures, the machine was to be turned off and reported to the supervisor. Review of the P&P titled, Dish Machine Temperature Recording, dated October 1, 2014, indicated the dish machine would be routinely monitored during use to ensure appropriate temperatures. The wash temperature was to be from 120 degrees F to 150 degrees F and the rinse temperature was to be between 120 degrees F and 150 degrees F. In addition, the concentration of the chlorine sanitizer solution during the rinse cycle had to be 50 ppm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1. The dish washing machine not reaching the required minimum temperature for the wash cycle and leaking. (Cross reference F908) 2. Hand Hygiene protocol was not followed. 3. Expired food items were found in the dry storage room. 4. Multiple dry food items did not have a use by date or open date on them. 5. Sanitizer strength for food contact surface using red bucket was not an appropriate strength. 6. There was no air gap (a gap of air between the floor and a drainpipe to prevent backflow of sewage into the equipment) for food preparation sink. 7. Toaster was not cleaned regularly and had buildup of black and brown residue. 8. Microwave was not cleaned and had food residue on the top inside surface. 9. Industrial Can opener was not clean with sticky yellow and black residue build up and the blade coating was peeled off. 10. Kitchen vents and surrounding ceiling were dirty with black residue. 11. Kitchen ceilings were not cleaned. 12. Kitchen floor surrounding stove was not cleaned and had black/white/brown debris and residue buildup. 13. Kitchen wall near back door had crumbling dry wall. 14. Grease trap (a plumbing fixture that contains decomposing food waste, bettering the sewer system) under 3-compartment sink had thick yellow/brown greasy residue build up on top and around edges. 15. Three frying pans used for cooking food were not in good condition. 16. One Cutting board was scratched with black residue on surface. 17. A reach-in freezer door handle was broken, covered with tape, and not a smooth surface. These failures had the potential to cause food borne illnesses for 52 residents who received food from the kitchen for a facility census of 54. Findings: 1. During a concurrent observation and interview on 7/26/22 at 9 :18 a.m., Certified Nursing Assistant/Dietary Aide 1 (CNA 1) washed dishes using the dish machine. CNA 1 demonstrated the dishwashing procedures and explained the operation of the machine. During the dishwashing process, water was pouring from dish machine catch tray onto the Kitchen floor. CNA 1 also stated that it was a low temperature machine and has specific temperature ranges for the operation of the machines. Concurrent review of the manufacturer's guidelines, printed on a sticker affixed to the front of the machine noted the minimum manufacturer recommended wash and rinse temperature was minimum 120 degrees Fahrenheit (*F). Additionally review of 2 wash and rinse cycles, revealed that during the observation the machine did not reach manufacturer's recommendations, rather the maximum temperature for wash was only 110*F. CNA 1 confirmed the wash temperature reached a maximum of 110* F and stated the temperature was okay (Cross-reference F802). During a concurrent observation and interview on 7/26/22 at 9:49 a.m., Regional Dietary Manager (RDM), RDM confirmed the dish machine wash cycle was not reaching 120-degree Fahrenheit. During a review of the facility's Policy and Procedure (P&P) titled, Dish machine Operation and Cleaning, revised on 10/1/2014, the P&P indicated, Policy- The dietary staff will use the dish machine according to the manufacturer's guidelines .II. Operation of equipment. A Check water temperature gauges. (Wash must be between 120 * and 160* F.) to reach proper temperatures upon startup, several empty racks should be sent through the machine. If the machine fails to reach the proper temperature, turn off the machine and report the incident to the supervisor. Review of the P&P titled, Dish Machine Temperature Recording, dated October 1, 2014, indicated the dish machine would be routinely monitored during use to ensure appropriate temperatures. The wash temperature was to be from 120 degrees F to 150 degrees F and the rinse temperature was to be between 120 degrees F and 150 degrees F. In addition, the concentration of the chlorine sanitizer solution during the rinse cycle had to be 50 ppm. 2. During an observation on 7/25/22, at 10:13 a.m., [NAME] 2 entered kitchen and did not perform hand hygiene. [NAME] 2 put on gloves and checked on potatoes that were defrosting. Then [NAME] 2 took off her gloves and put on new gloves without performing hand hygiene. Next cook 2 took out turkey from the freezer and placed it in a sink to defrost it. Then [NAME] 2 took off her gloves and put on new gloves without performing hand hygiene. Next cook 2 peeled onions. During an interview on 7/25/22, at 12:24 p.m., with Regional Dietary Manager (RDM), RDM stated staff should have performed hand hygiene when they entered the kitchen and when they changed gloves, to prevent cross contamination. During a review of the facility's P&P titled, Hand Hygiene, revised September 1, 2020, the P&P indicated, Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, Residents, volunteers and visitors. The following situations require appropriate hand hygiene . Before and after food preparation. According to the 2017 Federal Food Code food employees are to wash hands immediately before engaging in food preparation including exposed food and clean equipment and utensils, before donning gloves to initiate a task that involves working with food, and after engaging in other activities that contaminate hands. 3. During a concurrent observation and interview on 7/25/22 at 11:21 a.m., with RDM, the dry storage room had 7 X 16-ounce bags of tortilla chips with use by date 1/25/22. RDM stated the tortilla chips were expired and should be removed. During a concurrent observation and interview on 7/25/22 at 10:35 am, with Assistant Dietary manager/lead [NAME] (Asst. DM), the preparation table storage had 16 oz- chocolate sauce - 16 oz with use by date of April 2022. Asst. DM stated it is expired and she is not sure if it is still ok to use. A review of facility's document titled, Dry goods storage guidelines, indicated, chips, potato, tortilla unopened on shelf should be stored for one month. The document indicated, Do check expiration dates on boxes of foods to be sure the length of time is correct. 4. During a concurrent observation and interview on 7/25/22 at 10:35 a.m., with Asst. DM, a bag of opened crouton and 16 oz beef broth were noted to have no use by date. Asst. DM stated they should have an open date and use by date/expiration date on them. During a concurrent observation and interview on 7/25/22 at 11:21 a.m., with RDM, the dry storage room had six bags of croutons removed from original boxes with [NAME] codes (These codes are used to indicate the date when a food item was packaged. The code represents the year and what day of the year out of 365 days. For example, 22-165 represents the year 2022 and the165th day of the year) and no expiration/use by dates. RDM stated she does not know what the [NAME] codes mean and will contact the vendor to find out the expiration dates. During a concurrent observation and interview on 7/26/22 at 8:45 a.m., with RDM, blue plastic bag with pasta with no dates or labels. RDM stated she has never seen them before and removed them. During a concurrent observation and interview on 7/26/22 at 9:00 a.m., with RDM, two unopened and one opened all Bran cereal with no manufacturer expiration date was found. RDM stated the supervisor was supposed to check daily and discard any expired items. During a concurrent observation and interview on 7/29/22 at 10:31 a.m., with [NAME] 2, [NAME] 2 was not able to find use by dates on bag of cereals, croutons, and a bag of sugar substitute. [NAME] 2 stated the dates on the crouton bags were received dates and it did not show the expiration dates. [NAME] 2 stated the expiration dates are on the boxes and when things are taken out of the boxes, she does not know the expiration dates. [NAME] 2 stated she has no idea what the codes [[NAME] codes] on the crouton bags mean. During a concurrent observation and interview on 7/29/22 at 10:35 a.m., with Registered Dietician (RD,) the RD stated the bag of cereals and crouton only had received dates and [NAME] codes. RD stated the expiration dates might be on the boxes that the food bags/boxes are removed from. RD stated they should go by expiration date of manufacturer and the information should be transferred when food item is taken out of original boxes. During a review of the facility's P&P titled, Food Storage, revised on 11/1/2014, the P&P indicated, Policy- Food and supply items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated . Procedure- XII. Dry Storage Guidelines . H. Label and date all storage products. 5. During a concurrent observation and interview on 7/27/22 at 9:32 a.m., with [NAME] 2, [NAME] 2 stated she refills the red buckets every four hours with sanitizer solution used to clean food contact surfaces such as preparation tables. [NAME] 2 stated she changed the sanitizer solution at 9 a.m. and used the sanitizer to sanitize the food preparation area. [NAME] 2 demonstrated how to test the sanitizer strength with a test strip. The test strip indicated 100 PPM and turned yellow in color. [NAME] 2 stated the strength was too low. [NAME] 2 repeated the testing process by refilling the red bucket with fresh sanitizer and the strength test strip turned dark green and indicated a reading of 300 and the strength was appropriate. [NAME] 2 stated she did not test the strength of the solution of the sanitizer at 9 a.m. During a concurrent interview and record review of facilities document titled, Red bucket sanitizer log, with RD and RDM, the log indicated they test and log the strength of sanitizer for breakfast, lunch, and dinner and not every time they change the sanitizer solution. RDM stated she tested and logged the strength at 7/27/22 at 6 am and the strength was 300 ppm. During a follow up interview on 7/28/22 at 9:16 a.m., cook 2 stated she did not know that she was supposed to test the red bucket sanitizer strength every time she changed the solution. [NAME] 2 stated she was using the sanitizer that was 100 ppm in strength on 7/27/22 at 9 a.m. During a review of the facility's undated P&P titled. Quaternary ammonium log policy, the P&P indicated, Procedure; The dietary worker will record the ammonium level on the log prior to sanitizing the counters or washing pots and pans daily to assure the level is at least 200 ppm 6. During a concurrent observation and interview on 7/25/22 at 12:35 p.m., with Maintenance Director/Housekeeping (MD/HSK), the drainpipe from the sink connected directly into the wall so there was no air gap (a gap of air between the floor and a drainpipe) for food preparation sink. MD/HSK confirmed that it is pumped directly into wastewater system/sewer. During an interview on 07/28/22 at 12:29 p.m., with RD, RD stated she did not see a proper air gap under the food preparation sink in kitchen. 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. 7. During a concurrent observation and interview on 7/25/22 at 10:31 a.m., with [NAME] 2, the toaster was observed to have significant amount of black and brown residue resembling crumbs on tray that pulls out and are under the rolling compartment. [NAME] 3 stated it was not clean and was not cleaned today. [NAME] 3 stated they are supposed to clean it after every use. During an interview with on 7/25/22 at 10:35 a.m., the Asst. DM stated toaster oven was not clean and was supposed to be cleaned after every use. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .9. All utensils, counters, shelves, and equipment shall be kept clean. 8. During a concurrent observation and interview on 7/25/22 at 10:50 a.m., with Asst. DM, the microwave was noted to have spots of orange residue on the inside top and inside side surface. There was build up of black and brown residue resembling crumbs on the hinge of microwave door. Asst. DM stated the microwave was not clean and is not aware of the cleaning schedule. During an interview on 7/28/22 at 12:29 p.m., with RD, RD stated the microwave should be cleaned after each use. RD stated cleaning schedule was not being followed as there was no supervisor to oversee it. During a review of the facility's P&P titled, Microwave oven- Operation and Cleaning, revised on 10/1/2014, the P&P indicated, Policy- The microwave oven will be cleaned after each use . Sanitation of equipment .A. The microwave will be cleaned after each use. 9. During a concurrent observation and interview on 7/25/22 at 10:34 a.m., with Asst DM, the blade of industrial can opener was observed to have orange/red and yellow residue. The coating of the blade was peeling off and thick black residue in space between cog wheel and base, sticky yellow residue on slide-insert on can opener holder attached to counter. The surveyor easily wiped off residue on the white tissue paper towel. Asst.DM stated the blade and base were not clean and she did not know how often they needed to be cleaned. During an interview on 7/28/22 at 12:29 p.m., with RD, RD stated opener can be cleaned after each use. RD stated cleaning schedule is not being followed as there is no supervisor to oversee. During a review of the facility's P&P titled, Can Opener Use and Cleaning, revised on 10/1/2014, the P&P indicated, Policy- The dietary staff will use the can opener according to the manufacturer's guidelines. The can opener will be sanitized between uses 10. During a concurrent observation and interview on 7/26/22 at 10:11 a.m., with MD/HSK, the ceiling vents /fans were noted with black residue on surface and surrounding ceiling surfaces in proximity. MD/HSK stated the vents were dirty and needed to be cleaned. MD/HSK stated he was not responsible for cleaning areas in kitchen unless kitchen staff requested it. MD/HSK stated there is no schedule to clean anything in kitchen. During a review of facility's document titled, Dietary Quality Control review, dated 6/27/22, by RD, the dietary quality control review indicated the standard I. Ceiling vents in good repair, clean and with adequate paint was Not met. During an interview with RD on 7/27/22 at 9:40 a.m., RD stated cleaning were done by kitchen staff but if cleaning involved difficult to reach areas, then dietary manager should contact maintenance to help with cleaning. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .4. The maintenance department will assist dietary as necessary in maintaining equipment and in doing janitorial duties which the dietary employees cannot do .14. The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stove, which will be cleaned by the maintenance staff. According to the 2017 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. 11. During an observation and interview on 7/26/22 at 10 a.m., with [NAME] 2, [NAME] 2 confirmed there were spots of orange residue splattered on the ceiling above the microwave. [NAME] 2 stated she did not know what the residue was. During an observation and interview on 7/26/22 at 10:11 a.m., with MD/HSK, ceiling above the microwave was noted with orange residue. MD/HSK stated he was not responsible for cleaning areas in kitchen unless he was asked by kitchen staff either verbally or through maintenance log. During a concurrent observation and interview on 07/27/22 at 9:40 a.m., with RD, RD stated cleaning was done by kitchen staff but if cleaning involved difficult to reach areas, then dietary manager should contact maintenance to help with cleaning. During an interview on 7/28/22 at 12:35 p.m., RD stated any maintenance requests should be put in maintenance logbook and there is no entry in logbook since February 2022. During a review of the facility's P&P titled, Cleaning schedule, revised on 10/1/2014, the P&P indicated, Policy- The dietary staff will maintain a sanitary environment in the dietary department by complying with the routine cleaning schedule developed by the dietary manager. Review of the Daily Quality Control Review dated 6/27/22 provided as the monthly tool the RD used to ensure the kitchen was safe and sanitary showed the standard was for kitchen ceilings to be clean. According to the 2017 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. 12. During an observation on 07/25/22 at 10:39 a.m., floor surrounding stove was observed with black/white/brown debris resembling pieces of food and crumbs and had dark black residue build up. During a concurrent observation and interview on 7/27/22 at 9:35 a.m., with RD, RD stated the floor around the stove is not clean and looks like food crumbs from food preparation. RD stated she reported floor needed general cleaning in her inspection report. RD stated Kitchen staff were responsible for cleaning except for hard-to-reach areas, then Kitchen manager would contact maintenance Dept for help with cleaning. During a review of facility's undated P&P titled, General appearance of dietary department, the P&P indicated, Floors and walls must be scheduled for routine cleaning and maintained in good condition .8. Mop under and around equipment, along the walls and in corners. Wipe all splash and soil marks from baseboards and walls. According to the 2017 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. 13. During a concurrent observation and interview on 7/25/22 at 12:25 p.m., with MD/HSK, wall on the lower side near back door had missing and crumbling drywall-1.5 feet by 3 inches. MD/HSK stated he was not aware of the crumbling drywall by back door. MD/HSK stated Kitchen staff notified maintenance department if there were things needed to be fixed in kitchen either verbally or writing in the maintenance log. During a review of facility's document, Dietary Quality Control review, dated 6/27/22, by RD, the dietary quality control review indicated, the standard B. Kitchen walls, floors, baseboards and ceilings in good repair and clean was Not met and the observation indicated, wall has damage next to door outside back area. During a concurrent interview on 7/28/22 at 12:35 p.m., with RD, RD stated any maintenance requests should be put in maintenance logbook and there were no entry in logbook since February 2022. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .4. The maintenance department will assist dietary as necessary in maintaining equipment and in doing janitorial duties which the dietary employees cannot do. During a review of the facility's P&P titled, Maintenance service, revised on 10/1/2014, the P&P indicated, Policy-The maintenance Department maintains all areas of the building, grounds, and equipment. According to the 2017 Federal Food Code, walls shall be constructed so they are smooth and easily cleanable. 14. During a concurrent observation and interview on 7/25/22 at 12;25 p.m., with MD/HSK and Asst. DM, the grease trap under the sink was noted with thick yellow/brown greasy residue build up. Asst.DM stated grease trap was not clean. MD/HSK stated it was grease on top and was probably full and overflowing and kitchen staff should have notified him, so he could call the vendor company to empty the grease trap. MD/HSK stated grease trap was cleaned every two weeks and the last cleaning was done on 7/18/22 by the vendor. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .4. The maintenance department will assist dietary as necessary in maintaining equipment and in doing janitorial duties which the dietary employees cannot do. According to the 2017 Federal Food Code, physical facilities are to be cleaned as often as necessary to keep them clean. 15. During a concurrent observation and interview on 07/26/22 at 9:41 a.m., with [NAME] 2, two non-stick pans were noted to have coating of the entire cooking surface, scratched and coming off. In addition, one stainless steel pan had black residue build-up along inside surface and the cooking surface was significantly scratched with brown residue on scratched surface. [NAME] 2 stated the non-stick pans were scratched and not okay to be used and should be replaced. [NAME] 2 stated the stainless-steel pan had black residue and needed more thorough cleaning. During an interview on 7/28/22 at 12:35 p.m., with RD, RD stated surface of pans should be smooth and coated pans should not be peeling. RD stated condition of pans was not on her inspection but RD should still look at and notify Dietary manager to replace it. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .9. All utensils ., and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. According to the federal food code, food-contact surfaces are to be smooth and clean to sight and touch. In addition, food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulations. 16. During a concurrent observation and interview on 7/26/22 at 9: 45 a.m., with RDM, one cutting board in color green had black residue on surface. RDM confirmed that there is residue on cutting board and it was scratched. During an interview on 7/28/22 at 12:35 p.m., RD stated condition of cutting board should not be worn and should not be stained. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, Procedure .9. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .17. Separate chopping boards are to be used for preparing means and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. According to the federal food code, food-contact surfaces are to be smooth and clean to sight and touch. 17. During an observation on 07/26/22 at 8:45 a.m., the door handle on a reach-in freezer had plastic broken off/missing part over three inches with clear tape over the area broken off. The tape surface had crevices and creases and was not smooth. During a concurrent observation and interview on 07/27/22 9:40 a.m., with RD, RD stated the handle was a concern, but she did not report it yet. During an interview on 07/27/22 12:10 p.m., with MD/HSK, MD/HSK stated he called the vendor to fix the freezer two months ago but did not have any documentation about it. MD/HSK stated he put the tape on it, so staff did not cut themselves on the broken handle. MD/HSK stated the door handle was not sharp. During a review of the facility's undated P&P titled, Sanitation, the P&P indicated, 9. all . equipment shall be . maintained in good repair and shall be free from breaks, corrosions, open seem, cracks and chipped areas. According to the 2017 Federal Food Code, Nonfood-contact surfaces are to be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure to ensure safe and sanitary storage and consumption of food brought in for residents from outside the facility when outside food belonging to 52 residents were not labeled upon storage or discarded after two days. This failed practice had the potential for consumption of unsafe food and cause foodborne illness to 52 residents who ate food by mouth out of a census of 54 residents. Findings: During an interview on 7/25/22 at 12:45 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the resident refrigerator in the facility was used for storing resident food only and expired food was cleaned out every week by the Housekeeping Department. During a review of facilities document titled, Attention all Staff:, affixed to the resident refrigerator, the document indicated, All perishable food placed in this refrigerator MUST have a room number and date marked on it and can ONLY be held for TWO days (48 hrs.). Any expired Dates will be thrown out. During a concurrent observation and interview on 7/25/22 at 1:10 p.m., with Assistant maintenance supervisor (Asst.MS), the resident refrigerator at Nursing Station 1 was observed to have multiple food items without room number, resident name, or room number on it. Items with no resident name, room number, or date, included: an open can of whipped cream, an open container of almond milk, two hard boiled eggs in brown bag, a container of left-over veggies, meat and fried rice in a disintegrating cardboard container, container of blueberries, container from restaurant with chicken wings, and cooked pasta The following items had a date but no resident name: a can of Oat milk with a best by date of 6/11/22, and a bag of rotisserie chicken with a sell be date of 6/29/22 but no date for when it arrived in the facility. There was also a bag with rice meat/veggies in container and chocolate cake in container from restaurant with resident name but no date on it, and a ceramic bowl with room number and resident name, dated 6/16/22 had bad odor when lid was removed and white fuzz resembling mold on surface of food noted. Asst. MS stated the food was moldy. Asst. MS also stated the rotisserie chicken should be discarded. During a concurrent observation, interview with Asst. MS on 7/25/22 at 1:15 p.m., and record review of the facility's health record, the health record indicated the resident whose name was on the moldy food was discharged from the facility on 7/14/22. As the observation of the resident food refrigerator continued, a container with macaroni and cheese with a name but no date. Asst. MS stated he had no idea who it belonged to in the facility. Asst.MS stated he goes through the refrigerator every Friday and cleaned it out. Asst. MS stated food can be held in the refrigerator for two days only or until it's manufacturer expiration date. Asst. MS stated certified nursing assistants and nurses are supposed to label and date food items when they place it in refrigerator. Asst. MS confirmed the items in the refrigerator were not labeled and dated. During an interview on 7/28/22 at 1:57 p.m., with Case Manager, CM confirmed the name on the macaroni and cheese was from their previous interim Director of Nursing, who left the faciity on 6/6/2022. During an interview on 7/28/22 at 2:20 p.m., with Director of Staff Development (DSD), DSD stated nurses needed to label resident food with a room number, name, and date when they put it in the refrigerator. DSD stated all expired resident food should be tossed after 72 hours and inform the resident. DSD stated she did not provide any in-services on resident refrigerator food storage and handling and did not have documentation indicating nurses were trained prior to her being the DSD at the facility. During a review of facilities Policy and Procedure (P&P) titled, Food brought in by Visitors, revised on 6/2018, the P&P indicated, Procedure .II. Perishable food requiring refrigeration will be discarded after two (2) hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours.

Based on interview and document review, the facility failed to ensure registry staff were vaccinated for COVID-19 (a serious respiratory disease) when 8 of 23 registry staff did not receive the COVID-19 booster immunization and one vaccine exempt registry staff did not meet the religious exemption criteria. This failure had the potential for unvaccinated staff to increase the spread of COVID-19 and its complications of severe illness, hospitalization and/or death to residents they cared for and other staff that worked in the facility. Findings: During an interview and concurrent document review on 7/28/22 at 9:25 a.m., the logs for staff vaccination logs were examined. The Registry staff log indicated, 8 of 23 did not have COVID-19 booster vaccinations. One of two exempt registry staff identified on the log did not meet the religious justification criteria. The IP stated registry staff were from out-of-state where they were not required to have COVID boosters. During an interview on 7/29/22 at 10:30 a.m., the [NAME] President of Operations (VPO) stated all staff, including registry staff, needed to be vaccinated of COVID-19 unless they were exempt, meaning to have a medical or religious justifications. Review of the facility's undated COVID-19 Vaccination History, log indicated 23 staff members. The log indicated six registry staff did not receive the COVID-19 booster vaccine and two staff had vaccine exemptions. Review of Registry Staff (RS) 1's vaccine exemption documents indicated RS 1 was not authorized by a a clergy to validate the religious exemption. Review of facility's COVID-19 Mitigation Plan, revised 6/22/22, indicated, Exemption to Vaccination . For a religious exemption, the worker must provide the employer with a written request for exemption and a qualified-religious belief exemption. Review of the facility's policy on COVID-19 Staff Vaccination Program, dated 09/02/21, indicated, All personnel providing services or performing work at the facility, including but not limited to paid and unpaid employees, physicians, contracted personnel/vendors, students and volunteers, regardless of work location (Personnel), are required to be vaccinated against COVID-19. Only those who have a medical or religious reason will be granted an exemption.

Based on observation, interview and record review, the facility failed to maintain essential equipment when there were issues with dish washing machine not reaching the required minimum temperature for the wash cycle and leaking. (Cross reference 812) This failure had the potential for equipment not functioning as per manufacturers guidance resulting in ineffective ware washing processes and in turn could cause contamination of food, leading to foodborne illness for 52 residents who received food from the kitchen and negatively affect residents ' well-being out of a census of 54 Findings: An observation during the initial tour of the kitchen on 07/25/22 at 10:12 a.m., showed the dish machine was dripping water from the catch tray onto to floor. During a concurrent observation and interview on 7/26/22 at 9 :18 a.m., the dishwashing procedure were reviewed with Certified nursing Assistant/ Dietary aide (CNA 1). CNA 1 explained the operation of the machine. The dishwashing process, water was pouring from dish machine catch tray onto the Kitchen floor. CNA 1 also stated that it was a low temp machine and has specific temperature ranges for the operation of the machines. Concurrent review of the manufacturer's guidelines, printed on a sticker affixed to the front of the machine noted the minimum manufacturer recommended wash and rinse temperature was minimum 120 degrees Fahrenheit (*F). Additionally review of two loads revealed that during the observation the machine did not reach manufacturer's recommendations, rather the maximum temperature for wash was only 110*F. During a concurrent observation and interview on 7/26/22 at 9:49 a.m., Regional Dietary Manager (RDM) confirmed the dish machine wash cycle was not reaching 120-degree Fahrenheit. During a concurrent observation and interview on7/26/22 at 10:11 a.m., with Maintenance Director/ Housekeeping (MD/HSK), MD/HSK stated he was aware the dishwashing machine was leaking for past two days but did not call the dishwashing machine company for repair yet. During an interview on 7/29/22 at 9:15 a.m., CNA 1 stated the dish machine was overflowing since it was installed about a month ago. Stated MD/HSK was on vacation so reported to the administrator multiple times as they did not have a Dietary manager. Stated she also reported to MD/HSK about three times after he returned from vacation. During a review of the facility's undated Policy and Procedure (P&P) titled. Sanitation, the P&P indicated, 4.6. The maintenance department will assist dietary as necessary in maintaining equipment and in doing janitorial duties which the dietary employees cannot do . During a review of the facility's Policy and Procedure (P&P) titled. Maintenance service, revised on 1/1/2012, the P&P indicated, Policy- The maintenance Department maintains all areas of the building, grounds, and equipment in a safe and operable manner at all times . According to the 2017 Federal Food Code, equipment, including warewashing machines (dish machine), is to be maintained in a state of repair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interview and record review, the facility failed to provide grooming assistance for one (Resident 229) of twelve sampled residents. For Resident 229, the failure to provide grooming assistance resulted in presence of brown substances under her fingernails, and facial hair. Findings: A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/4/19 indicated Resident 229 had severe impairments to thinking and remembering skills. The MDS dated [DATE], indicated Resident 229 required total assistance for all personal hygiene activities including cleaning of face and hands. During an observation on 6/10/19 at 9:05 a.m., the fingernails on Resident 229's left hand extended beyond the end of the finger tips, with brown substances visible underneath the fingernails. Resident 229 also had one-quarter inch long, white facial hair along her jaw line from the left side to the right side. During an interview with Family Member 1 (FM 1) on 6/10/19 at 12:40 p.m., FM1 stated she had asked the staff to trim Resident 229's nails, and shave off her facial hair, but no one had done so. During an interview with Certified Nursing Assistant 2 (CNA 2) on 6/11/19 at 12:45 p.m., CNA 2 stated personal grooming, such as trimming fingernails and removing female resident facial hair were part of CNA duties. CNA 2 stated she had not had the time to perform these tasks for Resident 229. A review of the facility policy and procedure titled, Resident Rights, Quality of Life, undated, indicated, Each resident shall be cared for in a manner that promotes and enhance the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being. Residents are groomed as they wish, including bathing, dressing, and oral care. A review of the facility policy and procedure titled, Shaving, indicated, The facility provides for the removal of facial hair as a component of the resident's hygienic program. Male residents may be shaved daily and female residents may be shaved as needed.

Based on observation, interview, and record review, the facility failed to follow physician orders to flush the feeding tube (a tube inserted through the nose or mouth into the stomach to deliver food, fluid, and/or medications) between administration of different medications for one of 16 sampled residents (Resident 7). This failure resulted in Resident 7 not receiving flush solution according to physician instructions. Findings: Review of Resident 7's Face sheet dated 3/19/19 showed Resident 7 was admitted to the facility in 2018 with a condition of altered mental state. Review of Resident 7's Physician orders dated 8/29/18 showed Resident 7 was to receive medications through a feeding tube, and the medication administration instructions included, To flush the feeding tube with 30 milliliters (ml) of water in between medications. During medication administration observation on 6/10/19 at 9:12 a.m., Licensed Vocational Nurse (LVN 1) administered six different kinds of tablets and capsules via feeding tube. LVN 1 administered 30 ml of water before the first medication administration, five ml between each medication, and 30 ml after completing administration of all the medications. During an interview on 8/10/19 at 1:03 p.m., LVN 1 confirmed she did not follow physician orders to administer 30 ml of water after each medication. Review of facility's policy and procedure titled Feeding Tube- Administration of Medication revised 11/2018 showed Flush tube with 30-50 cc (unless a different amount is specified by the Physician/Prescriber) of water before administering medication.

Based on interview and record review, the facility failed to provide a fortified diet (a diet structured to provide more calories than a regular diet) for one (Resident 229) of 14 residents. For Resident 229 this failure had the potential to result in weight loss. Findings: A review of the Facesheet indicated Resident 229 was re-admitted to the facility with a diagnosis of difficulty swallowing. A review of the physician's orders dated 5/29/19, indicated Resident 229's diet changed from a tube feeding (liquid nutrition delivered by a tube directly into the stomach), to a pureed, fortified diet. A review of Resident 229's dietary lunch ticket (a document delivered with the food tray listing the type of diet, and foods, on the individual resident's tray) dated 6/10/19 reflected the diet was regular, with a puree texture. During an interview with the Dietary Supervisor (DS) on 6/10/19 at 12:48 p.m., DS confirmed Resident 229's dietary lunch ticket did not indicate presence of a fortified diet. During an interview with the Assistant Director of Nursing (ADON) on 6/10/19 at 1:00 p.m., ADON confirmed Resident 229 should receive a fortified diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Remove expired stock from treatment cart three (two expired skin staple removal kits, and one bottle of povidone iodine (disinfecting) solution). This failure had the potential for use of expired, and potentially less effective items. 2. Label two opened bottles of liquid nutritional supplements with either a date opened or expiration date. This failure had the potential for use of expired nutritional supplements which could lead to gastrointestinal distress. 3. Label a white colored cream in a medication cup in treatment cart three with type of cream, resident name, or date. This failure had the potential to result in use of expired cream on the wrong resident and/or for the wrong reason. Findings: 1. During an observation of treatment cart three, with Registered Nurse (RN 1) on [DATE] at 11:35 p.m., the bottom drawer contained a 16-ounce bottle of povidone iodine solution dated 12/2017. RN 1 stated the solution was expired and should not be in the drawer. During a concurrent observation, the 4th drawer of treatment cart three contained two skin staple removal kits dated 09/2015. RN 1 stated the kits were expired. 2. During an observation of medication cart one, with DON, on [DATE] at 11:29 p.m., the cart contained two previously opened 30-ounce bottles of liquid nutritional supplement. The bottles were undated. A review of the bottle label reflected, Discard 3 months after opening, record date opened on bottom of container. DON stated the undated bottles should be discarded. 3. During an observation of treatment cart 3, with Registered Nurse (RN 1), on [DATE] at 11:35 p.m., an undated and unlabeled 30-ounce medication cup with white colored cream was in the top drawer. RN 1 stated she did not know what the cream was, and she discarded the medication cup. Review of the facility policy and procedure titled, Medication Ordering and Receiving from Pharmacy, dated 04/2014 showed, Medications are labeled in accordance with facility requirements and state and federal laws. Review of the facility policy and procedure titled, Medication storage in the facility, dated 04/2008, showed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier Outdated, contaminated, or deteriorated medications are immediately removed from stock, disposed of

Based on observation, interview, and record review, the facility failed to store, prepare, and served food under sanitary conditions when: 1. Multiple food items were outdated, unlabeled, and undated; 2. Staff belongings were stored on a 3 step ladder next to refrigerator 3 and 4; 3. Freezer 1 had brown sticky residue on the bottom shelves, and unlabeled ice cream bowls. These failures had the potential to cause food contamination or food borne illness. Findings: 1. During observation and concurrent interview on 6/9/19 at 8:05 a.m., the following were observed: a. In the kitchen refrigerator number three: three glasses of nectar thick liquid did not have preparation date or use by date; four tuna half-sandwiches had a prepared date of 6/7/19, and no use by date; seventeen half-sandwiches had no label and no use by date; three bowls of cottage cheese had a prepared date of 6/6/19, and no use by date; four bowls of fruit had no label and no use by date; three pitchers of thickened liquid had a prepared date of 6/8/19, and no use by date; two quarts of lime juice had a prepared date of 6/7/19, and no use by date. b. In the kitchen refrigerator number five, four bags of dialysis snacks had a prepared date of 6/7/19, and no use by date. During an interview with [NAME] 1(Cook 1) on 6/9/19 at 8:10 a.m., [NAME] 1 confirmed the above findings. 2. During an observation on 6/9/19 at 8:11 a.m., a staff jacket, a scarf, and a purse were stored in the kitchen on a step ladder between refrigerator number three and refrigerator number four. During an interview with Dietary Supervisor (DS) on 6/9/19 at 11:45 a.m., DS stated staff belongings should be kept in a different location outside the kitchen. 3. During an observation and concurrent interview with Dietary Aide (DA 1) on 6/9/19 at 8:12 a.m., the kitchen freezer number 1 bottom shelves had a brown and sticky substance, and bread crumbs; and there were two bowls of undated, unlabeled ice cream on the second shelf. DA 1 stated the freezer bottom shelves should be cleaned. A review of the facility policy and procedure titled, Leftovers, dated 7/1/14, showed, label and date all containers. A review of the facility policy and procedure titled, Food Storage, showed, label and date all food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During an observation on 6/9/19 at 8:22 a.m. in room [ROOM NUMBER], the closet door was missing, and replaced by a white curtain with brown stains. During an observation in room [ROOM NUMBER] with Assistant Maintenance Supervisor (AMS 1) on 6/10/19 at 10:45 a.m., AMS 1 stated the closet was covered with the curtain because the door had been broken for three months. AMS 1 confirmed the curtain was stained, and needed to be replaced. Review of undated policy and procedure titled, Resident Room and Environment, indicated, The Facility provides residents with a safe, clean, comfortable and homelike environment. Based on an observation, interview, and record review, the facility failed to maintain a comfortable and sanitary environment for both residents by: 1. In room [ROOM NUMBER] and room [ROOM NUMBER] the sliding closet doors did not close, the floors had fluffy particulates under the beds, and there was a thick, brown, sticky substance on the areas between the sliding doors and the clothes racks. 2. A certified nursing assistant (CNA 2) left a basin of water used for grooming on the over-bed table for one of 12 residents (Resident 229). 3. In room [ROOM NUMBER] the closet door was missing, and was replaced by a stained curtain. These failures had the potential for residents to not experience a clean, homelike environment. Findings: 1. During an observation on 6/9/19 at 8:52 a.m., the following findings were observed: the closet doors in room [ROOM NUMBER] and room [ROOM NUMBER] did not close, the floor areas between the sliding doors and the clothes racks had a thick, brown, sticky substance, and the floor areas under the beds had fluffy particulates. During an observation and interview with the Maintenance Supervisor (MS) in room [ROOM NUMBER] and room [ROOM NUMBER] on 6/10/19 at 9:08 a.m., the MS confirmed the floors were not clean, but stated the rooms were cleaned according to a schedule. 2. A review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/4/19 reflected Resident 229 was completely dependent on others for all activities of daily living, including eating, mobility, and hygiene. The MDS also indicated Resident 229 had severe impairments to thinking and remembering skills. During an observation on 6/11/19 at 11:45 a.m., certified nursing assistant 2 (CNA 2) left a basin containing water used for grooming Resident 229 on the over-bed table. During an interview with CNA 2 on 6/11/19 at 12:45 p.m., CNA 2 stated she had forgotten about the basin. CNA 2 stated dirty water basins should be removed from over-bed tables and emptied directly after completion of grooming tasks.