Based on observation, interview, and record review the facility did not provide proper supervision to one of two Residents (Resident 1) during transfer from bed to wheelchair using Hoyer Lift [(a mechanical assistive device used by caregivers to safely transfer patients with limited mobility from one place to another (i.e. bed to wheelchair)]. This failure placed Resident 1 at risk for fall and injury. Findings: During a review of Resident 1's admission Record, printed on 4/14/25, the admission record indicated Resident 1 was originally admitted to the facility in 1999 and was readmitted in 2022. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 2/21/25, revealed Resident 1 had multiple diagnoses that included, muscle weakness and personal history of traumatic brain injury. MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 00, meaning Resident 1 had severely impaired cognition. MDS also indicated, Resident 1 was dependent on the assistance of two or more helpers with transfer from bed to chair. During a concurrent observation and interview on 4/14/25, at 11:49 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 1's room, CNA 1 transferred Resident 1 from bed to wheelchair using Hoyer Lift by himself. When asked why he was operating the Hoyer lift without proper supervision, CNA 1 stated, I made a mistake. I'm not supposed to do it alone. It's supposed to be two person. CNA 1 also stated, there was risk to drop Resident 1 from Hoyer lift without support from another staff. During an interview on 4/14/25, at 2:42 p.m., with the Director Of Nursing (DON), DON stated, Hoyer lift with sling like the ones used for Resident 1, required two person to assist with the transfer. DON further added, there was increased risk for fall when CNA 1 transferred Resident 1 by himself using the Hoyer lift. During a review of Resident 1's care plan (a document that outlines the specific needs, goals, and services required for a resident's well-being and care), dated 9/4/24, indicated Resident 1 had self-care performance deficit that included impaired balance. The care plan also indicated, the resident was dependent on staff with transfer. During a concurrent interview and review of the facility's policy and procedure (P&P) titled, Lifting Machine, Using a Mechanical, dated 7/2017, on 4/14/25, at 3:20 p.m., with the DON, the DON confirmed, at least two nursing assistants are needed to safely move a resident with mechanical lift which included transferring a resident from bed to chair;

Based on observation, interview and record review, the facility failed to assist in maintaining a sufficient food and fluid intake for one of three sampled residents (Resident 5) when Resident 5's poor meal and fluid intake were not addressed in a timely manner to maintain proper nutrition and hydration. This failure resulted in dehydration (dangerous loss of body fluid causes by illness or inadequate fluid intake) and potential for malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs to maintain healthy tissues and organ function) and further decline in Resident 5's health condition. Findings: A review of Resident 5's admission Record, printed on 4/16/25, indicated Resident 5 was admitted to the facility in March 2025 with multiple diagnoses of Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavioral abilities), severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and pressure injury (develops when one or more layers of skin and tissue are damaged from continuous pressure to the area) of right and left heel. During a record review of Resident 5's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/8/25, Resident 5's assessment on Section C - Cognitive Patterns indicated Resident 5's cognitive skills for daily decision making was severely impaired. During a record review of Resident 5's Care Plan, initiated on 3/2/25, the Care Plan indicated Resident 5 had a goal to meet more than 75% of meal intake to promote wound healing and prevent further skin breakdown. During a review of Resident 5's record, titled, Nutrition - Amount Eaten (NAR), dated 4/16/25, the NAR record indicated the following percentage of the meal eaten by Resident 5: 4/9/25 9:03 a.m.- Resident refused to eat 1:38 p.m. - 26% - 50% 7:28 p.m. - 0% - 25% 4/10/25 1:35 p.m. - 26% - 50% 1:36 p.m. - 26% - 50% 6:39 p.m. - Resident refused to eat 4/11/25 11:04 a.m. - 26% - 50% 12:56 p.m. - 0% - 25% 6:00 p.m. - 0% - 25% 4/12/25 8:47 a.m. - Resident refused to eat 1:30 p.m. - 26% - 50% 6:29 p.m. - 0% - 25% 4/14/25 9:20 a.m. - 0% - 25% 1:29 p.m. - 0% - 25% 6:22 p.m. - 26% - 50% 4/15/25 11:30 a.m. - Resident refused to eat 1:36 p.m. - 26% - 50% 4/16/25 10:30 a.m. - Resident refused to eat 1:16 p.m. - Resident refused to eat During a review of Resident 5's Progress Notes documented by Registered Dietician (RD), dated 3/27/25, the Progress Notes indicated RD recommended Resident 5's estimated needs for fluids was between 1,830 ml to 2,140 ml per day. During a review of Resident 5's record, titled, Nutrition - Fluids, dated 3/18/25 to 4/16/25, the Nutrition - Fluids record indicated the following daily total amount of fluid that was consumed by Resident 5: 4/1/25 - 720 milliliters (ml) 4/9/25 - 480 ml 4/2/25 - 540 ml 4/10/25 - 480 ml 4/3/25 - 920 ml 4/11/25 - 720 ml 4/4/25 - 640 ml 4/12/25 - 720 ml 4/5/25 - 860 ml 4/13/25 - 180 ml 4/6/25 - 680 ml 4/14/25 - 300 ml 4/7/25 - 770 ml 4/15/25 - 480 ml 4/8/25 - 480 ml During a record review of Resident 5's document, titled, Laboratory Results Report, dated 4/17/25, the Laboratory Results Report indicated Resident 5 had the following result: a. Blood Urea Nitrogen (BUN, measures the amount of urea nitrogen, a waste product formed when body breaks down protein, in the blood. High levels may indicate kidney damage.) result of 47 milligrams (mg)/dilution (dL). The Laboratory Results Report indicated the reference range for normal BUN was between 7 - 25 mg/dL. b. Creatinine (a test that measures creatinine levels, a waste product produced by muscle metabolism, in the blood or urine to assess kidney function) result of 1.86 mg/dL. The Laboratory Results Report indicated the reference range for normal creatinine was 0.70 - 1.30 mg/dL. c. Sodium (a mineral that helps regulate fluid balance, nerve function, and muscle activity in the body. A high sodium concentration in the blood can be due to insufficient fluid intake, excessive water loss, or combination of both) result was 156 milliequivalent (mEq)/liter (L). The Laboratory Results Report indicated the reference range for normal sodium level was 136-145 mEq/L. During a concurrent observation and interview on 4/14/25, at 12:38 p.m., with Certified Nurse Assistant (CNA) 5, CNA 5 assisted and fed Resident 5 during lunch time in the dining room. Resident 5's eyes were closed and was observed not eating when CNA 5 tried to feed Resident 5. CNA 5 stated for Resident 5 there were incidents when Resident 5 would fall asleep during mealtimes. CNA 5 stated Resident 5 only consumed 10% of his meals and only drank half a cup of his drink. During an interview on 4/16/25, at 2:10 p.m., with RN 6, RN 6 stated CNAs were responsible for reporting to licensed nurses if a resident refused to eat or had poor meal intake. RN 6 stated licensed nurses were responsible for assessing and determining the root cause of why a resident would have a poor meal and fluid intake. RN 6 stated an RD should have been alerted first to discuss the poor meal and fluid intake of a resident. RN 6 stated after three consecutive incidents of poor meal and fluid intake, RN 6 stated it should have been considered a change of condition and should have been reported to the physician and responsible family members. RN 6 stated residents who were not eating and drinking had the potential to have dehydration that could have symptoms such as dry mouth, confusion, decreased urine output, and skin issues. RN 6 further stated residents who had skin issues such as wounds could have a delay in wound healing if they were not getting proper nutrition and hydration. During an interview on 4/17/25, at 10:12 a.m., with RD, RD stated she did not get a notification from the licensed nurses that Resident 5 recently experienced poor meal and fluid intake. RD stated she was also not informed that Resident 5 refused to eat or drink. RD stated the recommended amount of meal intake of 1,830 to 2,140 kcal (kilocalorie, which is a unit of energy commonly used to measure the amount of energy in food) and 1,830ml - 2,140ml of fluids were based on Resident 5's current height and body weight. RD stated Resident 5 was not meeting the recommended fluid intake per day. RD stated Resident 5 had a recent abnormal laboratory result with high levels of BUN and sodium. RD stated the laboratory result indicated Resident 5 was severely dehydrated. RD further stated Resident 5's poor nutrition and hydration was a risk for delayed wound healing. During an interview on 4/16/25, at 2:52 p.m., with the Director of Nursing (DON), the DON stated the licensed nurses should have notified the physician when Resident 5 had signs of poor meal and fluid intake so interventions could have been provided to prevent the dehydration. The DON stated Resident 5 started an intravenous (IV, into the vein) hydration therapy on 4/17/25 because Resident 5's recent weekly laboratory result indicated Resident 5 was dehydrated. The DON stated there were no interventions documented by the licensed nurses to address Resident 5's poor meal and fluid intake. During a concurrent observation and interview on 4/17/25, at 12:01 p.m., with Resident 5's Responsible Party (RP) 3, in Resident 5's room, Resident 5 was sitting in the wheelchair with an ongoing IV administration. RP 3 stated she visited Resident 5 almost every day. RP 3 stated she was only notified on 4/14/25 that Resident 5 ate less than 25% of his lunch. RP 3 stated she was not aware Resident 5 had also poor fluid intake. RP 3 stated prior to 4/14/25, the facility had not informed her personally of Resident 5's recent poor meal and fluid intake. RP 3 stated Resident 5 must have had an ongoing infection or illness because Resident 5 usually had a good appetite. During a record review of the facility's policy and procedure (P&P), titled, Resident Hydration and Prevention of Dehydration, revised in October 2017, the P&P indicated, This facility will strive to provide adequate hydration and to prevent dehydration .6. Nurses' Aides will provide and encourage intake at bedside, snack, and meal fluids, on a daily and routine basis as part of daily care .b. Aides will report intake of less than 1,200ml/day to nursing staff .7. If potential intake/and or signs and symptoms of dehydration are observed .b. The physician will be notified .9. The dietician, nursing staff, and the physician will assess factors that may be contributing to inadequate fluid intake . During a record review of the facility's P&P, titled, Nutritional Assessment, revised in October 2017, the P&P indicated, 1. The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident .and as indicated by a change in condition that places the resident at risk for impaired nutrition .2. As part of the comprehensive assessment, the nutritional assessment will be systematic, multidisciplinary process that includes gathering and interpreting data to help define meaningful interventions for the resident at risk for or with impaired nutrition . During a record review of the facility's P&P, titled, Food and Nutrition Services, revised in October 2017, the P&P indicated, Nursing personnel, with the assistance of the food and nutrition staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems .a. Variations from usual eating or intake patterns will be recorded in the resident's medical record and brought to the attention of the nurse .b. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician or dietician . During a review of the facility's P&P, titled, Change in Resident's Condition or Status, revised in February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been .f. refusal of treatment or medications two or more consecutive times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident when Registered Nurse (RN) 2, who failed to observe infection control procedures for contact precautions and identify a change in resident's bowel elimination status, did not complete annual competency/skills evaluation. This failure had the potential to result in unsafe resident care. Findings: During review of Resident 169's admission Record, the admission Record indicated Resident 169 was admitted to the facility on [DATE] with diagnoses that included enterocolitis (an inflammation of both the small and large intestines. It can be caused by various factors, including bacterial infections) due to Clostridium difficile (C. diff, a bacteria that can cause diarrhea and colitis, an inflammation of the colon) infection. During an observation on 4/15/25, at 12:34 p.m., Resident 169's room had Contact Plus Precaution sign tucked inside a fabric door organizer. During an interview on 4/16/25, at 11:43 a.m., with Registered Nurse (RN) 2, RN 2 stated, medical devices, like the blood pressure monitor, used for Resident 169 were also used for other residents after disinfecting them with Clorox wipes or Sani-Cloth disinfecting wipes, but most of the time used Clorox with the white top because Clorox is Pretty good with everything. During a concurrent observation and interview on 4/17/25, at 11:20 a.m., with IP, IP stated any disinfecting wipes that have bleach could be used to disinfect a contact precaution room. An observation of a tub of Sani-Cloth disinfecting wipes with orange top indicated it was effective against C. diff spores. During a concurrent observation and interview on 4/17/25, at 2:34 p.m., with Director of Nursing (DON), DON stated not being sure if the Clorox wipes with the white top contained bleach. A tub of Clorox wipes with the white top found in the housekeeping cart indicated Bleach-free. During a review of Resident 369's admission Record, the admission Record indicated Resident 369 was admitted to the facility in March 2024 with diagnoses that included hypertension (high blood pressure) and personal history of urinary tract infection. During a review of Resident 369's clinical record, Medication Review Report (MRR), dated 4/17/25, indicated an order dated 3/25/25 for Cephalexin (treats infection) oral capsule 250 mg 1 capsule by mouth once daily for personal history of urinary tract infections. The clinical record did not indicate a urinalysis or urine culture was done. During an interview on 4/16/25, at 12:10p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 369 had diarrhea in the morning and had to be taken to the bathroom because Resident 369 kept going. CNA 4 stated Resident 369 also had diarrhea/loose stools too on 4/15/25. CNA 4 also stated Resident 369 was feeling bad for the night shift CNAs for cleaning up after a big loose bowel movement. During a joint interview on 4/16/25, at 12:19 p.m., with RN 2 and CNA 4, RN 2 stated he did not know about Resident 369 having episodes of diarrhea. CNA 4 reminded RN 2 that he had been told Resident 369 had been having diarrhea for two days. RN 2 stated, having loose stools was less serious than watery stools and it was normal for residents to use the bathroom constantly. During an interview on 4/17/25, at 11:20 a.m., with Infection Preventionist (IP), IP stated not being happy with antibiotics used as prophylaxis. IP also stated if a resident had more than three episodes of diarrhea, a stool specimen should be sent for testing to prevent spread of a possible infection. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, last revised December 2016, the P&P indicated, training and education of staff will include emphasis on the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections like C. diff and evolution of drug-resistant pathogens. During a review of the facility's P&P titled, Antibiotic Stewardship-Staff and Clinician Training and Roles, last revised December 2016, the P&P indicated nurses will receive initial orientation and ongoing training on the facility's Antibiotic Stewardship Program, common clinical conditions treated at the facility. During a review of the Facility Assessment last revised 8/8/24, the Facility Assessment indicated the staff training necessary to provide the level of support and care for the resident population included infection control that includes written standards, policies, and procedures for the program, and such mandatory training should be provided to all staff upon hire, annual and as needed. The Facility Assessment also indicated residents with common diagnoses, conditions, and/or combinations of conditions that require complex care are admitted to the facility, including residents with infectious diseases such as C. diff, infections with multi-drug-resistant organisms, and urinary tract infections. During a concurrent interview and record review on 4/17/25, at 2:40 p.m., with Director of Nursing (DON), RN 2's Annual Skill Check dated 8/2023 was reviewed. DON stated RN 2 did not have annual Skills Check for 2024. DON stated if skills for licensed nurses were not evaluated, significant errors may happen.

Based on observation, interview and record review, for one of one sampled resident (Resident 59) reviewed for psychotropic (any drug that affects brain activities associated with mental processes and behavior) medication use, the facility failed to ensure Resident 59 received antipsychotic medication (treats mental disorders, including schizophrenia and bipolar disorder) with appropriate indication. This failure had the potential to result in unnecessary adverse reactions from the medication. Findings: During a review of Resident 59's admission Record, the admission Record indicated Resident 59 was admitted to the facility in February 2025 with diagnoses that included metabolic encephalopathy (a brain disorder resulting from imbalances in the body's chemical or electrolyte levels, leading to brain dysfunction), Alzheimer's dementia (a general term for the decline in memory and other cognitive abilities that interfere with daily life), major depressive disorder (a mental disorder characterized by persistent sadness, loss of interest or pleasure, and other symptoms that significantly impair daily functioning), and dementia without behavioral disturbance and anxiety (a person diagnosed with dementia doesn't exhibit the typical behavioral symptoms associated with the condition, such as aggression, agitation, or anxiety). The admission Record listed Resident Representative (RR) as Resident 59's responsible party. During a review of Resident 59's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 2/10/25, the MDS indicated Resident 59 was rarely/never understood and rarely/never understands others, had inattention (difficulty focusing attention, being easily distractible or having difficulty keeping track of what was being said). The MDS also indicated Resident 59 did not have potential indicators of psychosis as there were no hallucinations (sensory perceptions that a person experiences as real, even though they are not actually present) or delusions (false, fixed beliefs that someone holds despite evidence to the contrary) and no behavioral symptoms were noted. During a review of Resident 59's Medication Review Report (MRR), the MRR indicated a physician's order to give olanzapine (antipsychotic medication used to treat mental disorders, including schizophrenia and bipolar disorder) oral tablet 2.5 milligrams (mg) by mouth at bedtime for major depressive disorder, recurrent, moderate. The MRR also indicated behavior monitoring for 1. hallucinations, 2. delusions, and 3. Others, for olanzapine use. During a concurrent observation and interview on 4/14/25, at 12:24 p.m., with Registered Nurse (RN) 4, Resident 59 was in bed, calm and quiet. RN 4 stated Resident 59 had refused to get out of bed and sometimes became combative when transferred to the wheelchair. During a telephone interview on 4/15/25, at 11:37 a.m., with RR, RR stated, Resident 59 used to be active and very energetic, but now only stares at the ceiling and does not talk much. RR also stated, Resident 59 used to fear the water so giving a shower would make Resident 59 yell and scream. RR stated that behavior was more under control, and it was now easier for staff to care for Resident 59. During an interview on 4/15/25, at 12:15 p.m., with Certified Nursing Assistant (CNA) 5, CNA 5 stated Resident 59 did not speak English, but knew Resident 59 spoke a little bit of Japanese or Chinese? CNA 5 stated she was not sure what language Resident 59 spoke. CNA 5 stated when Resident 59 was newly admitted , Resident 59 would scream and grab the staff's hand, but that behavior has improved. CNA 5 stated, sometimes, Resident 59 only needed to be re-assured that everything would be okay. During an interview on 4/16/25, at 3 p.m., with RN 6, RN 6 stated Resident 59 became combative during care when not familiar with the staff providing the care. RN 6 also stated, because Resident 59 did not speak English, there was no way to tell if Resident 59 was having hallucination or if it was real. During an interview on 4/17/25, at 9:58 a.m., with Social Service Designee (SSD), SSD stated, during a care conference with RR, RR said Resident 59 had combativeness during care, SSD stated RR did not say anything about Resident 59 having any hallucinations. During a review of Resident 59's Psychotropic Evaluation (PE), dated 2/14/25, the PE indicated, under behaviors: stable, Medications has improved some of the resident's above symptoms .there has not been any recent medication reductions. Under Medication Evaluation, Resident has been prescribed antipsychotic medication olanzapine. Six Month History was blank, Physician Review Completed, Completed Clinical Suggestions, Comments were all left blank. During a review of the facility's policy and procedure (P&P) titled Antipsychotic Medication Use last revised July 2022, the P&P indicated, The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others .diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident .Antipsychotic medications will not be used if the only symptoms are one or more of the following: restlessness, uncooperativeness, mild anxiety or inattention or indifference to surroundings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure infection prevention and control procedures were followed when: -Housekeeping Aide (HA) did not disinfect Resident 169's room, a contact precaution (a set of infection control practices used to prevent the spread of germs through direct or indirect contact. These precautions are implemented when a patient has a disease that can be transmitted by touching the patient, contaminated surfaces, or objects in their environment) room, with appropriate disinfectant. -Registered Nurse (RN) 1 did not disinfect medical device with appropriate disinfectant in between resident use. This failure had the potential to result in spreading Clostridium difficile (C. diff, a bacteria that causes diarrhea and colitis (inflammation of the colon). It's a serious infection that can be life-threatening, especially in vulnerable populations like older adults in healthcare settings) infection to other residents. Findings: During a review of Resident 169's admission Record, the admission Record indicated Resident 169 was admitted to the facility on [DATE] with diagnoses that included enterocolitis (an inflammation of both the small and large intestines. It can be caused by various factors, including bacterial infections) due to C. diff infection. During an observation on 4/15/25, at 12:34 p.m., Resident 169's room had Contact Plus Precaution sign tucked inside a fabric door organizer. During an interview on 4/16/25, at 10:01 a.m., with Housekeeping Aide (HA), HA stated, when entering Resident 169's room, she made sure to wear Personal Protective Equipment (PPE, a variety of equipment designed to protect the wearer from injury or illness, including clothing, helmets, gloves, face shields). HA stated she used the pink Ecolab Smartpower Sink and Surface sanitizer to clean the tables, doorknobs, cabinets, night stand, bed and bed frame, and left the sanitizer on for five minutes. HA stated she used the purple Oasis 499 Disinfectant Cleaner to clean the bathroom and the floor. HA stated these two chemicals came in pre-mixed. During an interview on 4/16/25, at 10:12 a.m., with Infection Preventionist (IP), IP stated, for contact precaution rooms, housekeeping staff are supposed to use the orange top disinfectant wipes (Sani-Cloth Germicidal Disposable Wipe/Bleach), not the purple cleaner spray as it is only a cleaner and not a disinfectant. During a follow-up interview on 4/16/25, at 10:30 a.m., with HA, HA stated she only used the spray solution, either the pink or purple, and wiped with cleaning towel. HA stated she did not use the Sani-Cloth disinfecting wipes and did not have any of those in the cart. During an interview on 4/16/25, at 11:43 a.m., with Registered Nurse (RN) 2, RN 2 stated they used the wrist BP cuff on all the residents and disinfected it with Clorox wipes and the Sani-Cloth disinfecting wipes, but most of the time used Clorox with the white top because Clorox was pretty good with everything. During an observation on 4/16/25, at 11:46 a.m., HA cleaned room [ROOM NUMBER] by spraying a wash towel with the pink solution and wiped down the door, a walker that was at the bedside, cabinet, walls, overhead light, bed rails and overbed tables. During a concurrent observation and interview on 4/17/25, at 11:20 a.m., with IP, IP stated any disinfecting wipes that has bleach could be used to disinfect a contact precaution room. An observation of a tub of Sani-Cloth disinfecting wipes with orange top indicated it is effective against Clostridium difficile spores. During a concurrent observation and interview on 4/17/25, at 2:34 p.m., with Director of Nursing (DON), DON stated not being sure if the Clorox wipes with the white top contained bleach. Clorox wipes was found in the housekeeping cart that indicated Bleach-free. During a review of the facility's policy and procedure (P&P) titled, Clostridium Difficile, last revised October 2018, the P&P indicated, the primary reservoir for C.difficile are surfaces, spores can persist on resident-care items and surfaces for several months and are resistant to some common cleaning and disinfection methods. Environmental cleaning in rooms of residents with C. difficile is done with a disinfecting agent recommended for C.difficile (e.g. household bleach and water solution or an EPA registered germicidal agent effective against C.difficile spores). Steps toward prevention and early intervention include disinfection of items with potential fecal soiling (e.g. commode chairs, bed rails, etc.) with a disinfecting agent recommended for C. diff. During a review of the manufacturer's information of the Sani-Cloth Bleach Germicidal Disposable Wipe with EPA registration number 9480-8, the manufacturer's information indicated the wipes are effective against 52 microorganisms and is ideal for disinfecting high-risk areas contaminated with Clostridioides difficile spores.

Based on interview and record review, for one randomly selected resident (Resident 369), the facility failed to establish and implement infection prevention and control program that included antibiotic stewardship program when: -Resident 369 was administered antibiotics without adequate indication. -Resident 369's possible symptoms of antibiotic side effects were not monitored. This failure had the potential to result in the development of antibiotic-resistant infections (occur when bacteria develop the ability to withstand the effects of antibiotics, making them difficult or impossible to treat, can be serious and even life-threatening, often requiring longer hospital stays, more expensive treatments, and potentially toxic medications). Findings: During a review of Resident 369's admission Record, the admission Record indicated Resident 369 was admitted to the facility in March 2024 with diagnoses that included hypertension (high blood pressure) and personal history of urinary tract infection. During a review of Resident 369's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 3/31/25, the MDS indicated 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) score of 13. A BIMS score of thirteen to fifteen is an indication of intact cognitive status. During a review of Resident 369's clinical record, Medication Review Report (MRR), dated 4/17/25, indicated an order dated 3/25/25 for Cephalexin (treats infection) oral capsule 250 mg 1 capsule by mouth once daily for personal history of urinary tract infections. The clinical record did not indicate a urinalysis or urine culture was done. During an interview on 4/16/25, at 12:10 p.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 369 had diarrhea in the morning and had to be taken to the bathroom because Resident 369 kept going. CNA 4 stated Resident 369 also had diarrhea/loose stools too on 4/15/25. CNA 4 also stated Resident 369 was feeling bad for the night shift CNAs for cleaning up after a big loose bowel movement. During a joint interview on 4/16/25, at 12:19 p.m., with RN 2 and CNA 4, RN 2 stated he did not know about Resident 369 having episodes of diarrhea. CNA 4 reminded RN 2 that he had been told Resident 369 had been having diarrhea for two days. RN 2 stated, having loose stools was less serious than watery stools and it was normal for residents to use the bathroom constantly. During an interview on 4/16/25, at 12:20 p.m., with Resident 369, Resident 369 stated having diarrhea for a few days, and a big portion of the bed being soiled made her feel like she might have gone so many times. Resident 369 also stated having diarrhea this bad was a new thing and felt bad for the staff who had to clean up. During a review of Resident 369's clinical record, Skilled Evaluation (written and signed by licensed staff) and Bowel and Bladder Elimination record (completed by assigned CNAs) indicated the following: - Skilled Evaluation dated 4/6/25 indicated, genitourinary: Urine yellow. Denies urinary complaints., gastrointestinal: Abdomen is flat. Abdomen is non-tender; Bowel sounds present x 4 .Bowel movement appearance: WNL [within normal limits]. Bowel and Bladder Elimination dated 4/6/25 indicated Resident 367 had diarrhea in the day shift. - Skilled Evaluation dated 4/7/25 indicated, under genitourinary; No urinary complaints .New onset incontinence; No. under gastrointestinal; Abdomen flat, non-tender, Bowel sounds present x 4 [all four quadrants, divides the abdomen into four quadrants], Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Bowel and Bladder Elimination dated 4/7/25 indicated Resident 369 had diarrhea. - Skilled Evaluation dated 4/11/25 indicated, genitourinary: Resident continent of bladder. Urine clear yellow. Denies urinary complaints., gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x 4, Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Bowel and Bladder Elimination dated 4/11/25 indicated Resident 369 had diarrhea. - Skilled Evaluation dated 4/12/25 indicated genitourinary: Resident continent of bladder. Urine clear yellow. Denies urinary complaints., gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x 4, Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Bowel and Bladder Elimination dated 4/12/25 indicated Resident 369 had diarrhea. - Skilled Evaluation dated 4/16/25 indicated genitourinary: Resident continent of bladder. Urine clear yellow. Denies urinary complaints., gastrointestinal: Abdomen flat, non-tender. Bowel sounds present x 4, Denies indigestion, nausea, vomiting, diarrhea, constipation or bowel incontinence. Bowel and Bladder Elimination dated 4/16/25 indicated Resident 369 had diarrhea. During an interview on 4/17/25, at 11:20 a.m., with Infection Preventionist (IP), IP stated being unhappy with antibiotics that were used as prophylaxis. IP stated, for urinary tract infections, the following needed to be present before starting antibiotics; symptoms such as fever, burning sensation and signs of infection such as increased heart rate AND a culture and sensitivity to determine what organism and what antibiotic needed to be used, otherwise, if a resident was prescribed an antibiotic that was not going to work, it could mess up their immune system. IP also stated if a resident had more than three episodes of diarrhea, a stool specimen should be sent for testing to prevent spread of a possible infection. IP stated, for Resident 36, a discussion with nursing was done about having to re-do urinalysis and culture, but there was no update as to when this was going to be done. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, last revised December 2016, the P&P indicated the facility will provide training and education with emphasis on the relationship between antibiotic use and gastrointestinal disorders, opportunistic infections like C. difficile and evolution of drug-resistant pathogens. During a follow-up interview on 4/17/25, at 3:01 p.m., with IP, IP stated the facility was using McGeer Criteria (a set of clinical and laboratory findings used to define and track infections in long-term care facilities. They help identify potential infections, such as urinary tract infections (UTIs), respiratory tract infections, and skin and soft tissue infections, and monitor their incidence and trends). A review of Revised McGeer Criteria for LTC (Long Term Care) indicated, for urinary tract infections without an indwelling catheter, an infection is present when either 1a, 1b or 1c AND 2 are present: Criteria 1a- acute dysuria, or acute pain, swelling or tenderness on the suprapubic area (the region of the abdomen located directly above the pubic bone) Criteria 1b-fever or increased white blood cell count AND one or more of the following; suprapubic pain, gross hematuria (visible blood in the urine), new or marked increase in incontinence, urgency and frequency. Criteria 1c- two or more of the following- suprapubic pain, gross hematuria, new or marked increase in incontinence, urgency and frequency. AND 2- one of the following must be present; at least 100,000 colony forming units (cfu/ml) of no more than 2 species of microorganisms in a voided urine sample, or at least 100 cfu/ml of any number of organisms in a specimen collected by in-and-out catheter (a temporary tube inserted into the urethra to drain urine from the bladder and then removed).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Resident 18, 33, 14 and 7), received activities of daily living (ADL) care when the following was noted: 1. Resident 18 had long fingernails with black matter underneath both hands. 2. Resident 33 had long fingernails with black matter underneath both hands. 3. Resident 14 had overgrown fingernails. 4. Resident 7, who was dependent on staff, was not turned and repositioned every two hours as indicated in the care plan. Findings: 1. During a review of Resident 18's admission record, printed on 4/15/25, indicated Resident 18 was admitted to the facility on [DATE] with multiple diagnoses that included primary osteoarthritis (joint disease) and motor and sensory neuropathy (damage or dysfunction of nerves that control movement). During a review of Resident 18's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated, 2/15/25, indicated Resident 18 had a Brief Interview for Mental Status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 05, meaning Resident 18 was cognitively impaired. The MDS also indicated, Resident 18 required set up or clean up assistance with personal hygiene. During a concurrent observation and interview on 4/15/25, at 9:40 a.m., in Resident 18's room, Resident 18 had thick and black matter underneath fingernails on left and right hand. Resident 18 stated, he did not like long and dirty nails. Resident 18 further stated, Certified Nursing Assistant (CNA) 2 did not offer to clean and trim his nails for a long time. During an interview on 4/15/25, at 9:48 a.m., with CNA 2, CNA 2 acknowledged Resident 18's nails were dirty. CNA 2 stated, even though Resident 18 had diabetes (a disease that occurs when your blood sugar is too high), it was not an excuse to not keep Resident 18's fingernails clean. During a concurrent observation and interview on 4/15/25, at 10:03 a.m., with CNA 2 in the presence of Registered Nurse (RN) 1, CNA 2 stated, Resident 18 refused nail care. Resident 18 said, that's not true. CNA 2 then acknowledged, she did not offer to trim or clean Resident 18's fingernails. RN 1 stated, it was important to keep fingernails clean because Resident 18's fingernails on his left hand had fungal infection and there was risk to spread infection to other parts of his body. 2. During a review of Resident 33's admission record, printed on 4/15/25, indicated Resident 33 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with multiple diagnoses that included delirium (change in mental state characterized by confusion, difficulty paying attention, and a fluctuating level of alertness). During a review of Resident 33's MDS dated [DATE], indicated Resident 33 had a BIMS score of 01, meaning Resident 33's cognition was severely impaired. The MDS also indicated, Resident 33 required partial/moderate assistance with personal hygiene. During a concurrent observation and interview on 4/15/25, at 9:53 a.m., in Resident 33's room, with CNA 2, Resident 33's fingernails on both hands were long and had thick black matter underneath. CNA 2 stated, she knew Resident 33's nails were dirty but did not clean or trim his nails. CNA 2 also added, Resident 33 had a band aid on his forehead because Resident 33 liked to scratch his wound with his fingernails. During a concurrent observation and interview on 4/15/25, at 10:15 a.m., in Resident 33's room with RN 1, RN 1 stated Resident 33 was at risk for infection due to tendency to scratch his head. RN 1 further added, keeping Resident 33's fingernails clean and trimmed was important to prevent infection. 3. During a review of Resident 14's admission record, printed on 4/15/25, indicated Resident 14 was admitted on [DATE] with multiple diagnoses that included cataract (blurry or hazy vision), primary angle closure glaucoma (vision loss), low vision right eye and blindness left eye. During a review of Resident 33's MDS dated [DATE], the MDS indicated, Resident 33 had a BIMS score of 06, meaning Resident 33 had severely impaired cognition. The MDS also indicated, Resident 33's vision was severely impaired. The MDS revealed, Resident 33 required partial/moderate assistance with personal hygiene. During a concurrent observation and interview on 4/15/25, at 9:57 a.m., in Resident 14's room, with CNA 2, Resident 14 stated, he cannot see but he can feel his fingernails were long because fingernails felt heavy and uncomfortable. Resident 14 also stated, CNA 2 did not offer to trim his fingernails. During a concurrent observation and interview on 4/15/25, at 10:17 a.m., in Resident 14's room, with RN 1, RN 1 acknowledged Resident 14 hand overgrown fingernails and stated the nails had been long for a while. RN 1 stated, she told CNA 2 prior to today, to trim Resident 14's nails but CNA 2 did not do it. During an interview on 4/17/25, at 9:52 a.m., with the Director of Nursing (DON), DON stated, there was risk for possible infection or skin tears due to Resident 18, 33, and 14's long and dirty fingernails. DON added, Resident 18 had diabetes but there was no excuse for CNA 2 not to keep nails clean. During a review of the facility's policy and procedure (P&P) titled, Fingernails/Toenails, Care of, dated 2/2018, indicated; The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. The P&P also indicated, under General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed.' 4. During a record review of Resident 7's admission Record, printed on 4/18/25, the record indicated Resident 7 was admitted to the facility in July 2023 with multiple diagnoses of Alzheimer's disease (A progressive disease that destroys memory and other important mental functions.), muscle weakness, and chronic pain. During a record review of Resident 7's MDS, dated [DATE], the MDS assessment Section G (Functional Abilities and Goal) indicated Resident 7 was dependent on facility's staff to roll from lying on back to left and right side, and to return to lying on back on the bed. The MDS assessment section C indicated Resident 7's BIMS score was zero out of 15 which indicated severe cognitive impairment. During a record review of Resident 7's Care Plan, dated 3/25/25, the Care Plan indicated Resident 7 was at risk for fall and had to be checked and repositioned every 2 hours. During an observation on 4/16/25, at 9:49 a.m., with Resident 7, Resident 7 was awake and lying on her back on the bed. During an interview on 4/16/25, at 10:08 a.m., with Certified Nurse Assistant (CNA) 3, CNA 3 stated Resident 7 was dependent to all Activities of Daily Living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating) including repositioning every two hours. CNA 3 stated there were no records that Resident 7 was being repositioned every two hours on a daily basis because it was not included in their daily tasks for Resident 7. CNA 3 stated if the turning and repositioning task was included in their daily task for Resident 7, the CNAs would have been reminded to reposition Resident 7. CNA 3 stated it was important to provide repositioning every two hours to Resident 7 to prevent pneumonia (an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli) and skin breakdown. During a follow up observation on 4/16/25, at 12:23 p.m., with Registered Nurse (RN) 4, Resident 7 was in the same position and was observed still lying on her back on the bed. RN 4 stated Resident 7 should have been turned and repositioned every two hours. During a concurrent record review and interview on 4/16/25, at 2:52 p.m., with the DON, Resident 7's electronic health record (EHR, an electronic version of the patient's medical history that include all of the key clinical data) for CNA's daily task was reviewed. The DON stated and confirmed that there was no turning and repositioning task included in Resident 7's EHR. The DON stated the facility should have included the turning and repositioning task for Resident 7. The DON stated Resident 7 was at risk for developing pressure injury (develops when one or more layers of skin and tissue are damaged from continuous pressure to the area). During a record review of the facility's P&P, titled, Repositioning, dated March 2018, the P&P indicated, The purpose of this procedure is to provide guidelines for the evaluation of resident needs .to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents .General Guidelines .Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning .Documentation .The following information should be recorded in the resident's medical record .1. The position in which the resident was placed. This may be in a flow sheet .2. The name and the title of individual who gave the care . During a review of the facility's P&P, titled, Activities of Daily Living (ADL), Supporting, dated March 2018, the P&P indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently .in accordance with the plan of care, including appropriate support and assistance with .b. mobility .Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice .

Based on interview and record review, for three of 22 sampled residents (Resident 41, 20 and 5), the facility failed to provide treatment and care in accordance with professional standards of practice when: 1. Resident 41 did not receive multiple medications that included anti-hypertensives (blood pressure lowering medications), stool softeners and phosphate binders, according to physician's orders. This failure had the potential for complications that included hypertensive emergency (a severe and immediate medical condition characterized by dangerously high blood pressure and signs of end-organ damage, such as to the brain, heart, or kidneys), and hyperphosphatemia (or high phosphorus levels in the blood, a common and serious complication in patients with end-stage renal disease (ESRD). 2. Resident 20's elevated blood pressure (circulating volume of the blood on the walls of the arteries, veins, and chambers of the heart) was not addressed multiple times and the physician was not notified of Resident 20's change of condition. This failure had the potential to result in stroke or death. 3. Resident 5's refusal to take oral medications multiple times was not addressed in a timely manner. This failure had the potential to result in delayed treatment and management of medical condition. Definition: Daily Med is a nationally recognized publication of the National Institute of Health in the U. S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration [Reference: dailymed.nlm.nih.gov]. Findings: 1. During a review of Resident 41's admission Record, the admission Record indicated Resident 41 was admitted to the facility in April 2023 with diagnoses that included hypertensive emergency, end stage renal disease (a serious condition where the kidneys can no longer function properly), dependence on renal dialysis (a person relies on dialysis as a life-sustaining treatment for kidney failure, where their kidneys can no longer adequately filter blood and remove waste), essential hypertension (a chronic condition characterized by sustained high blood pressure with no identifiable underlying cause), pulmonary hypertension (a condition where the blood pressure in the lungs becomes abnormally high), anemia (a condition where the blood doesn't carry enough oxygen to the body's tissues) and atherosclerotic heart disease of native coronary artery (the buildup of fats, cholesterol and other substances in and on the artery walls). During a review of Resident 41's Medication Review Report (MRR), dated 4/16/25, the MRR indicated Resident 41 was to have dialysis (a life-sustaining treatment for individuals with kidney failure or injury, removing waste and excess fluid from the blood when the kidneys cannot do so themselves) every Monday, Wednesday, and Friday from 8:30 a.m.-11:30 a.m. The MRR indicated Physician's Orders for the following blood pressure and heart disease management medications: a. Aspirin Oral Tablet Delayed Release 81 MG (milligrams) Give 1 tablet by mouth one time a day related to ATHEROSCLEROTIC HEART DISEASE OF NATIVE CORONARY ARTERY WITHOUT ANGINA PECTORIS (a type of chest pain or discomfort caused by reduced blood flow to the heart muscle). Aspirin is used to treat pain and reduce fever or inflammation. b. Isosorbide Mononitrate ER Oral Tablet Extended Release 24 Hour 120 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION Hold if SBP <125. Isosorbide mononitrate tablets, USP are indicated for the prevention and treatment of angina pectoris (a type of chest pain or discomfort caused by reduced blood flow to the heart muscle) due to coronary artery disease. [Reference: dailymed.nlm.nih.gov]. c. Minoxidil Oral Tablet 10 MG Give 0.5 tablet by mouth two times a day for HTN (hypertension). Hold for SBP (systolic BP, the top number in a blood pressure reading) <110. d. Nifedipine ER Oral tablet Extended Release 24 Hour 60 MG (Nifedipine) Give 2 tablet by mouth one time a day related to HYPERTENSIVE EMERGENCY (I16.1); ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for SBP <110. Nifedipine Extended-release Tablet is indicated for the treatment of hypertension, to lower blood pressure. Lowering blood pressure reduces the risk of fatal and nonfatal cardiovascular events, primarily strokes and myocardial infarctions. [Reference: dailymed.nlm.nih.gov]. e. Polyethylene Glycol 3350 Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for bowel regularity mix with 4-8 oz of liquid and take by mouth. Hold for loose stools. Polyethylene Glycol is a laxative to relieve constipation. f. Renal-Vite Oral Tablet (B-Complex with C & Folic Acid) Give 1 tablet by mouth one time a day for supplement related to END STAGE RENAL DISEASE. Multivitamins for patients on dialysis. g. Renvela Oral Tablet 800 MG (Sevelamer Carbonate) Give 2 tablet by mouth three times a day related to END STAGE RENAL DISEASE. Renvela is indicated for the control of serum phosphorus in patients with chronic kidney disease (CKD) on dialysis. [Reference: dailymed.nlm.nih.gov]. h. Iron (Ferrous Sulfate) Oral Tablet 325 (65 Fe) MG (Ferrous Sulfate) Give 1 tablet by mouth one time a day related to ANEMIA IN CHRONIC KIDNEY DISEASE (D63.1) on empty stomach. Ferrous Sulfate is a dietary supplement for anemia. During a review of Resident 41's hypertension care plan initiated 9/14/23, the care plan indicated for licensed staff to give all medications for hypertension as ordered. During a review of Resident 41's Medication Administration Records (MAR) for March 2025 and April 2025, the MARs indicated the following medications were documented as omitted (not given as prescribed) by licensed staff with the reason as Other/See Progress Notes: a. The 9 a.m. dose of Aspirin Oral Tablet on 3/7, 3/12, 3/14, 3/17, 3/19, 3/21, 3/24, 3/26, 3/28, 3/31, 4/2, 4/4, 4/7, 4/8, 4/9, 4/11, 4/14, and 4/16. b. The 9 a.m. dose of Isosorbide Mononitrate ER Oral Tablet on 3/7, 3/12, 3/14, 3/17, 3/19, 3/21, 3/24, 3/26, 3/28, 3/31, 4/2, 4/4, 4/7, 4/8, 4/9, 4/11, 4/14, and 4/16. c. The Minoxidil Oral Tablet 10 MG on 3/12, 3/14, 3/17, 3/19, 3/21, 3/24, 3/26, 3/28, 3/31, 4/2, 4/4, 4/7, 4/8, 4/9, 4/11, 4/14, and 4/16. d. The 9 a.m. dose of NIFEdipine ER Oral tablet on 3/7, 3/12, 3/14, 3/17, 3/19, 3/21, 3/24, 3/26, 3/28, 3/31, 4/2, 4/4, 4/7, 4/8, 4/9, 4/11, 4/14, and 4/16. e. The 9 a.m. dose of Polyethylene Glycol 3350 Oral Powder on 3/12, 3/14, 3/17, 3/19, 3/21, 3/24, 3/26, 3/28, 3/31, 4/2, 4/4, 4/7, 4/8, 4/9, 4/11, 4/14, and 4/16. f. The 9 a.m. dose of Renal-Vite Oral Tablet on 3/7, 3/12, 3/14, 3/17, 3/19, 3/21, 3/24, 3/26, 3/28, 3/31, 4/4, 4/7, 4/8, 4/9, 4/11, 4/14, and 4/16. g. The Renvela Oral Tablet on 3/12, 3/14, 3/17, 3/19, 3/21, 3/24, 3/26, 3/28, 3/31, 4/2, 4/4, 4/7, 4/8, 4/9, 4/11, 4/14, and 4/16. h. The 11 a.m. dose of Iron (Ferrous Sulfate) Oral Tablet 325 on 3/14, 3/19, 3/21, 3/24, 3/26, 3/28, 3/31, 4/4, 4/7, 4/11, 4/14, and 4/16. During an interview on 4/14/25, at 1:10 p.m., with Registered Nurse (RN) 5, RN 5 stated, For Resident 41, except for hydralazine (used to treat high blood pressure (hypertension), all scheduled medications in the morning were On hold on dialysis days. During an interview and concurrent record review on 4/16/25, at 2:26 p.m., with RN 6, RN 6 stated sometimes blood pressure medications were on hold if blood pressure readings met parameters that was ordered (e.g. SBP <110). RN 6 stated the clinical record did not indicate a physician's order to hold medications when Resident 41 went to dialysis. During a review of Resident 41's Dialysis Communication Record, the following blood pressure readings were documented by facility staff before and after dialysis treatments: -On 3/12/25, pre-dialysis BP was 157/65, post-dialysis BP was 156/63. -On 3/14/25, pre-dialysis BP was 138/65, post-dialysis BP was 174/73. -On 3/17/25, pre-dialysis BP was 146/78, post-dialysis BP was 163/70. -On 3/19/25, pre-dialysis BP was 129/61, post-dialysis BP was 163/70. -On 3/21/25, pre-dialysis BP was 170/70, post-dialysis BP was 149/63. -On 3/24/25, pre-dialysis BP was 152/64, post-dialysis BP was 158/76. -On 3/26/25, pre-dialysis BP was 147/56, post-dialysis BP was 124/68. -On 3/31/25, pre-dialysis BP was 159/71, post-dialysis BP was 152/61. -On 4/2/25, pre-dialysis BP was 147/59, post-dialysis BP was 168/75. -On 4/4/25, pre-dialysis BP was 135/61, post-dialysis BP was 152/87. -On 4/9/25, pre-dialysis BP was 155/76, post-dialysis BP was 180/89. During an interview on 4/16/25, at 12:58 p.m., with Director of Nursing (DON), DON stated scheduled medications should be given before Resident 41 leaves for dialysis, or the time of administration should be adjusted so the medications are given after Resident 41 returns from dialysis. 2. During a record review of Resident 20's admission Record, printed on 4/18/25, the record indicated Resident 20 was admitted to the facility in August 2024 with multiple diagnoses including end stage renal disease (permanent stage of chronic kidney disease, where kidneys can no longer function on their own), cerebral infarction (stroke, a condition where blood flow to the brain is disrupted), and essential hypertension (high blood pressure). During a record review of Resident 20's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score 13 to 15 is an indication of intact cognitive response.), dated 1/11/25, the record indicated Resident 20's BIMS score was 15. During a record review of Resident 20's Care Plan, dated 9/29/22, the Care Plan indicated Resident 20 had hypertension, and the goal was to maintain Resident 20's Systolic BP (SBP, pressure in the arteries when the heart contracts) to less than 140 mmHg and above 90 mmHg and Diastolic BP (DBP, measured between heartbeats when the heart is filling with blood) to less than 90 mmHg and above 60 mmHg. The Care Plan also indicated, Monitor/document/report as needed any signs and symptoms of malignant hypertension (occurs when a sudden spike in blood pressure puts you at risk for organ damage) .Monitor/record use/side effects of medication. Report to physician as necessary. During a record review of Resident 20's Weights and Vitals Summary, dated 4/16/25, the following BP reading was noted: - 4/14/25 at 9:11 p.m. - 169/68 millimeters pf mercury (mmHg, a unit of pressure, specifically used to measure BP) - 4/13/25 at 5:07 p.m. - 162/74 mmHg - 4/12/25 at 9:00 p.m. - 168/82 mmHg - 4/12/25 at 6:38 p.m. - 164/86 mmHg - 4/12/25 at 2:01 p.m. - 163/65 mmHg - 4/11/25 at 9:27 p.m. - 162/80 mmHg - 4/11/25 at 5:03 p.m. - 171/85 mmHg - 4/11/25 at 2:55 p.m. - 196/87 mmHg - 4/11/25 at 6:19 a.m. - 182/79 mmHg During an interview on 4/14/25, at 10:39 a.m., with Resident 20, Resident 20 stated he did not receive his BP medication on the night of 4/13/25. Resident 20 stated Licensed Vocational Nurse (LVN) 1 informed Resident 20 that if he wanted his BP medication, Resident 20 needed to get it from LVN 1. Resident 20 stated it was important that he received his BP medications because he was a dialysis (a procedure that removes waste and excess fluid from the blood when kidneys can no longer function properly) patient. Resident 20 further stated he needed his BP medications because of his high BP. During an interview on 4/15/25, at 2:40 p.m., with LVN 1, LVN 1 stated Resident 20 had a history of refusing medications. LVN 1 stated she did not notify the physician that Resident 20 refused the BP medications multiple times because the Director of Nursing (DON) told her to just document the refusals and inform them about it. LVN 1 stated the physician should have been notified of Resident 20's refusal to take the BP medications because Resident 20 could have had an elevated BP. During a concurrent record review and interview on 4/16/25, at 10:19 a.m., with the DON, Resident 20's electronic health record (EHR, an electronic version of the patient's medical history that include all of the key clinical data), was reviewed. The DON stated their policy for elevated BP included notifying the physician if the SBP was more than 160 mmHg. The DON stated there was no documentation from the licensed nurses that the physician was notified when Resident 20's BP was elevated multiple times. The DON stated on 4/11/25, when Resident 20's BP reached to 197/87 mmHg, there was no documentation that the licensed staff provided appropriate care, and the physician was not notified. The DON stated Resident 20 could have had a stroke due to very high BP. During a review of the facility's policy and procedure (P&P), titled, Blood Pressure, measuring, revised in September 2010, the P&P indicated, Hypertension is usually defined as BP over 140/90 mmHg .Hypertension should be reported to the physician . During a review of the facility's P&P, titled, Change in Resident's Condition or Status, revised in February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been a .d. significant change in the resident's physical/emotional/mental condition .2. A significant change of condition is a major decline or improvement in resident's status that .a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 3. During a record review of Resident 5's admission Record, printed on 4/16/25, the record indicated Resident 5 was admitted to the facility in March 2025 with multiple diagnoses of urinary tract infection (UTI, an infection in any part of the urinary tract, the system of organs that makes urine), Alzheimer's disease (a progressive brain disorder that primarily affects memory, thinking, and behavioral abilities), neuromuscular dysfunction of bladder (urinary bladder problems caused by damage or disease to the nerves that control urination), pressure injury (develops when one or more layers of skin and tissue are damaged from continuous pressure to the area) of right and left heel. During a record review of Resident 5's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/8/25, Resident 5's assessment on Section C - Cognitive Patterns indicated Resident 5's cognitive skills for daily decision making was severely impaired. During a review of Resident 5's record, titled, Medication Administration Record, dated 4/1/25 to 4/30/25, the MAR indicated the following medications were not administered to Resident 5: a. Tamsulosin (helps relax the smooth muscles in prostate and bladder improving the flow of urine) oral capsule 0.4 milligrams (mg) Give 1 capsule by mouth at bedtime for prostate was not administered on 4/11/25, 4/12/25, 4/13/25 at 9:00 a.m. and 4/7/25, 4/8/25, 4/11/25, 4/13/25, and 4/14/25 at 9:00 p.m. b. Zinc sulfate (supplement for low levels of zinc, a mineral that helps immune system, wound healing and cell growth) Give 1 capsule by mouth one time a day for supplement was not administered on 4/11/25, 4/12/25, and 4/13/25. c. Melatonin (helps regulate sleep) oral tablet 3 mg Give 1 tablet by mouth at bedtime for circadian rhythm (a natural, roughly 24-hour cycle that regulates sleep-wake cycles and other bodily functions, influenced by light and dark) was not administered on 4/7, 4/8/25, 4/11/25, 4/13/25, and 4/14/25. During a concurrent observation and interview on 4/16/25, at 10:09 a.m., with Certified Nurse Assistant (CNA) 3, Resident 5 was sleeping in his bed. CNA 3 stated Resident 5 had cognitive impairment, unable to verbalize needs, and was totally dependent to staff with all the activities. During an interview on 4/16/25, at 12:18 p.m., with Registered Nurse (RN) 4, RN 4 stated Resident 5 refused to take his oral medications multiple times that included the tamsulosin. RN 4 stated Resident 5 had the risk of urinary retention when he had missed the tamsulosin multiple times. RN 4 stated Resident 5's medical record indicated licensed nurses explained the risks and benefits of the tamsulosin medication to Resident 5. RN 4 stated Resident 5 would have not understood the risks and benefits because Resident 5 had cognitive impairment. During a record review and interview on 4/16/25, at 2:52 p.m., with the DON, Resident 5's Progress Notes were reviewed. The DON stated there were no documentations that Resident 5's physician and responsible family members were notified when Resident 5 refused multiple times to take the oral medications. The DON stated the physician should have been notified because missing the tamsulosin medication could have caused Resident 5 bladder pain. During a concurrent observation and interview on 4/17/25, at 12:01 p.m., with Resident 5's Responsible Party (RP) 1, in Resident 5's room, Resident 5 was sitting in the wheelchair. RP 1 stated she visited Resident 5 almost every day. RP 1 stated she was not aware that Resident 5 had been refusing to take his oral medications. RP 1 stated Resident 5's refusal of treatment was not a normal behavior for Resident 5. During a review of the facility's P&P, titled, Change in Resident's Condition or Status, revised in February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been .f. refusal of treatment or medications two or more consecutive times .

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent for three out of eight sampled Residents (Resident 25, 57, and 270). This failure had the potential for negative health outcomes. Findings: 1. During a concurrent observation and interview on 4/15/25, at 8:32 a.m., with Registered Nurse (RN) 2, outside of Resident 57's room, RN 2 was observed pouring 1 tablet of the multi-vitamin into a small medication cup and then administered it along with all other morning medications scheduled for Resident 57. During a concurrent interview and record review on 4/15/25, at 1:11 p.m., with RN 2, Resident 57's medication orders for the observed medication pass were reviewed. Resident 57 was noted as having an order for multi-vitamin tablet with minerals and to be administered daily in the morning. Review of the ingredients on the multi vitamin bottle that RN 2 had used earlier for Resident 57 revealed the multi-vitamin tablets contained no minerals in them. When RN 2 was asked if there was another type of multi vitamin tablets available in his medication cart (med cart), RN 2 looked through the med cart and found a bottle of multi-vitamin with minerals deep in the top drawer. RN 2 stated he did not see this bottle of multi-vitamin with minerals, and he also acknowledged the packaging of both bottles (the multi-vitamin and the multi-vitamin with minerals) looked almost the same. 2. During a concurrent observation and record review on 4/15/25, at 10:05 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 270 was noted as having an order for chlorhexidine gluconate solution (a prescription mouthwash for oral care). This medication was not observed as being passed to Resident 270 for oral care treatment during the morning medication pass. During a concurrent interview and record review on 4/15/25, at 10:59 a.m., with LVN 2, she confirmed that the chlorhexidine gluconate solution was not given to Resident 270 in the morning. And LVN 2 also stated she was about to prepare it now for oral use by the Resident. 3. During a concurrent observation and interview on 4/15/25, at 9:29 a.m., with Licensed Vocational Nurse (LVN) 1, she was observed getting a blood sugar reading from Resident 25. LVN 1 stated Resident 25's blood sugar was 302 and the resident would be getting 8 units of Humulin R (a short acting form of insulin that starts working in 30 minutes after injection to lower blood sugar). During a concurrent interview and record review on 4/15/25, at 10:59 a.m., with LVN 1, Resident 25 was noted as having an order to obtain his blood sugar at 7 a.m. And when LVN 1 was asked as to why she did not get the blood sugar from Resident 25 at 7 a.m. or at least before his breakfast time to get an accurate measurement of his blood sugar control, LVN 1 stated she missed it and did not know that Resident 25 had an insulin order this morning. During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated 4/2019, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame .Medications areadministered with one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on observation, interview, and record review, the facility failed to ensure safe medication storage practices when two expired medications in a medication cart were available for use. These failures had the potential to result in Residents receiving expired and ineffective medications. Findings: During a concurrent observation and interview on 4/14/25, at 2:50 p.m., with Registered Nurse (RN) 7, in the hallway of nursing station 2, medication storage cart (2A) was audited, and observed there were a bottle of 2.5 ml Rocklatan (medication used to treat high pressure inside the eye) eye drop and a vial of 10 ml Humalog (a short acting form of insulin that starts working in 15 minutes after injection to lower blood sugar ) insulin inside the medication cart (med cart) with an expiration date of 4/7/25 and 4/8/25 respectively. RN 7 confirmed both of these medications were expired. She also stated this med cart was not my regular one, I was here just helping out with med pass today. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage dated 2/2023, the P&P indicated, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on observation, interview, and record review, the facility failed to employ a qualified Dietary Services Manager (DSM) in the absence of a full-time Registered Dietitian (DC) for 64 Residents who received food from the kitchen. This failure had the potential for the residents' nutritional needs not to be met; and dietary staff were not supervised by a qualified person. Findings: During the initial kitchen tour on 4/14/25, at 9:38 a.m., with the Dietary Service Supervisor (DSS), the tour revealed improper food preparation, improper storage of food items, and un-maintained kitchen equipment. (Cross-reference F812). During concurrent interview and record review on 4/14/25, at 10:37 a.m., with the DSS, in the DSS office, the DSS revealed she was not a certified Dietary Manager. DSS also stated she took the dietary manager course but failed to complete the course. During an interview on 4/14/25, at 10:42 a.m., with Registered Dietician (RD), RD stated the facility did not have a qualified Dietary Manager. RD added she worked part time in the facility because she had other facilities to supervise. During an interview on 4/16/25, at 8:35 a.m., with the Administrator (ADM), ADM confirmed there was no qualified dietary manager. ADM added, RD worked two to three days per week. ADM further added, RD and Nutrition Support Specialist (NSS) shared the responsibility to ensure there was full coverage of qualified Registered Dietician. During a telephone interview on 4/16/25, at 9:45 a.m., with NSS, NSS stated she had not passed the exam to be a qualified Registered Dietician. NSS also stated she was responsible to oversee the kitchen and staff when RD was not in the facility. During an interview on 4/16/25, at 11:56 a.m., with DSS, DSS confirmed RD came to the facility part time and NSS came and worked the rest of the week to cover RD's role. (Cross-reference F800). A review of facility's document titled, Nutrition Therapy Essentials - Registered Dietician Consultant Services Agreement, dated, 2/1/23, the agreement indicated, .V. COMPENSATION .2. Contracted hours for the Facility will be 16 hours a week as negotiated with Consultant and Facility's appointed person of contact. A review of the California Code, Health and Safety Code - HSC § 1265.4 (HSC), the HSC indicated, (a) A licensed health facility .shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. (b) The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6).

Based on observation, interview, and document review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. [NAME] 1 prepared food in the emergency three compartment sink. 2. Open package pasta was not stored in airtight container. 3. 12 Quart clear container stored multiple sprouted, soft, and wrinkled red potatoes. 4. Powdered sugar in tin can labeled with used by 4/10/25. 5. One and half pint cherry tomatoes was not labeled and dated with used by. 6. 12 Quart full container with wrinkled, mushed, liquified cherry tomatoes were stored. 7. Unlabeled 12 ounce (oz - unit of measurement) clear plastic container contained; a. four green bell peppers that were extremely soft with white fuzzy matter and discoloration; b. three wrinkled red bell peppers had caked in black matter and white fuzzy discoloration, two yellow peppers were wrinkled. 8. Two 16 oz containers had mushy strawberries with liquid juice was labeled with delivery date 4/7/25. 9. One dented can good was stored with ready to use cans. 10. Mounted can opener had a reddish and brown flaky coating on surface near the blade. These failures had the potential to cause food borne illness to residents who receive food from the kitchen out of a facility census of 64. Findings: During the initial tour of the kitchen on 4/14/25, at 9:38 a.m., in the presence of Dietary Service Supervisor (DSS) and Registered Dietician (RD), the following was observed; 1. [NAME] (CK) 1 prepared food in the emergency three compartment sink. 2. Open package of pasta was not stored in airtight container. 3. 12 Quart clear container stored multiple sprouted, soft, and wrinkled red potatoes. 4. Powdered sugar in tin can labeled with used by 4/10/25. 5. One and half pint cherry tomatoes was not labeled and dated with used by. 6. 12 Quart full container with wrinkled, mushed, liquified cherry tomatoes were stored. 7. Unlabeled 12 ounce (oz - unit of measurement) clear plastic container contained; a. four green bell peppers that were extremely soft with white fuzzy matter and discoloration; b. three wrinkled red bell peppers had caked in black matter and white fuzzy discoloration; c. two yellow peppers were wrinkled and soft. 8. Two 16 oz containers had mushy strawberries with liquid juice was labeled with delivery date 4/7/25. 9. One dented can good was stored with ready to use cans. 10. Mounted can opener had a reddish and brown flaky coating on surface near the blade. During a concurrent observation and interview on 4/14/25, at 9:43 a.m., with RD, the RD acknowledged CK 1 prepared food in the three-compartment sink. RD stated, the sink should not have been used as food preparation area due to risk of cross contamination with food and pathogen from sink. During an interview on 4/14/25, at 9:45 a.m., with DSS, DSS stated staff were used to using the three-compartment sink as food preparation area and it was hard to undo. DSS further stated, staff needed re-training to not use the sink for food preparation. During a review of facility's policy and procedure (P&P) titled, FOOD PREPARATION, dated 2023, the P&P indicated, Employees will prepare food in a clean and safe manner to protect residents and staff from foodborne illness. During a review of facility's P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, the P&P indicated, Food preparation should not occur in two or three compartment sinks. During a concurrent observation and interview on 4/14/25, at 9:50 a.m., with DSS, DSS attempted to seal the open package of pasta with plastic wrap. DSS stated, staff forgot to put the open package of pasta in airtight container. DSS added, there was potential for pest to get inside unsealed package. During a review of facility's P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, the P&P indicated, under PROCEDURES: .9. Metal, plastic containers (with tight fitting lids and NSF approved), or resealable plastic bags will be used for staples and opened packages of items such as pastas, rice, dry cereals, etc. During a concurrent observation and interview on 4/14/25, at 9:54 a.m., with DSS, DSS discarded the unlabeled container of cherry tomatoes and stated the tomatoes may possibly be stored beyond used by. DSS added, kitchen staff would not know when the tomatoes could be used and discarded because it was not labeled. During a concurrent observation and interview on 4/14/25, at 10:11 a.m., with RD, RD stated the sprouted tomatoes and wrinkled, soft cherry tomatoes were compromised and should have been discarded. RD also stated, there was potential for the residents in the facility to get sick if compromised food items were ingested. During a review of facility's PRODUCE STORAGE GUIDELINES, dated 8/15, on 4/14/25, at 10:19 a.m., with DSS, the guidelines indicated, strawberries are to be stored in the refrigerator for 3-5 days. During an observation on 4/14/25, at 10:25 a.m., in the presence of DSS, one dented can of six-pound sweet potatoes was stored in the rack along with ready to use can goods. During a review of facility's P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, the P&P indicated, under PROCEDURES: .10. Canned food items should be routinely inspected for damage such as dented, bulging or leaking cans. These items should be set aside in a designated area for return to the vendor or disposed of properly. During a concurrent observation and interview on 4/14/25, at 10:45 a.m., with RD, RD removed the can opener shaft from the mount and inspected the can opener. RD stated the can opener should not be used because of the rust. RD further stated rust could transfer toxin to food ingested by residents and residents could get sick. During a review of facility's P&P titled, SANITATION AND INFECTION CONTROL, dated 2023, indicated under policy, Equipment will be cleaned and sanitized to prevent food borne illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of three sampled residents (Resident 1) when Treatment Nurse 1 (TN 1) did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove changes during the wound dressing change. This failure had the potential to result in infection and spread of infection. Findings: A review of Resident 1s admission Record, printed 12/11/24, indicated resident was readmitted to the facility on [DATE] with diagnosis of diabetes mellitus (high blood sugar). A review of Resident 1's Physician Order, with a revision date of 12/5/24, indicated a treatment order for resident's sacral region (the triangular shaped bone at the base of the spine that connects the spine to the pelvis) Stage III pressure ulcer (a full thickness tissue loss but do not reach muscle, tendon, or bone). The treatment order indicated, Wound care: Cleanse with normal saline (NS), gently pat dry, apply Santyl (a topical enzyme [proteins that help with wound healing] medication used to remove damaged or burned skin, aiding in wound care and the growth of healthy skin), cover with Mepilex (a soft and highly conformable antimicrobial foam dressing) until healed one time a day . During a concurrent observation and interview on 12/11/24, at 1:20 p.m., TN 1 prepared for Resident 1's wound dressing change. Resident's old wound dressing has been removed during incontinent care just before the wound care began. TN 1 donned a clean pair of gloves, cleansed the wound site with NS, removed soiled gloves, then donned a new pair to apply Santyl to the wound, without performing hand hygiene. As TN 1 continued with Resident 1's wound care, TN 1 covered the wound site with Mepilex dressing, removed her soiled gloves, then donned a new pair again without performing hand hygiene. Upon interview, TN 1 stated hand hygiene should be performed when moving from wound cleaning (a dirty procedure) to application of a new dressing (a clean procedure) to prevent contamination. During an interview on 12/11/24, at 2 p.m., with the Director of Nursing (DON), DON stated changing gloves without performing hand washing or hand hygiene increases the risk of infection. DON stated staff should change gloves and perform hand hygiene in between clean and dirty procedures to prevent spread of infection. A review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised date August 2019, indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infection to others personnel, residents, and visitors .Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled. B. After contact with resident .Use an alcohol-based hand rub containing at least 62 percent (%) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents .d. Before performing any non-surgical invasive procedures .g. before handling clean or soiled dressings, gauze pads .h. Before moving from contaminated body site to a clean body site during resident care .k. After handling used dressings, contaminated equipment .m. After removing gloves .The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections .

Based on interview and record review, the facility failed to provide dental services to meet the needs of two of three sampled residents (Resident 2 and Resident 3) when: 1. The facility failed to promptly refer Resident 2 for dental services, within three days as required, when Resident 2's tooth was chipped. 2. The facility did not provide timely dental services to obtain full dentures for Resident 3. These failures had the potential to result in decreased food intake and potential significant weight loss for both residents. Findings: 1. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility in May 2023 with diagnoses that included moderate protein-calorie malnutrition. During a review of Resident 2's Medication Review Report (MRR), the MRR indicated an order, dated 5/11/23, for Resident 2 to have dental consult with treatment and follow-up as indicated, and for Resident 2 to have regular, fortified diet regular texture and thin liquids. During a review of Resident 2's Dental Notes, dated 7/9/24, the Dental Notes indicated Resident 2's tooth has been Fractured for a month. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 5/18/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information.) score of 13. A BIMS score of thirteen to fifteen is an indication of intact cognitive status. During an interview on 7/16/24 at 1:22 p.m. with Resident 2, Resident 2 stated it took the facility more than three months to get a dentist to check on the damaged tooth. Resident 2 stated she is having to chew food on the opposite side so as not to put more pressure on the affected tooth. Resident 2 stated she is not able to eat enough because of it. Resident 2 stated the damaged tooth should have been treated like an emergency. During a review of Resident 2's MRR, dated 7/16/24, the MRR indicated a physician's order dated 6/9/23 for Resident 2 to have regular, fortified diet with regular texture. During a telephone interview on 7/22/24 at 11:28 a.m. with Social Services Director (SSD), SSD stated Social Services Assistant (SSA) took over Resident 2's case some time in May 2024. SSD stated Resident 2's fractured tooth was part of the partial lower dentures. During a review of Resident 2's Care Conference Summary, dated 5/20/24, written and signed by SSA, the Care Conference Summary indicated The resident wears upper and lower dentures, and one tooth has chipped. During a telephone interview on 7/23/24 at 11:43 a.m. with SSA, SSA stated a referral was sent to the dentist on 6/6/24, 16 days after SSA knew of the issue. SSA stated Resident 2 did not have any problems with eating and was able to chew as normal. SSA stated there was no documentation of the extenuating circumstances for the delay in sending the referral. SSA stated she was not aware that referrals for damaged or lost dentures should be made within three days. 2. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility in October 2023 with diagnoses that included dysphagia (difficulty swallowing) following cerebral infarction (otherwise known as stroke, loss of oxygen supply to the brain leading to damage of brain tissues) and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During a review of Resident 3's MRR, dated 7/17/24, the MRR indicated a physician's order, dated 10/19/23, for Resident 3 for Dental consult with treatment and follow-up as indicated. During an interview on 7/16/24 at 1:02 p.m. with Resident 3, Resident 3 stated being admitted in October 2023 to the facility, and some time later Resident 3's full dentures got lost. Resident 3 stated it took a long time for the dentist to come and start the process of replacing dentures. Resident 3 also stated feeling depressed and frustrated by the very slow process. During a review of Resident 3's MDS, dated 4/26/24, Resident 3's BIMS score was 15, indicating intact cognitive response. During a review of Resident 3's Dental Notes, dated 12/12/23, the Dental Notes indicated Resident 3 stated the facility Lost my dentures. The Dental Notes indicated Resident 3 did not have any natural teeth both upper and lower. During a review of Resident 3's Dental Notes, dated 7/9/24, the Dental Notes indicated a full set of dentures with case was ready but was not fitted because of COVID. During an interview on 7/18/24 at 10:02 a.m. with SSA, SSA stated the process of replacing Resident 3's dentures started on 2/6/24 when the dentist came to take dental impressions. SSA stated between then and 7/9/24, the delay was because of the dentist not coming to the facility for timely follow-up. During a telephone interview on 7/23/24 at 1:14 p.m. with SSA, SSA stated Resident 3's new dentures have not been delivered (seven months after report of loss). During a review of the facility's policy and procedure (P&P) titled Dental Services, last revised December 2016, the P&P indicated routine and emergency dental services are provided to the residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident's personal dentist, to a community dentist or to other health care organizations that provide dental services. The P&P also indicated if dentures are damaged or lost, residents will be referred for dental services within three days. If the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting dental services, and the reason for the delay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was free from physical abuse when Resident 2 repeatedly hit Resident 1 on the left lower extremity. This failure had the potential to result in physical injury and psychosocial harm. Findings: During a review of Resident 1's Face Sheet, undated, the Face Sheet indicated Resident 1 was admitted to the facility in March 2021 with diagnoses that included Alzheimer's 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), severe open-angle glaucoma (group of eye conditions that damage the nerves in the eye causing visual impairment), and type 2 diabetes mellitus (a long-term [chronic] disease in which the body cannot regulate the amount of sugar in the blood). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 1/9/24, the MDS indicated Resident 1 had impaired vision and had a Brief interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of nine (A BIMS score of nine is an indication of moderately impaired cognitive response). During a review of Resident 2's Face Sheet, undated, the Face Sheet indicated Resident 2 was admitted to the facility in April 2011 with diagnoses that included intracranial injury (injury inside the confined area of the skull), aphasia (loss of ability to understand or express speech, caused by brain damage), obesity, and left hemiplegia (weakness of one side of the body). During a review of Resident 2's MDS, dated 3/11/24, the MDS indicated Resident 2's BIMS score is 15 (an indication of an intact cognitive response). During a review of Resident 2's Progress Notes, dated 2/14/24, the Progress Notes indicated on 2/14/24 around 7:15 a.m., Certified Nursing Assistant (CNA) 1 saw Resident 2 Physically hit his roommate [Resident 1] on both legs ., with slurred speech, Resident 2 stated being bothered by Resident 1's constant calls. During an interview on 3/7/24 at 11:50 a.m. with Resident 1, Resident 1 stated, while in bed, Resident 2 came over to Resident 1's bedside, growling and making noises. Resident 1 started tapping the table next to the bed to signal staff to come to the room. Resident 1 stated, Resident 2 got annoyed by the table tapping, and with a closed fist, hit Resident 1's left knee. Resident 1 stated he only felt safe in the same room with Resident 2 when staff was around. During a review of Resident 1's Skilled Evaluation (SE), dated 2/14/24, the SE indicated, Resident was upset and afraid after being hit by [roommate] this morning. During an interview on 3/7/24 at 11:55 a.m. with Resident 2, Resident 2 stated going over to Resident 1's bedside after Resident 1 had refused to turn the light off. Resident 2 stated he was banging on Resident 1's bed to make Resident 1 turn off the light. During a review of Resident 2's SE, dated 2/14/24, the SE indicated Resident 2's Mood and Behavior as agitated with No recent change in mood. During a telephone interview on 3/7/24 at 1:06 p.m. with CNA 1, CNA 1 stated she responded to the call light in Resident 1 and Resident 2's room before breakfast time on 2/14/24. CNA 1 stated Resident 2 had asked CNA 1 to turn off the overbed light which CNA 1 did and left the room. CNA 1 stated, a few moments later, the call light in Resident 1's room came on again. CNA 1 stated she went back to the room to find out what the residents needed. CNA 1 stated, halfway through the hallway, CNA 1 could hear Resident 1 calling for help. CNA 1 stated, as she got to the room, CNA 1 saw Resident 2 sitting in the wheelchair by Resident 2's bed and hitting Resident 1 in the legs. CNA 1 stated Resident 2 was shouting and appeared very angry, Resident 2's right hand was balled up in a fist and he hit Resident 1's left leg. CNA 1 stated Resident 2 was separated from Resident 1. CNA 1 stated this was not the first incident that Resident 2 got involved in. During a review of Resident 2's clinical record, the Progress Notes, dated 11/20/23, indicated a staff member witnessed Resident 2 repeatedly hitting a roommate's back and twisting the roommate's wrist and arm. The roommate was very confused and had gone under Resident 2's bed. Resident 2's roommate was found to have two small skin tears on the left arm after the two residents were separated.

Based on observation and interview, the facility failed to accommodate individual needs and preferences of one (Resident 31) of three sampled residents, when Resident 31 did not have access to dietary menu. This deficient practice had the potential to affect the quality of life for Resident 31 and his needs not being met while at the facility. Findings: During a record review of admission Record, printed on 12/7/23, the admission Record indicated Resident 31 was admitted to the facility in September 2022. The admission Record indicated that Resident 32 has a medical diagnoses including hemiplegia (loss of muscle function on one side of body) and hemiparesis (weakness or the inability to move on one side of the body), following a cerebral infarction. (a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). During a record review of Resident 31's Minimum Data Set (MDS- An assessment used to guide care), Section C, dated 9/12/23, the MDS showed Resident 31's Brief Interview for Mental Status (BIMS- cognition assessment) score was 15 out of 15, indicating intact mental status. During an interview on 12/4/23 at 11:06 a.m., with Resident 31, Resident 31 stated he doesn't get the menu for food anymore. During an interview on 12/4/23 at 12:10 p.m., with Registered Dietician Nutritionist (RDN), the RDN stated all residents have the menu available on their TV and the menu is posted on the bulletin boards. During a concurrent observation and interview on 12/5/23 at 12:15 p.m., with Resident 31, Resident 31 checked the menu channel, channel 3, on the TV displayed in his room. The TV channel was blank, and no menu was available. Resident also checked channel 1 and channel 2 and the channels were blank. Resident 31 stated the facility did not provide any paper menu to him either. During an interview on 12/5/23 at 12:20 p.m. with RDN, RDN stated the menu is usually displayed in Channel 3, but she could not find it in channel 3 and it's not working. RD stated she checked the channel a few months ago but did not check recently. During an interview on 12/6/23 at 12:43 p.m. with RD, RD stated Residents should have access to menu because food is the biggest part of choice and Residents will be able to know what they are getting and if they don't like it, they can request for something else.

Based on interview and record review, the facility failed to follow its policy and procedure to immediately report an alleged abuse allegation to the California Department of Public Health (CDPH) for over 24 hours for one (Resident 31) of 3 sampled residents when Resident 31 alleged CNA 3 touched him inappropriately. This failure had potential risk of delay in investigation and affect physical and psychological well-being of residents. Findings: During a record review of admission Record, printed on 12/7/23, the admission Record indicated Resident 31 was admitted to the facility in September 2022. The admission Record indicated that Resident 31 had a medical diagnoses including hemiplegia (loss of muscle function on one side of body) and hemiparesis (weakness or the inability to move on one side of the body), following cerebral infarction. (a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off). During a record review of Resident 31's Minimum Data Set (MDS- An assessment used to guide care), Section C, dated 9/12/23, showed Resident 31's Brief Interview for Mental Status (BIMS- cognition assessment) score was 15 out of 15, indicating intact mental status. During an interview on 12/6/23 at 9:15 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated that on 10/18/23 a.m. shift, Resident 31 reported to her that Certified Nursing Assistant 3 (CNA 3) tapped his thighs. CNA 2 stated she reported the incident to Director of staff Development/ Infection Preventionist (DSD/IP) around 8 am. During a concurrent interview and record review on 12/6/ 23 at 1:45 p.m., with DSD/IP, Resident 31's progress notes were reviewed. DSD/IP stated she reported the incident to Administrator (ADM) on 10/18/23 after CNA 2 had reported the incident to her. Stated CNA 3 was immediately removed from the schedule. DSD/IP stated the abuse incidents should be reported within 24 hours. DSD/IP stated there were no nursing progress notes or assessment notes for Resident 31 on 10/18/23 and 10/19/23. DSD/IP stated it is important to do that to ensure resident doesn't feel threatened and for emotional wellbeing. During a concurrent interview and record review on 12/6/23 at 2:08 p.m., with ADM, ADM stated the abuse incident was reported to him on 10/18/23 by CNA 2, followed by Resident 31. ADM stated Abuse with serious injury is reported within 2 hours and without serious bodily injury is reported within 24 hours. ADM stated SOC - 341 (abuse reporting form) was sent to Department of Health on 10/19/23 at 3:49 pm. ADM stated he was still doing the investigation. During a review of facility's Policy and Procedure (P&P) titled, Abuse Investigation and Reporting, revised on 7/2017, the P&P indicated Reporting . 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury: or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Based on interview and record reviews, the facility failed to meet the needs for one of two sampled residents (Resident 167) when the facility did not develop and implement a comprehensive care plan for Resident 167 with an indwelling urinary catheter (a tube that is inserted into the bladder to drain urine). This deficient practice placed Resident 167 at risk for developing physical and psychosocial complications related to use the of urinary catheters including infection. Findings: During a review of Resident 167's, admission Record, printed on 12/7/23, the admission Record indicated Resident 167 was originally admitted to the facility in November 23 with a diagnosis of Bacteremia (Bacteremia is the presence of bacteria in the bloodstream) and chronic kidney disease (kidneys are damaged and can't filter blood the way they should and causes them to gradually lose their ability to function). During a review of Resident 167's electronic health record titled, Care plan, dated 11/11/23, the care plan indicated there was no interventions planned or implemented for the use and/or preventions of complications related to the use of urinary catheter. During an interview on 12/8/23 at 8:59 a.m., with Director of Nursing (DON), DON stated Resident 167 came from the hospital with the urinary catheter and they did not develop a care plan for the urinary catheter. DON stated it is important to have a comprehensive care plan to ensure all the planned interventions to meet the needs of a resident is provided. DON stated the risk of not having a care plan is that any appropriate changes to resident's plan of care will be missed. During a review of the facility's policy and procedures (P & P), titled, Care Plans, Comprehensive Person -Centered, revised in March 2022, the P & P indicated, Policy Statement- A comprehensive, person-centered care plan the includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .7. The comprehensive, person- centered care plan: .c. includes the resident's goals upon admission and desired outcomes; . E. reflects currently recognized standards of practice for problem areas and conditions.

Based on observation, interview, and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 167) had a physician order to maintain an indwelling catheter (a tube inserted into the bladder that drains urine into a bag outside the body) in place after admission and indication of a medical condition for the use of the indwelling urinary catheter. This deficient practice placed Resident 167 at risk for developing complications related to use of urinary catheters including urinary tract infection. Findings: During observation on 12/4/23 at 10:28 a.m., Resident 167 was observed with a urinary catheter in place. During a review of Resident 167's, admission Record, printed on 12/7/23, the admission record indicated Resident 167 was originally admitted to the facility in November 2023 with a diagnosis of bacteremia (the presence of bacteria in the bloodstream) and chronic kidney disease (kidneys are damaged and can't filter blood the way they should and causes them to gradually lose their ability to function). During a review of Resident 167's Physician Orders, there were no orders or indications for use of a urinary catheter. There were no standardized orders for monitoring urinary catheter for prevention of complications in the orders reviewed. During an interview on 12/8/23 at 8:59 a.m. with Director of Nursing (DON), DON stated Resident 167 came from the hospital with a urinary catheter. DON stated they did not have a physician's order for Resident 167 indicating the need of a urinary catheter. DON stated they have an order set that is put in for residents with urinary catheters which was not present for Resident 167. DON verified the orders were started on 12/7/23. DON also stated it is important to have a physician order to understand why an intervention is done. DON stated they can track the progress and monitor if the intervention was successful. DON stated monitoring of urinary catheters is important to prevent complications like infections. During a review of the facility's policy and procedure (P & P), titled, Catheter Care, Urinary, revised in August 2022, the P & P indicated, Catheter evaluation .2. Review and document the clinical indications for catheter use prior to inserting. 2. Nursing and interdisciplinary team should assess and document the ongoing need for a catheter that is in place. Use standardized tool for documenting clinical indications for catheter use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to show an Interdisciplinary Team meeting was conducted after one sampled resident (Resident 19) had severe weight loss. This failure had the potential to result in inadequate resident care for one resident out of a census of 58. Findings: A record review for Resident 19 showed he was [AGE] years old admitted in January of 2020 and had diagnoses including but not limited to Parkinson's disease, acute kidney failure, amenia, and major depressive disorder. A record review of Resident 19's weight history showed he weighed 178.4 pounds (lbs.) on 10/9/23 and on 10/30/23 he weighed 143.6 lbs., which was a 19.5 percent (%) weight loss in 21 days. Resident 19 was weighed again on 11/2/23 and his weight was 145.6 lbs. which was a 18.4 % weight loss in 24 days. A record review for Resident 19 showed Registered Dietitian Nutritionist (RDN) documented a Nutrition Assessment on 10/31/23. The documentation showed Resident 19 lost 34.8 lbs./19.5% in one month (10/9/23-10/30/23) and was not on a prescribed weight loss program. In an interview on 12/7/23 at 12:05 p.m., RDN stated the facility did not have regular scheduled Interdisciplinary Team (IDT) meetings. RDN stated she could not find a documented IDT/weight variance meeting for Resident 19 after his significant weight loss on 10/30/23. In an interview on 12/7/23 at 12:30 p.m., the DON stated when a resident had a significant weight loss, usually the Assistant Director of Nursing (ADON), the DON, and the Provider discussed what the plan was for the resident. He confirmed this meeting was not documented for Resident 19. During a review of the facility policy and procedure (P&P) titled Weight Assessment and Intervention, revision date of March 2022, the P&P showed the threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant; greater than 5% is severe. The document also showed weight change is evaluated by the treatment team, and the physician and IDT will identify conditions and medications that may be causing anorexia, weight loss, or increasing risk of weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan for dementia (progressive decline in memory that affects the ability to perform everyday activities) was developed for one of two sampled residents (Resident 167). This failure had the potential for Resident 167 to not receive the appropriate treatment and services needed to meet her dementia care needs. Findings: During a review of Resident 167's admission Record, printed on 12/7/23, the admission Record indicated Resident 167 was originally admitted to the facility in November 2023 with a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) and unspecified dementia. During a record review of Resident 167's Minimum Data Set (MDS- an assessment used to guide care), Section C, dated 11/15/23, the MDS showed Resident 167's Brief Interview for Mental Status (BIMS- cognition assessment) score was 0 out of 15, indicating severely impaired mental status. During a concurrent interview and record review on 12/6/23 at 10:27 a.m., with Director of Nursing (DON), Resident 167's, Care plan, dated 11/11/23, was reviewed. DON stated they do not have a care plan for dementia for Resident 167. During an interview on 12/8/23 at 8:59 a.m. with Director of Nursing (DON), DON stated they did not develop a patient centered care plan for dementia for Resident 167. DON stated it is important to have comprehensive care plan to ensure all the planned interventions to meet the needs of resident is provided. DON also stated the risk of not having a care plan is that any appropriate changes to resident's plan of care will be missed. During a review of the facility's policy and procedure (P&P) titled, Dementia- Clinical Protocol, revised in [DATE], the P&P indicated, Treatment /Management. 1. For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life .Monitoring and Follow- Up .2. The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure four of thirty-six sampled residents (Residents 24, 25, 56 and 215) had complete and current care plans. This failure had the potential to cause residents to not receive appropriate and adequate care thereby affecting their physical and psychosocial well-being. During a concurrent interview and record review on 12/6/23 at 7:58 a.m. with Director of Nursing (DON), Resident 25's care plans were reviewed. DON stated Res 25 was hospitalized from [DATE] to 10/5/23 and was diagnosed with pneumonia. DON further stated Res 25 received antibiotics from 10/5/23 to 10/7/23. DON stated Resident 25 did not have care plans for pneumonia and antibiotic treatment and without a care plan for antibiotics, the facility would not be able to check if the antibiotic was effective and monitor for side effects. During a concurrent interview and record review at 8:30 a.m. with DON, Resident 24's care plans were reviewed. Resident 24's care plans for Risk for Pain, Risk for decline in ADL (activities of daily living), Risk for Skin Breakdown, Risk for Ineffective Airway Clearance, Limited Activity Involvement, Hypertension, Assisted Fall, and Antibiotic Therapy all had target dates of 11/12/23. DON stated a care plan's target date was 3 months from admission date and then quarterly. DON stated Resident 24's care plans were out of date. During a concurrent interview and record review at 8:31 a.m. with DON, Resident 215's care plans were reviewed. Resident 215's care plans on Risk for Pain, Risk for decline in ADL, Risk for Impaired Nutrition, Risk for Fall, Risk for Skin breakdown, No activity involvement, Hypothyroidism, Osteomyelitis, Antibiotic Therapy, IV Medications, Seizure Disorder, Poor Food Intake, and Actual Impairment to Skin Integrity all had target dates of 11/26/23. DON stated that Resident 215 did not have a care plan on communication. During a concurrent interview and record review at 8:36 a.m. with DON, Resident 56's care plans were reviewed. Resident 56's did not have care plans for foley catheter and pressure ulcer. DON stated the care plans got missed. DON stated the care plans determine goals, necessary interventions, review of treatment and its effectiveness or if needed to make changes. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan.

Based on observation, interview, and facility document review the facility failed to ensure pureed food was the appropriate consistency. This failure had the potential for eight residents on pureed diet to aspirate (drawing food into the lungs) and/or negatively impact the residents' dining experience resulting in poor food intake compromising their nutritional status out of facility census of 58. Findings: Review of the Diet Manual Rehabilitation, Residential and Long Term Care Facilities, dated 2018, showed the pureed diet should be smooth and the consistency of pudding. During a review of facility's policy and procedure (P&P) titled Food Preparation .Food Cookery, dated 2018, the P&P indicated, Pureed Food Preparation .Pureed food should be prepared to the consistency and thickness of mashed potatoes rather than a gravy or watery texture. Review of the daily menu, dated 12/04/23, showed the lunch menu included a pureed diet which received pureed pork with apples, pureed sweet potato, and pureed green beans. During an observation on 12/04/23 at 12:50 p.m. with Registered Dietitian Nutritionist (RDN), a test tray was conducted. The test tray contained the same pureed food served to residents for lunch. The plate which contained pureed hot food showed the pureed pork, sweet potato, and green beans were flat and spread out on the plate, so the foods ran into each other. Review of the daily menu, dated 12/05/23, the lunch menu showed the pureed diet received pureed smothered cube steak, pureed brown rice with gravy, pureed California blend mixed vegetables. During an observation on 12/05/23 at 11:45 a.m. in the kitchen, [NAME] 2 pureed cooked rice by adding scoops of rice to a blender. Then he added water from the tap without measuring the water. Before starting to blend the rice and water, he added more water into the blender. Then he blended the water and rice. When he was finished blending, the mixture was thin and pourable. [NAME] 2 poured the pureed rice into a metal container and placed it on the tray line to serve. During a concurrent observation and interview on 12/05/23 at 11:50 a.m. with RDN, a test tray was conducted. The test tray contained the same pureed food served to residents for lunch. The pureed smothered cube steak, pureed brown rice with gravy, and pureed California blend mixed vegetables were runny and spread out on the plate, so the different food items came into contact with each other. RDN stated when the staff pureed food, the food should be blended first, then water added gradually if needed. In an interview on 12/6/23 at 2:05 p.m., RDN confirmed the diet manual showed the pureed food should be pudding thick. She stated the pureed food served was thinner than pudding thick.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that staff followed proper infection control precautions to prevent spread of infection for five (Resident 16, Resident 55, Resident 21, Resident 60, and Resident 167) of 58 sampled residents when: 1) Resident 167's urinary catheter bag was touching the floor. 2) The nasal cannula for Resident 55 was not changed weekly. 3) The tube feeding for Resident 60 was not dated and labelled. 4) Nursing assistant (NA) did not perform hand hygiene after providing incontinent care to Resident 21. NA did not perform hand hygiene before entering and exiting resident rooms. 5) Registered Nurse 2(RN 2) did not change gloves and perform hand hygiene after handling Resident 16's device, and then gave medications to Resident 16 and applied eye drops. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: 1. During a review of Resident 167's, admission Record, printed on 12/7/23, the admission record indicated Resident 167 was originally admitted to the facility in November 2023 with a diagnosis of Bacteremia (Bacteremia is the presence of bacteria in the bloodstream) and chronic kidney disease (kidneys are damaged and can't filter blood the way they should and causes them to gradually lose their ability to function). During a concurrent observation and interview on 12/4/23 at 10:28 a.m., with Certified Nursing Assistant (CNA)1, Resident 167's urinary bag and tubing attached to the bottom of the bed, was touching the floor. CNA 1 stated Resident 167's Urinary bag and tubing was touching the floor. CNA 1 stated it should be secured without touching the floor in a privacy bag to prevent infection. During an interview on 12/6/23 at 10:25a.m. with Director of Nursing (DON), DON stated the urinary bags should be secured without touching the floor and covered in privacy bag. DON stated there is risk of infection to the patient. During a review the facility's policy and procedures (P&P) titled, Catheter Care, Urinary, revised in August 2022, the P&P indicated, Infection Control .2. b Be sure the catheter tubing and drainage bag are kept off the floor. 2. During a review of Resident 55's admission Record, printed on 6/14/23, the admission record indicated Resident 55 was originally admitted to the facility in June 2023 with medical diagnosis including Covid-19 (Caused by corona virus often with respiratory symptoms that can feel much like a cold, the flu, or pneumonia. COVID-19 may attack more than your lungs and respiratory system). During a review of Resident 55's, Order Summary, 12/4/23, the order summary indicated, Resident 55 had order for Intermittent oxygen via Nasal canula (a device that delivers extra oxygen through a tube and into your nose.) @1-3 liters (L). Order summary also indicated to change nasal cannula night shift every Sunday. During a concurrent observation and interview on 12/4/23 at 2:45 p.m. with LVN 2, Resident 55's nasal cannula was observed. LVN 1 stated the tubing is dated 11/19/23 at 6 am. LVN 2 stated the nasal cannula should be changed every week. LVN 2 stated if the tubing's are not changed the tubing can get contaminated and can cause lung infections like pneumonia. During an interview on 12/6/23 at 10:20 a.m. with DON, the DON stated their policy is to change the nasal cannula every Sunday night shift and it should be dated and labelled. DON stated it is important due to increased risk of infection and general hygiene issues. During a review the facility's, P&P, titled, Departmental (Respiratory Therapy) - Prevention of Infection ., the policy indicated Infection control considerations related to oxygen Administration .7. Change the oxygen cannula and tubing every seven (7) days, or as needed. 3. During a review of Resident 60's, admission Record, printed on 12/7/23, the admission Record indicated Resident 60 was originally admitted to the facility on [DATE] with medical diagnosis including Dyskinesia of Esophagus (disorders affecting the motor function of the esophagus [the esophagus is the hollow, muscular tube that carries food and liquids from the throat to the stomach]). During a concurrent observation and interview on 12/4/23 at 2:35 p.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 60's tube feeding in Kangaroo bag (a kind of tube feeding bag) was observed. LVN 1 stated the tube feeding does not have any date or label on it and cannot identify when the feeding was started and/or what type of feeding Resident 60 is receiving. LVN 1 stated it is important to date and label the tube feeding. During a review of Resident 60's, Order Summary, 12/4/23, the Order Summary indicated Resident 60 was receiving tube feeding (a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation): Isosource 1.5.@60ml/hr. with 300 ml water flushes every 4 hours. During an interview on 12/6/23 at 10:18 a.m., with Director of Nursing (DON), the DON stated it is important that Nurses label and date the tube feeding formula to ensure it is the right patient and the right formula. During a review of the facility's P&P titled, Enteral Feedings- Safety Precautions, revised in November 2018, the P&P indicated, General Guidelines. Preventing errors in administration .2. On the formula label document initials, date, and time the formula was hung, and initial that the label was checked against the order. 4. During an observation on 12/7/23 at 2:23 p.m., the Nursing Assistant (NA) came out of Resident room and without performing hand hygiene entered Resident 21's room. NA wore gloves and provided incontinent care to Resident 21. After completion of care, NA removed gloves and did not perform hand hygiene. NA then took the trash bag and disposed the trash bag in the trash bin outside the room. NA then grabbed the dirty linen bin and parked it outside room [ROOM NUMBER]. NA without performing hand hygiene entered room [ROOM NUMBER]. During an interview on 12/7/23 at 2:33 p.m. with NA, NA stated she cleaned the bed for Resident 21 and changed Residents diaper. NA stated after removing gloves they should wash hands, but she forgot to do it. NA stated it is important to prevent patients from getting infections. During an interview on 12/7/23 at 3:30 p.m. with Director of Staff Development/Infection Preventionist (DSD/IP), DSD/IP stated staff should perform hand hygiene before entering residents' room and when exiting rooms. DSD/IP also stated staff should perform hand Hygiene after removing gloves. DSD/IP stated it is important to protect themselves and residents from getting infections. During a review the facility's P&P titled, Handwashing/Hand Hygiene, revised in August 2019, the P&P indicated, Policy interpretation and Implementation .2. All personnel shall follow the handwashing /hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% alcohol: . b. before and after direct contact with residents: .m. after removing gloves: . 5. During a medication pass observation on 12/5/23, at 1:56 pm, in room [ROOM NUMBER] B, with RN 2, RN 2 did not remove gloves and perform hand hygiene and wear a clean pair of gloves after putting on Resident 16's right hand brace. Then, RN 2 administered oral medications, pulled down each eyelid, and instilled 1 eye drop in each eye of Resident 16. During an interview on 12/5/23, at 3:20 pm, with RN 2, RN2 stated I am sorry. RN 2 acknowledged she should have removed her gloves and performed hand hygiene after handling Resident 16' s hand brace and wear clean gloves before administering the oral medications and eye drops. RN 2 stated it was a risk for cross contamination to Resident. During an interview on 12/8/23, at 9:19 am, with the DSD/IP, the DSD/IP stated staff were expected to follow the facility's infection control protocol, and staff were supposed to be performing hand hygiene and wearing gloves for administration of medications, and if they are doing eye drops, they should be washing their hands. During a review of the facility's P&P titled, Administering medications, dated August 2019, the P&P indicated staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves . etc.,) for the administration of medications, as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide 80 square foot of space per resident for 30 residents who occupied 12 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside. Findings: During multiple room observations on 12/4/23 through 12/8/23, there were three residents in Rooms 22, 24, 27, 31, 33, and 35 and two residents occupying three-bedroom rooms in Rooms 23, 25, 26, 30, 32, and 34. 1. room [ROOM NUMBER] measured 11.3 feet by 19 feet which equaled 71.56 square feet per resident. 2. room [ROOM NUMBER] measured 19 feet by 11.4 feet which equaled 72.2 square feet per resident. 3. room [ROOM NUMBER] measured 19.3 feet by 11.4 feet which equaled 73.34 square feet per resident. 4. room [ROOM NUMBER] measured 19.1 feet by 11.3 feet which equaled 71.94 square feet per resident. 5. room [ROOM NUMBER] measured 19.1 feet by 11 feet which equaled 70.03 square feet per resident. 6. room [ROOM NUMBER] measured 19 feet by 11.4 feet which equaled 72.2 square feet per resident. 7. room [ROOM NUMBER] measured 19 feet by 11.4 feet which equaled 72.2 square feet per resident. 8. room [ROOM NUMBER] measured 18.9 feet by 11.4 feet which equaled 71.82 square feet per resident. 9. room [ROOM NUMBER] measured 18.9 feet by 11.4 feet which equaled 71.82 square feet per resident. 10. room [ROOM NUMBER] measured 18.9 feet by 11.3 feet which equaled 71.19 square feet per resident. 11. room [ROOM NUMBER] measured 18.1 feet by 11.7 feet which equaled 70.59 square feet per resident. 12. room [ROOM NUMBER] measured 19.1 feet by 11.3 feet which equaled 71.94 square feet per resident. During random observations of care and services from 12/4/23 to 12/8/23, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment in the rooms that might interfere with resident's care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. During an interview on 12/05/23, at 3:40 p.m., with Resident 6, Resident 6 stated, he had sufficient space in his room. Resident 6 stated, he liked the room. During an interview on 12/05/23, at 3:45 p.m., Resident 22 stated, he is comfortable in his room and had room for his personal belongings. There were no negative consequences resulted from decreased space. No safety concerns for residents in the 12 rooms. Granting of room size waiver recommended.

Based on staff interviews and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time, qualified dietetic supervisor when the dietitian was not full time. The lack of a qualified, competent, and full-time supervisor resulted in staff not having adequate supervision, training, and knowledge to carry out Food and Nutrition Services in a safe and sanitary manner. The lack of qualified, full time person to supervise the Food and Nutrition Services Department had the potential to result in unsafe food practices and food borne illness for 58 residents eating facility prepared foods. Findings: According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes the following: The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). Review of the job description titled Dietary Services Director signed by the Dietary Services Manager (DSM) on 10/10/23, the primary purpose of the job position was to assist the Dietitian in planning, organizing, developing, and directing the overall operation of the Food Services Department in accordance with current Federal, State, and local standards, guidelines and regulations governing the facility, to assure quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. The job description also showed the specific requirements for the position included must be registered as a Food Service Director in the State. In an interview on 12/04/23 at 9:22 a.m., DSM stated she was the supervisor for the kitchen. In an interview on 12/4/23 at 12:34 a.m., Registered Dietitian Nutritionist (RDN) stated she worked at the facility part time, twice a week for 16 hours total per week. In an interview on 12/8/23 at 10:30 a.m., DSM stated she was currently working on her qualifications to because a Certified Dietary Manager (CDM). She confirmed she did not have qualifications to qualify her for the full-time supervisor of Food and Nutrition Services. In an interview on 12/8/23 at 11:16 a.m., the Administrator (ADM) confirmed DSM was not qualified for the Dietary Services Director position per the California Code, Health, and Safety Code - HSC § 1265.4.

Based on observation, interview, and facility document review, the facility failed to ensure kitchen staff were competent regarding job duties when: 1. A cook did not know the appropriate method for manually cleaning soiled utensils and equipment using the 3-compartment sink. 2. A diet aide did not know the appropriate procedures for testing the strength of the sanitizer solution used for sanitizing kitchen surfaces. 3. A diet aide did not demonstrate appropriate procedures for testing the sanitizer in the dish machine. These failures had the potential to result in contamination of kitchen equipment and/or utensils leading to illness caused by pathogens (harmful organisms) for 58 residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 12/05/23 at 10:35 a.m. with [NAME] 2, [NAME] 2 stood by the 3-compartment sink and described the process for cleaning soiled utensils/equipment in the sink. He stated the first sink was filled with water only, the second sink was filled with water and soap, and the third sink was filled with sanitizer. [NAME] 2 stated the water in all the sinks had to be room temperature and the equipment/utensils had to be submerged in the sanitizer for no less than five minutes. During an interview on 12/05/23 at 1:45 p.m. with the Dietary Services Manager (DSM), DSM stated that three compartment sinks should be in the following order of wash, rinse and sanitize. She stated the sanitizer used was the acid-based sanitizer. A review of the manufacturer's instruction for the acid-based solution, which was located on the inside of the kitchen's chemical room door, titled, [Brand Name] Sink and Surface Cleaner Sanitizer indicated the sanitizer could be used in a 3-compartment sink and immersed items in the sanitizer until thoroughly wet for at least 60 seconds. Review of the facility's Policy and Procedure (P&P) titled, Sanitation and Infection Control Warewashing (Handwashing Method), dated 2018, the P&P indicated using the 3-compartment sink, the first sink was for washing and the sink is filled with a detergent solution and the water is to be at least 100 degrees Fahrenheit (F); the second sink is for rinsing and is filled with clean hot water; and the third sink is for the sanitizer solution. 2. During a concurrent observation and interview on 12/05/23 at 10:39 a.m. with Diet Aide 1 (DA 1), DA 1 stated she was responsible for filling red buckets with sanitizer and checking the strength of the sanitizer. DA 1 demonstrated how she checked the sanitizer strength by filling a red bucket with an acid-based sanitizer solution dispensed from a hose located inside the kitchen's chemical closet. DA 1 picked up a test strip bottle used for testing chlorine sanitizer solutions from the drawer. DSM, who was nearby stated wrong one. DA 1 asked which one, then picked up a test strip bottle for the acid-based sanitizer. DA 1 proceeded to test the sanitizer strength by placing the test strip into the solution for eight (8) seconds. When asked, DA 1 stated, she held the strip in the solution for 10 seconds and was supposed to hold it in the solution for 10 seconds. During an interview on 12/05/23 at 10:42 AM with DSM, DSM stated test strips should be dipped and held in the acid-based solution for five seconds. During a review of the manufacturer's instruction for the acid-based solution which were located on the inside of the kitchen's chemical room door, titled, [Brand Name] Sink and Surface Cleaner Sanitizer, the instructions indicated, Dip strip for 5 seconds in test solution. 3. During a concurrent observation and interview on 10/05/23 at 10:25 a.m. with DA 1, in the kitchen, DA 1 was cleaning dishes using the dish machine. She stated she was responsible for checking the sanitizer strength for the sanitizer used in the dish machine. DA 1 demonstrated the process for testing the dish-machine sanitizer concentration. After the dish machine rinse cycle was completed, DA 1 opened the door to the dish machine and touched a chlorine sanitizer test strip to the surface of a plate. She compared test strip to the color chart located inside the test strip container. The color of the test strip was dark purple. DA 1 said the test strip showed the sanitizer strength was 200 parts per million (ppm) and was not good and the sanitizer was too strong. DA 1 stated she should report to her supervisor if the sanitizer strength was too strong. After testing the sanitizer strength, DA 1 continued to clean dishes using the dish machine and did not report to her supervisor, who was in the kitchen, that the sanitizer strength of the dish machine was too strong. During an interview on 12/05/23 at 10:39 a.m. with DSM, DSM stated 200 ppm reading was out of range. During a review of facility's P&P titled Sanitation and Infection Control Dishwashing Procedures (Dish machine), dated 2018, the P&P indicated, Use a chemical sanitizing rinse to achieve and maintain 50-100 PPM of chlorine at dish surface.

Based on observation, interview, and facility document review, the facility failed to ensure: 1. the menu met the nutritional needs of the residents; 2. there was a menu for a vegetarian diet; and 3. portions for diets provided matched what was indicated in the diet manual. These failures had the potential for residents to receive meals containing nutrients at levels not appropriate for their prescribed diet leading to food related medical complications for 58 residents who received food from the kitchen. Findings: 1. Per the National Institute of Health, Nutrient Recommendations: Dietary Reference Intake (DRI) are documents issued by the Food and Nutrition Board of the National Academies of Sciences Engineering, and Medicine. DRI is the general term for a set of reference values used to plan and assess nutrient intakes of healthy people. These values, which vary by age and sex, include Recommended Dietary Allowance (RDA): the average daily level of intake sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals and often used to plan nutritionally adequate diets for individuals; and Adequate Intake (AI): Intake at this level is assumed to ensure nutritional adequacy and is established when evidence is insufficient to develop an RDA. The following lists the recommended level of DRIs that were not met based on the hospital's nutrient analysis. Ranges are based on age and gender. Review of the daily nutrient analysis spreadsheet of the menu from 10/1/23 - 12/8/23, showed 14 nutrients and the corresponding amounts provided by the menu for each meal. The analysis showed values for seven nutrients with RDAs (Protein, Carbohydrate, Calcium, Iron, Phosphorus, Vitamin A, Vitamin C) out of 19 nutrients that have RDAs, and one nutrient with an AI (Potassium) out of six nutrients that have AIs. The nutrients listed were not a complete list of nutrients for which RDA and AI information are available. In addition, the nutrient analysis only provided information for the Regular diet and not the therapeutic diets. Review of resident tray tickets used for lunch on 12/4/23, showed residents were prescribed a variety of diets including Regular, Consistent Carbohydrate (a diet typically prescribed for a person with diabetes or issues with controlling blood sugar), Small Portion, Mechanical Soft (a diet where the food is mechanically altered to a texture that is easy to chew), Pureed (a diet where the food is mechanically altered to a smooth texture and thick enough to hold shape), Renal (a diet typically prescribed for a person with kidney disease), and Vegetarian (no meat). Review of the diet spreadsheet titled Diet Extensions, dated 12/4/23, showed the food sizes and portions for therapeutic diets were not always the same as the Regular diet, so the amount of nutrients in a therapeutic diet would differ from the amount in the Regular diet. For instance, for lunch a Regular diet received a 3 inch by 2 inch piece of spice cake and the CCHO and Renal diet received a half piece of cake. Also, the Regular diet received a number 8 scoop (about 4 fluid ounces) of baked sweet potato and the Renal diet received low sodium rice or pasta. In an interview with Registered Dietitian Nutritionist (RDN) on 12/5/23 at 9:04 a.m., RDN confirmed there was a nutrient analysis for the Regular diet but not for any of the therapeutic diets offered at the facility. She also confirmed for the Regular diet, the nutrient analysis did not include all available Dietary Reference Intake (RDAs and AIs) information. In an interview on 12/5/23 at 1:50 p.m., RDN confirmed she approved the menu, but she did not make sure the menu met the nutrient recommendations for the facility demographics. Review of the daily nutrient analysis of the menu from 10/1/23 - 12/8/23 (69 days), showed the daily calories were under 2000 kcals on 47 days and went as low as 1476 kcals on two of the days. In an interview on 12/6/23 at 12:05 p.m., RDN stated the diet manual used at the facility was not from the same company who made the menus. She confirmed the diet manual showed the Regular diet should provide 2000-2400 kcals (kilocalories) per day. She confirmed the calories shown on the nutrient analysis for the Regular diet were lower than what was recommended in the diet manual. She stated she did not think the menu according to the nutrient analysis provided enough calories to meet the estimated caloric needs of residents. In an interview on 12/7/23 at 12:12 p.m., RDN stated when she assessed whether residents' food intake met their estimated caloric needs, she used 2100-2300 kcals as the baseline for kcals provided by the daily menu. 2. An observation of tray line food service and concurrent interview with [NAME] 3 on 12/4/23 at 11:40 a.m., showed a food tray was prepared for Resident 57. Resident 57's tray ticket showed his diet was a Regular texture, Consistent Carbohydrate, No added Salt, Vegetarian. [NAME] 3 stated the vegetarian entrée for lunch today was grilled cheese. It was identified the grilled cheese sandwich provided to Resident 57 was not of equal nutrient content to the regular entrée served (Cross-reference F803). A record review for Resident 57 showed a diet order prescribed by his primary physician was placed on 8/24/23 and included Vegetarian. Review of the daily menu dated 12/04/23, showed 10 diets listed with corresponding food items and portion sizes to serve for each diet. A Vegetarian diet was not listed on the menu to show what a resident on a Vegetarian diet should receive for meals. In an interview on 12/5/23 at 12:40 p.m., Resident 57 stated he received repeated food daily such as salads and vegetables. He stated he would love to try other food options. He stated there was not a menu that he could look at, for his Vegetarian diet. In an interview with RDN on 12/5/23 at 1:50 p.m., she stated there was not a Vegetarian or Plant Based (no animal products) menu available because we don't get a lot of vegetarians. RDN confirmed the Vegetarian diet was a Doctor ordered diet. Review of the Diet Manual Rehabilitation, Residential and Long Term Care Facilities, dated 2018, showed a Vegetarian diet was included as a recognized diet and provided information about the diet such as the approximate macronutrient (nutrients that are needed in larger quantities in the diet) and calorie composition the diet was to provide. 3. During an observation of tray line food service and a concurrent interview with DSM on 12/04/23 at 11:40 a.m., showed residents on physician prescribed small portion and large portion diets. For the small portion diets, the portion sizes were the same as the regular except for the sweet potatoes, which were a small portion. Also, for the large portion diets, the portion sizes were the same as the Regular diet except for a larger portion of sweet potatoes were served. DSM confirmed small portion diets received a smaller portion of the carbohydrate food (starchy foods such as potatoes, pasta, rice) item and the large portion diets received double the amount of the carbohydrate food item. She stated the rest of the food portions were the same as the Regular diet. Review of the Diet Manual Rehabilitation, Residential and Long Term Care Facilities, dated 2018, showed Large Portion diets were to receive increased ¼ to ½ cup increments for the entrée and starch items. The diet manual also showed for Small Portion diets, food items should be reduced by ¼ cup increments for entrees and starch items. In an interview on 12/6/23 at 2:5 p.m., RDN stated the usual portions served on tray line for small and double portions were half the amount of carbohydrate for small portions and for large portions double the amount of carbohydrate and vegetables. RDN confirmed the diet manual was not followed for large and small portion diets. Review of the facility policy and procedure titled Food Preparation Subject: Portion Control, dated 2018, showed small portions and large portions may be given to residents per physician order. For small portions, unless otherwise stated on the menu, food items should be reduced by ¼ cup increments for entrees, starch, and vegetables. For large portions, unless otherwise stated on the menu, portion sizes should be increased in ¼ cup increments for entrees, starch, and vegetables.

Based on observation, interview, and record review, the facility failed to serve food that was palatable when food was bland (lacked flavor). This failure had the potential to negatively impact the residents' dining experience which may result in poor dietary intake compromising the health and nutritional status of 58 residents who received food from the kitchen. Findings: During an interview on 12/04/23 at 10:45 a.m. with Resident 16, Resident 16 stated the facility's food was lacking in taste and beans were very plain. During a review of daily menu, dated 12/04/23, the lunch menu indicated green beans were served for all diets. During a concurrent observation and interview on 10/04/23 at 12:50 p.m. with Registered Dietitian Nutritionist (RDN), a test tray was conducted. The test tray contained the same regular textured and pureed food served to residents for lunch. The food was tasted by three surveyors and the RDN. All the surveyors and the RDN agreed the green beans for both regular and pureed were lacking flavor. During a review of daily menu dated 12/05/23, the lunch menu indicated items served included, but were not limited to, smothered cube steak, brown rice with gravy, and California blend (mixed vegetables). During an interview on 12/05/23 at 11:40 a.m. with [NAME] 2, [NAME] 2 stated he never added salt to the food when he cooked it. During a concurrent interview and record review on 12/05/23 at 11:43 a.m. with RDN, the undated recipe titled Brown [NAME] with Gravy was reviewed and showed salt was an ingredient. RDN confirmed the recipe used salt. She said [NAME] 2 should follow the recipe when preparing food and should add salt if the recipe called for salt. During a concurrent observation and interview on 12/05/23 at 11:50 a.m. with RDN, a test tray was conducted. The tray consisted of the same regular and pureed food served to residents. Three surveyors and the RDN tasted the food. The surveyors and the RDN agreed the regular and pureed mixed vegetables, and the regular and pureed rice, lacked flavor. RDN stated the regular and pureed rice and vegetables were bland and could use salt. During a review of facility's policy and procedure (P&P) titled Food Preparation .Tasting of Food Prior to Serving, dated 2018, the P&P indicated, Cooks are required to taste all food prior to serving to ensure adequate seasoning and quality .5. Remember, if the food does not taste good, the residents/patients will not eat it.

Based on observation, interview, and facility document review, the facility failed to: 1. Provide an alternate vegetarian entrée of similar nutritive value to the regular entrée for one non-sampled resident (Resident 57). 2. Ensure peanut butter and jelly sandwiches offered as an alternate entrée were of similar nutritive value to the regular entrée. These failures had the potential to result in a decreased nutrient intake as indicated by the planned menu for 29 residents who received Regular textured food. Findings: 1. A review of Resident 57's admission Record, printed 12/08/23, showed Resident 57 was originally admitted in August 2023 with diagnoses of anemia (lack of red blood cells), diabetes (too much sugar in the blood), depression, and muscle weakness. A review of Resident 57's Order Details, dated 08/24/23, showed Resident 57 had an order for a vegetarian diet placed by a primary care physician. During a review of Resident 57's lunch tray ticket, dated 12/04/23, the ticket showed Resident 57 was on a vegetarian diet. During a review of the facility's menu spreadsheet, titled Diet Extensions, dated 12/04/23, the menu spreadsheet indicated the regular entrée for lunch was three ounces (oz) of Roasted Pork with Apples. A vegetarian diet was not listed on the menu. During an observation on 12/04/23 at 11:40 a.m., [NAME] 3 prepared a grilled cheese sandwich and placed it on the tray for Resident 57. She stated the grilled cheese sandwich was the vegetarian entrée for lunch that day. She stated she prepared the sandwich using two slices of cheese. A review of the undated recipe for Roasted Pork with Apples, showed a 3 oz serving contained 25 grams (gm) of protein. On 12/5/23 at 9:06 a.m., an observation showed a large package of sliced Pasteurized Process Swiss and American Cheese stored inside a reach in refrigerator in the kitchen. The nutrition facts on the package showed a slice of cheese was equivalent to three gm of protein. During an interview on 12/05/23 at 1:45 p.m. with Dietary Supervisor Manager (DSM) and Registered Dietitian Nutritionist (RDN), DSM confirmed two slices of processed Swiss American cheese was used to prepare the grilled cheese sandwiches. DSM confirmed the grilled cheese was a substitute for the Roasted Pork entrée for Resident 57's lunch on 12/4/23. During an interview on 12/06/23 at 12:05 p.m. with RDN, RDN stated for the grilled cheese sandwich, 2 slices of cheese which contained 6 grams of protein total, was not an adequate substitute for 3 ounces of meat or 25 grams of protein contained in one serving of the Roasted Pork entrée. During a review of facility's Policy and Procedure (P&P), titled Menus .Menu Alternate dated 2018, the P&P indicated, Menu alternates will be of similar nutritive value as the original menu item . 2. During a concurrent observation and interview with [NAME] 1 in the kitchen on 12/05/23 at 10:39 a.m., [NAME] 1 prepared peanut butter and jelly sandwiches. [NAME] 1 spread peanut butter and jelly on slices of white bread. [NAME] 1 stated that she prepared the peanut butter and jelly sandwiches which could be used for substitutes if residents disliked their meal. [NAME] 1 further stated that she did not measure the peanut butter and just spread a little, not too much on the bread. During an interview on 12/05/23 at 1:45 p.m. with DSM and RDN, DSM confirmed the peanut butter and jelly sandwich could be a substitute for an entrée. DSM stated that no other food items were added when the peanut butter and jelly sandwich was served as a substitute. RDN confirmed other food items were not added when peanut butter and jelly was served as a substitute, to make the substitute equal in nutritive value to the entrée served. DSM and RDN both stated they did not know if there was a recipe for peanut butter and jelly sandwiches. During a review of Peanut Butter and Jam Sandwich recipe, it indicated to spread 2 tablespoons peanut butter on each peanut butter and jelly sandwich. Each half slice of sandwich had an equivalent eight gm of protein. During an interview on 12/06/23 at 12:05 p.m., RDN stated she did not think that peanut butter and jelly sandwich recipe provided adequate protein for an entree substitute. During a review of facility's Policy and Procedure (P&P) titled, Menus .Menu Alternate, dated 2018, the P&P indicated, Menu alternates will be of similar nutritive value as the original menu item.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when the following was noted: 1. A 10-pound roll of ground beef and a 10-pound package of sausage were not thawed safely. 2. A juice dispenser was not clean. 3. A can opener was not clean. 4. Three cutting boards were not in a good condition and were not clean. 5. Dry food was not stored at least six inches off the floor. 6. Three pans were in poor condition. 7. A lowerator (plate warmer) was not clean. 8. A fan mounted to the wall inside the kitchen was not clean. 9. A vent inside the dry food storage closet was not clean. 10. The floor of three food storage/ supply closets located in the hallway, outside of the kitchen, had a rough, crumbling surface where transition strips (a long strip made of metal, wood, or other material, with rounded edges, used to bridge two floors together) were missing. 11. The handwashing sink was used for another purpose other than handwashing. 12. Expired test strips were available and used to test sanitizer concentrations for the dish machine and surface sanitizer. These failures placed 58 residents who received food from the kitchen at risk for food borne illnesses. Findings: 1. During an observation on 12/05/23 at 9:03 a.m. in the kitchen, a 10-pound roll of ground beef was thawing in a bucket filled with standing water in the 3-compartment sink. During an interview on 12/05/23 at 10:14 a.m. with [NAME] 2, he confirmed the bag of ground beef was being thawed. He stated the water should be running into the bucket with the ground beef. During a concurrent observation and interview on 12/05/23 at 10:16 a.m. with [NAME] 1., a 10-pound package of sausage was thawing in bucket under a running water in the three compartment sink. The end of the sausage package was exposed above the surface of water so at least two sausages were not submerged in the water. During an interview on 12/05/23 at 10:19 a.m., Dietary Services Manager (DSM) stated the sausage bag did not need to be fully submerged in the water. During a review of facility's policy and procedure (P&P) titled, Food Preparation .Food Defrosting Methods, dated 2018, the P&P indicated thawing food at room temperature is not acceptable. Meat may be defrosted by placing under cold running water under 70 degrees F (Fahrenheit) for no more than 2 hours. According to U.S. Food and Drug Administration Federal Food Code 2022, when thawing Time/Temperature Control for Safety (TCS) food (food more likely to grow harmful pathogens if not stored safely) in water, it is to be submerged completely under running water. 2. During the initial kitchen tour on 12/04/23 at 9:54 a.m., boxes of concentrated juices were connected to hoses which then connected to a bar gun dispenser. A plastic connector which connected the concentrated orange juice bag to the hose, had brown residue covering the surface and was sticky when touched. During an interview on 12/06/23 at 10:10 a.m. with DSM, DSM stated Dietary Aide (DA) 1 was one staff responsible for cleaning the juice dispenser gun. She stated staff did not clean the hose or connectors. She stated the juice machine was cleaned by diet aides three times a day. During an observation in the kitchen and concurrent interview with DA 1 on 12/06/23 at 10:12 a.m., DA 1 stated that she cleaned the juice dispenser gun during her shift. DA 1 demonstrated how she cleaned the dispenser gun. She removed a black plastic nozzle, so the surface of the diffuser (a part of the dispenser gun that spreads a liquid out to separate or slow down the speed of the flow of the liquid) and O-ring (a rubber ring that helps seal two parts together when the parts are connected) were visible. There was an accumulation of a moist, dark pink residue and clustered spots of light pink residue on the surface of the diffuser and O-ring. As the observation and interview continued on 12/6/23 which started at 10:12 a.m., DA 1 proceeded to demonstrate the cleaning process. She filled a metal container with a mixture of water and acid-based sanitizer dispensed from a hose in the chemical closet. It was noted DA 1 did not test the strength of the sanitizer solution. She placed the black plastic nozzle inside the solution and placed just the tip of the dispenser gun (the diffuser and O-ring) in the solution. DA 1 had difficulty keeping the dispenser gun inside the solution in the metal container, as it kept falling out. DA 1 stated she soaked the dispenser gun and black plastic nozzle in the solution for 30 minutes then rinse the pieces with water after. As the observation and interview continued on 12/6/23 which started at 10:12 a.m., DA 1 then demonstrated the rinsing process of the dispenser gun. DA 1 emptied the solution from the metal container, then filled it with water from the handwashing sink. DA 1 placed the tip of the dispenser gun in the water, she stated she soaked both nozzle and dispenser gun in water for 15 minutes then she would reinstall the black plastic nozzle to the dispenser gun. During an interview on 12/06/23 at 10:17 a.m. with DSM, DSM stated to clean the juice dispenser gun, the staff were to use warm water. She also stated the black plastic nozzle was to be removed to clean the dispenser gun and staff had to make sure the nozzle and diffuser were clean. DSM stated the whole dispenser gun should be fully submerged in warm water, not just the tip. DSM further confirmed the orange juice connector was sticky and dirty, she did not know who cleaned the connectors or the hoses, but she said the juice dispenser company provided services every 4-5 months. DSM also stated staff did not have instructions to follow on how to clean the dispenser gun or other parts of the machine. During an interview on 12/06/23 at 10:45 a.m. a photo of the dispenser gun diffuser and O-ring from when it was observed earlier in the day at 10:12 a.m., was showed to RDN. RDN stated there was a build-up and some sort of substance accumulation on the diffuser and it did not appear it was cleaned three times a day. In an interview on 12/6/23 at 12:05 p.m., RDN stated she was concerned staff were not cleaning the juice machine because she never saw them cleaning it, so she gave instructions to DA 1 on how to clean the machine. RDN stated she did not have instructions on how to clean the machine. On 12/7/23 at 2:05 p.m., RDN provided an undated document titled Weekly Cleaning Guide for Bar Gun Systems. RDN confirmed these were cleaning instructions from the company who serviced the juice machine but were not the juice machine/juice dispenser gun manufacturer's cleaning instructions. The instructions provided by the juice machine cleaning company showed to unhook the plastic connectors from the juice boxes and soak the connectors in warm water for one minute and ensure all juice residues were dissolved before reconnecting the connectors. The instructions also showed to remove the black plastic nozzle from the bar gun and clean with warm, soapy water. Then set aside to dry. The instructions then showed to wipe off any juice build-up accumulated on the nozzle of the bar gun, fill a container with warm water and allow the bar gun to soak for five minutes. Then reinstall. RDN stated she would look for the manufacturer's cleaning instructions. Review of the document titled [Manufacturer's Name] Post-Mix Beverage Dispenser, revision date of 4/9/21, provided by RDN as the manufacturer's manual for the juice machine dispenser gun, showed directions on preparing the chloromelamine sanitizer (a chlorine based sanitizer) solution to use for sanitizing the juice gun. The directions then showed how to clean the sheathing (hoses) for the juice machine using the sanitizer solution. The directions showed to clean the juice machine nozzle, to remove the black nozzle and place in the sanitizer solution for two minutes, and scrub with a brush to remove any build-up. Then immerse a brush in the sanitizer solution and scrub the diffuser with the brush to remove any build-up. Then the air-dry the nozzle and the diffuser. During a concurrent interview and manufacturer's cleaning instruction review on 12/08/23 at 9:40 a.m. RDN confirmed kitchen staff were not using the sanitizer recommended by the juice machine dispenser gun to clean the dispenser gun. RDN also confirmed the staff should clean the juice machine connectors and sheathing/hoses as shown in the manufacturer's instructions. During a concurrent interview and review of the Daily Cleaning Schedule, dated November 2023 and December 2023, on 12/8/23 at 9:50 a.m., the cleaning schedule showed boxes to initial for each day of the month, for various pieces of equipment. Many boxes for various pieces of equipment were filled with initials. However, all the boxes coinciding with the juice machine for each day of the month in November were not initialed. For the month of December two boxes for December 1 and 2 were initialed by the juice machine but boxes for December 3, 4, 5, 6, 7, and 8 were not initialed. It was also noted there were no boxes to initial to show the juice machine was cleaned three times per day as there was only one box per day to initial. DSM confirmed staff were not signing off on cleaning the juice machine. DSM stated when a piece of equipment was cleaned, the staff should initial the cleaning schedule. Review of the facility's P&P titled, Sanitation and Infection Control Subject: Cleaning Schedules, dated 2018, showed cleaning schedules will be developed and enforced by the Director of Food and Nutrition Services. Schedules should indicate the frequency of cleaning with tasks and designated to specific positions. Employees will initial on the schedule when designated tasks are completed. All staff will be trained to use the cleaning schedules/procedures. Cleaning procedures should specify products to be used. Cleaning solutions must be used in proper concentration and dilution. The Director of Food and Nutrition Services should routinely check cleaning schedules . According to U.S. Food and Drug Administration Federal Food Code 2022, equipment food-contact surfaces and utensils shall be clean to sight and touch. In addition, equipment nonfood-contact surfaces of equipment shall be kept free of an accumulation of food residue and other debris. 3. During a concurrent observation in the kitchen and interview with DSM on 12/04/23 at 9:50 a.m., the industrial can opener stored in a holder mounted on a table had a brown residue build-up on the can opener's blade and on the can opener holder mounted to the table. When wiped with a paper towel, a sticky brown substance transferred to the paper towel. In addition, the can opener shaft (handle) was sticky to the touch. DSM stated the can opener was dirty, it should be cleaned after each use. During a review of the facility's P&P titled, Sanitation and Infection Control .Cleaning Small Appliances/Equipment, dated 2018, the P&P indicated equipment will be cleaned and sanitized to prevent food borne illness .2. Can Openers are to be cleaned after each use and sanitized daily. 4. During a concurrent observation and interview on 12/05/23 at 11:07 a.m. with RDN, three randomly selected cutting boards from a clean storage rack, located on a preparation table, had a significant number of scratches on the cutting surface so the surfaces were rough to the touch. There were also visible black and brown residue deposits on the cutting surfaces. One cutting board was sticky when touched. RDN Confirmed the cutting boards were scratched and had visible residue. Review of facility's P&P titled, Sanitation and Infection Control .Cleaning Small Appliances/Equipment, dated 2018, showed cutting boards will be clean and sanitized after each use. According to U.S. Food and Drug Administration Federal Food Code 2022, Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. In addition, multiuse food-contact surfaces are to be smooth and free from inclusions, pits, and similar imperfections. 5. During a concurrent observation and interview with DSM on 12/04/23 at 10:05 a.m., showed dry food stored in a closet in the hallway outside of the kitchen. The bottom shelf was approximately 2 inches from the floor and a case of vanilla wafers, a case of tea bags, and a case of hot chocolate packages were stored on the bottom shelf. DSM stated the food should be stored six inches above the floor. During a review of the facility's P&P titled, Sanitation and Infection Control .Canned and Dry Goods Storage, dated 2018, showed All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly .5. Food and supplies should also be stored six inches off the floor. 6. During the initial tour of the kitchen on 12/04/23 at 9:45 a.m., a large pan stored via a hanging storage system above the 3-compartment sink, had a dry, black residue build-up on the food-contact surface. An observation on 12/4/23 at 11:40 a.m., showed [NAME] 3 prepared food on the stove using two pans. The cooking surface of the pans were significantly scratched. During a concurrent observation and interview on 12/05/23 at 9:05 a.m. with Registered Dietitian Nutritionist (RDN), two non-stick pans which appeared to be the same pans [NAME] 3 used to prepare food for lunch on 12/4/23 were stored on a shelf underneath the tray line counter. The cooking surface of these two non-stick pans were noted to have significant scratches, and pieces of the non-stick coating were peeled off. The three pans then were examined with RDN, including the large pan with black residue build-up observed hanging above the 3-compartment sink on 12/4/23. RDN confirmed there was black residue build-up on the large pan and the two smaller pans were scratched. According to U.S. Food and Drug Administration Federal Food Code 2022, multiuse food-contact surfaces are to be smooth and free from inclusions, pits, and similar imperfections. In addition, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. 7. During a concurrent observation and interview on 12/04/23 at 9:56 a.m. with DSM, in the kitchen, there was a lowerator located on one side of the tray line counter. There was what resembled food crumbs and other debris covering the inside bottom surface of the lowerator. DS stated the lowerator was dirty because it was difficult to reach the bottom. According to U.S. Food and Drug Administration Federal Food Code 2022, Equipment Food-NonFood-Contact Surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. 8. During an initial tour of the kitchen on 12/04/23 at 9:50 a.m., a large fan was mounted to the wall and facing the dish machine. The fan's plate guard was covered with a gray, fuzzy substance. During a concurrent observation and interview on 12/07/23 at 8:55 a.m. with the Maintenance Director (MD), MD stated the fan in the kitchen was dusty. He also stated housekeeping staff was responsible for cleaning the fan but there was no documentation to show when it was last done. He stated there was not a written schedule that included fan cleaning. He stated he did not think the fan was used. According to U.S. Food and Drug Administration Federal Food Code 2022, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust. In addition, the premises shall be free of items that are unnecessary to the operation or maintenance of the establishment such as equipment that is nonfunctional or no longer in use. 9. During a concurrent observation and interview on 12/04/23 at 10:05 a.m. with DSM, in the dry food storage room located in the hallway outside the kitchen, a vent in the ceiling, directly above shelving holding dry food goods, had a gray, fuzzy build-up on the surface. DSM stated the vent was not clean and dirty. DSM also stated that maintenance was responsible for cleaning the vents. During a concurrent observation and interview on 12/07/23 at 8:15 a.m. with MD, in the dry food storage room, MD stated the vent was dusty and needed to be cleaned. MD stated there was no documentation to show when the vent was last cleaned and there was not a written schedule that included vent cleaning. According to U.S. Food and Drug Administration Federal Food Code 2022, Maintenance and Operation .Physical facilities shall be cleaned as often as necessary to keep them clean. 10. During a concurrent observation and interview on 12/04/23 at 10:05 a.m. with DSM, there were three storage areas used for kitchen supplies located in the hallway outside of the kitchen. The first storage closet contained dry food goods, the second contained emergency food supplies, and the third contained single-use food service items. All three areas had a long gap in the floor between the hallway floor and the inside closet floor. At the gaps, the edges of the flooring were cracked, and the surface was not smooth. There were pieces of debris collected in the gaps. During a concurrent observation and interview on 12/07/23 at 8:15 a.m. with MD, MD stated the three storage room floors were missing transition strips (a long strip made of metal, wood, or other material, with rounded edges, used to bridge two floors together) between the hallway floor and the closet floors. According to U.S. Food and Drug Administration Federal Food Code 2022, floors and floor coverings are to be designed, constructed, and installed so they are smooth and can be easily cleaned. In addition, physical facilities shall be maintained in good repair. 11. During an observation on 12/06/23 at 10:12 a.m. with DA 1, DA 1 demonstrated how she cleaned the juice machine. During the demonstration, she emptied sanitizer solution from a metal container and filled it with water from the handwashing sink. Then she proceeded to clean the juice machine using the water in the metal container from the handwashing sink. During an interview on 12/06/23 at 10:17 a.m. with DSM, DSM stated that DA 1 should not use the water from the handwashing sink, that area was only intended for handwashing purposes. According to U.S. Federal Drug and Administration Food Code 2022, a handwashing sink may not be used for purposes other than handwashing. 12. An observation and concurrent interview with DSM on 12/5/23 at 10:47 a.m., showed two strip bottles, containing test strips for the purpose of testing the strength of the acid based surface sanitizer and the dish-machine chlorine sanitizer solution, were stored in a drawer under the tray line counter. The container with the acid-based sanitizer test strips had a label showing the expiration date of the test strips was September 2023 and the container with the chlorine sanitizer test strips had a label showing the expiration of the test strips was July 1, 2023. The containers of test strips were available for use. DA 1 used the expired acid based test strips to demonstrate how she tested the strength of the acid base surface sanitizer. DSM confirmed the chlorine and acid-based sanitizer test strips were expired and should not be used. During an interview on 12/08/23 at 10:45 a.m. with DSM, DSM stated she was responsible for checking the strips used to test sanitizing solution to ensure they were not expired. DSM also stated expired strips could result in an inaccurate test result of the sanitizing solution. According to U.S. Food and Drug Administration Federal Food Code 2022, the person in charge is to ensure employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused, through routine monitoring of solution chemical concentration. In addition, the Food Code annex shows, manufacturers are to provide methods such as test strips to verify the equipment consistently generates a solution on-site at the necessary concentration to achieve sanitation.

Based on observation, interview, and facility document review, the facility failed to have a policy and procedure to describe how food brought in by family and visitors would be stored safely for the residents. This failure had the potential to negatively impact the residents' dining experience and possibly result in poor food intake for 58 residents who ate food by mouth. Findings: A review of the policy and procedure titled Foods Brought by Family/Visitors with a revision date of October 2017, showed food brought to the facility by visitors and family is permitted. The staff will discard perishable food within the same day or 4-hours from the time food is brought into the facility to prevent risk of foodborne contamination. In an interview with the Director of Staff Development/Infection Preventionist (DSD-IP) on 12/7/23 at 8:25 a.m., DSD-IP stated the facility did not save/store food for residents when food was brought in from the outside by visitors and/or from restaurants because it was not known if the food was stored and/or prepared safely before it was brought into the facility.

Based on interview and record review, the facility failed to complete the annual Minimum Data Set (MDS- an assessment tool used in skilled nursing facilities), for one of ten sampled residents (Resident 9). This failure had the potential to delay care planning and care delivery. Findings: Resident 9's annual MDS had an Assessment Reference Date (ARD - the last day to finish the assessment of the resident) of 2/28/22. The annual MDS was submitted and accepted on 5/6/22. During an interview on 5/12/22 at 9:18 a.m., with Director of Nursing (DON), DON stated, Resident 9's annual MDS was submitted late. DON stated, the MDS was required and was a reflection of the resident's condition and care. DON stated, the MDS was an assessment and could pick up changes in the resident's condition and was used to write plan care. DON further stated, staff need to have accurate assessments to provide care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet the needs for one (Resident 114) of one sampled residents receiving dialysis when the facility did not develop and implement care plan for Resident 114's dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) care. This deficient practice may result in Resident 114's physical, psychosocial and functional needs to go unmet. Findings: A review of Resident 114's admission Record, dated 5/11/22, the Admision Record indicated, Resident 114 was admitted to the facility on [DATE] with a diagnosis of acute respiratory failure (condition in which the lungs have a hard time loading blood with oxygen or removing carbon dioxide). During a record review of Resident 114's doctor's orders, dated 5/11/22, indicated Resident 114 receives dialysis every Mondays, Wednesdays and Fridays at DaVita El [NAME] and has a right chest wall port-a-cath (an implanted device which allows easy access to a patient's veins) used for his dialysis access for his treatments. During a concurrent review of Resident 114's care plan on 5/11/22 at 12:12 p.m. with Director of Nursing (DON), care plan did not ndicate use and care of chest wall port-a-cath. DON stated, there should be a care plan for the use and care of right chest wall port-a-cath. A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, the policy indicated, 8. The comprehensive, person-centered care plan will: b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;. A review of the facility's policy titled, End-Stage Renal Disease, Care of a Resident with, revised September 2010, the policy indicated, 5. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (Resident 61), of three sampled residents, received effective oxygen therapy when staff did not assess and monitor Resident 61's use of oxygen. This deficient practice may result in ineffective oxygen therapy. Findings: A review of Resident 61's admission Record, dated 5/11/22, the admission Record indicated, Resident 61 was admitted to the facility on [DATE] with a diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain). A review of Resident 61's Medication Review Report, dated 5/11/22, the Medication Review Report indicated, doctor's order on 2/14/2020 to start oxygen at 1 liters per minute (LPM- flow rate) as needed to titrate oxygen saturation above 90% and to wean or discontinue as tolerated by the resident. During a concurrent observation and interview on 5/10/22 at 10:11 a.m., Resident 61 was in bed receiving oxygen by a nasal cannula at 3 LPM. Registered Nurse (RN) 2 confirmed Resident 61 was on oxygen at 3 LPM. RN 2 stated, Resident 61 usually receives oxygen at 2 LPM and does not know why the oxygen is at 3 LPM. RN 2 further stated, Resident 61 is rarely not on oxygen therapy. During a concurrent record review and interview on 5/11/22 at 11:30 a.m. of Resident 61's Medication Administration Record (MAR) for May 2022 with Director of Nursing , the MAR indicated no oxygen assessment. Director of Nursing (DON) stated, staff should document how much oxygen Resident 61 is receiving each time staff checks Resident 61's oxygen saturation the assess the effectiveness of oxygen therapy. A review of the facility document titled, Oxygen Administration, revised October 2010, the Oxygen Administration indicated, After completed the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 3. The rate of oxygen flow, route, and rationale.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care for one (Resident 114) that required dialysis (treatment of kidney failure that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood) when staff did not do a complete assessment before Resident 114's dialysis treatment. This deficient practice resulted in an incomplete assessment of Resident 114's dialysis access site before their dialysis treatment. Findings: A review of the document titled, admission Record, dated 5/11/22, the admission Record indicated, Resident 114 was admitted to the facility on [DATE], with a diagnosis of acute respiratory failure (condition in which the lungs have a hard time loading blood with oxygen or removing carbon dioxide). During a review of Resident 114's doctor's orders, dated 5/11/22, the doctor's order indicated, Resident 114 receive dialysis treatments every Mondays, Wednesdays and Fridays at DaVita El [NAME] and has a right chest wall port-a-cath (an implanted device which allows easy access to a patient vein) used for his dialysis access during treatments. During a concurrent interview and record review on 5/11/22, at 1:38 p.m. of Resident 114's Dialysis Communication Record on 5/9/22 and 5/11/22 with Director of Nursing (DON), the Dialysis Communication Record indicated, nursing staff did not assess Resident 114's dialysis site before his dialysis treatment. DON acknowledged Resident 114's dialysis access site was not assessed before his dialysis treatments on 5/9/22 and 5/11/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene between giving medications to two residents (Resident 21 and Resident 119) of 20 sampled residents This failure had the potential to cause or spread infections which can lead to hospitalization for Resident 21 and Resident 119, as well as the rest of the residents in the facility. Findings: 1. During concurrent observation and interview on 05/11/2022, at 4:08 p.m., with Registered Nurse 1 (RN1), in room [ROOM NUMBER], RN1 was observed giving medications to Resident 21. RN1 then went back to the medication cart and prepared medications for Resident 119 without performing hand hygiene. RN1 stated, she should have sanitized her hands between passing medications to different residents because it could spread infections. During an interview on 05/11/2022, at 12:05 p.m., with Director of Staff Development/Infection Preventionist (DSD/IP), DSD/IP stated, her expectation is that all staff perform hand hygiene between giving residents care, coming in and going out of resident rooms, and between glove changes. During a review of the facility handwashing/hand hygiene policy, dated August 2019, the policy indicated, 2. All personnel shall follow the handwashing/handhygiene procedures .7. c. Before preparing or handling medications .m. after removing gloves .

Based on interview and record review, the facility failed to complete quarterly Minimum Data Sets (MDS- an assessment tool used to quid care) timely for eight of ten sampled residents (Residents 10, 11,16, 24, 37, 40, 48, and 49). This failure had the potential to delay care planning and delivery. Findings: During a review of Resident 10's quarterly MDS, the MDS indicated, Assessment Reference Date (ARD - the last day to finish the assessment of the resident) 9/24/21, and completed on 10/26/21. During a review of Resident 10's Quarterly MDS, the MDS indicated ARD 12/25/21, completed 1/4/22. During a review of Resident 10's Quarterly MDS, the MDS indicated, ARD 3/27/22, completed on 5/10/22. During a review of Resident 11's Quarterly MDS, the MDS indicated, ARD 3/26/21, no assessment completed. During a review of Resident 11's Quarterly MDS, the MDS indicated, ARD of 5/30/21, completed on 6/23/21. During a review of Resident 16's Quarterly MDS, the MDS indicated, ARD of 3/11/2022, completed on 5/6/2022. During a review of Resident 16's Quarterly MDS, the MDSindicated, ARD of 12/9/21, completed on 2/7/2022. During a review of Resident 16's Quarterly MDS, the MDS indicated, of 9/9/21, completed on 1/21/2022. During a review of Resident 24's Quarterly MDS, the MDS indicated, ARD of 3/9/21, completed on 5/6/22. During a review of Resident 24's Quarterly MDS, the MDS indicated, ARD of 9/6/21, completed on 12/10/21. During a review of Resident 24's Quarterly MDS, the MDS indicated, ARD of 12/7/21, completed 2/7/22. During a review of Resident 37's Quarterly MDS, the MDS indicated, ARD of 8/22/21, completed on 10/14/21. During a review of Resident 37's Quarterly MDS, the MDS indicated, ARD of 11/22/21, completed on 12/29/21. During a review of Resident 37's Quarterly MDS, the MDS indicated, ARD of 2/22/22, completed on 4/26/22. During a review of Resident 40's quarterly MDS, the MDS indicated, ARD of 10/3/21, completed on 1/21/2022. During a review of Resident 40's quarterly MDS, the MDS indicated, ARD of 1/3/22, completed 5/3/2022. During a review of Resident 48's Quarterly MDS, the MDS indicated, ARD of 11/17/21, completed 1/17/22. During a review of Resident 48's Quarterly MDS, the MDS indicated, ARD of 2/17/22, completed 4/22/22. During a review of Resident 49's Quarterly MDS, the MDS indicated, ARD of 11/16/21, completed on 2/9/22. During a review of Resident 49's Quarterly MDS, the MDS indicated, ARD of 2/16/22, completed on 4/22/22. During an interview on 5/12/22 at 9:18 a.m., with Director of Nursing (DON), DON stated, Resident 9's annual MDS was submitted late. DON stated, the MDS was required and is a reflection of resident's condition . DON further stated, the MDS is an assessment and could pick up changes in the resident's condition and is used to formulate plan of care. DON also stated, staff have to accurately assess resident.