Based on observation, interview and record review, the facility failed to implement pain care plan for 1 of 14 sampled residents (Resident 38) when there was no evidence of pain assessment. This failure had the potential for not meeting Resident 38's nursing needs and goals to attain the resident's highest practicable well-being. Findings: Review of Resident 38's clinical record indicated, Resident 38 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of left femur (broken left thigh bone), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hyperlipidemia (high cholesterol). Review of Resident 38's Minimum Data Set (MDS, resident assessment tool) dated 10/2/24 indicated, Resident 38 was cognitively intact. During a concurrent observation and interview on 12/8/24 at 12:09 p.m., with Resident 38 in front of his room in hallway, he pointed to his abdomen while speaking in Chinese when asked if he had a pain. During a concurrent interview and record review on 12/8/24 at 12:11 p.m., with Registered Nurse (RN) 1, RN 1 stated, she gave Colace (a stool softener) and Miralax powder (an osmotic laxative, a medication that draws water into the stool to soften it and make it easier to pass) to Resident 38 for his abdominal discomfort. But she did not show the evidence of pain assessment of Resident 38 when asked. During a concurrent interview and record review on 12/9/24 at 2:42 p.m., with RN 1, RN 1 still did not show the evidence of pain assessment of Resident 38 when asked again. During an interview on 12/9/24 at 2:44 p.m., with Director of Nursing (DON), DON stated, every shift needs to assess pain when asked. Review of Resident 38's pain care plan initiated on 6/28/23 indicated, . Assess pain every shift and as indicated . During a concurrent interview and record review on 12/10/24 at 2:39 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 38's medication administration record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated December 2024 was reviewed. LVN 1 verified, there was no pain assessment until the night shift on 12/9/24. LVN 1 stated, the facility has 3 shifts which are day, evening, and night shift. LVN 1 stated, Every shift and as needed when asked about the facility's policy and procedure (P&P) regarding pain assessment. Review of the facility's P&P titled, Pain Assessment and Management dated October 2022 indicated, . Assessing Pain . 4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level . Review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered dated March 2022 indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is . implemented for each resident .

Based on observation, interview and record review, the facility failed to meet professional standards of quality when the facility did not follow doctor's order regarding oxygen for one of 2 sampled residents (Resident 8). This failure could potentially result in negative outcomes for Resident 8. Findings: Review of Resident 8's clinical record indicated, Resident 8 was admitted to the facility with diagnoses including spinal stenosis (the spaces inside the bones of the spine get too small), acute respiratory failure with hypoxia (a serious medical condition that occurs when there is not enough oxygen in the body's tissues), chronic obstructive pulmonary disease (COPD, a lung disease that makes breathing hard), and hypertension (high blood pressure). Review of Resident 8's Minimum Data Set (MDS, resident assessment tool) dated 11/16/24 indicated, Resident 8 was cognitively moderately impaired. Review of Resident 8's H&P (history and physical, a formal assessment of a resident that includes a review of their medical history, a physical exam, and a summary of any tests) dated 11/14/24 indicated, . with history of CHF (congestive heart failure, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), COPD . She used to use home O2 as needed for shortness of breath . she was given . Lasix (diuretic that can treat fluid retention called edema and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) and duonebs (a combination of two medicines called bronchodilators to treat COPD. It works by opening your airways and reducing inflammation in your lungs to help you breathe) on admission with significant improvement and remained stable on room air . During an observation on 12/8/24 at 10:26 a.m., in Resident 8's room, Resident 8 was on oxygen (O2) at 3.5 liters per minute (LPM or L/min, a unit that expresses flow rate) via nasal cannula (a medical device that provides supplemental oxygen to a resident through their nose). Resident 8 did not have shortness of breath (SOB). During a concurrent observation and interview on 12/8/24 at 10:42 a.m., with Registered Nurse (RN) 1 in Resident 8's room, Resident 8 was still on O2 at 3.5 liters per minute. RN 1 stated, the doctor's order was 1-2 liters per minute as needed when asked, then she decreased oxygen from 3.5 to 3 liters per minute. During a concurrent interview and record review on 12/8/24 at 10:45 a.m., with RN 1, the doctor's order titled, Order Details was reviewed. The order details indicated, . CONTINUOUS O2 @ 1-2 LPM VIA NASAL CANNULA PER CONCENTRATOR/TANK TO KEEP O2 SAT (oxygen saturation level, a measurement of how much oxygen the blood is carrying as a percentage) >90% as needed for SOB/COPD . RN 1 did not answer when asked about O2 Sat of Resident 8 in her shift. She acknowledged, O2 was not administered as the doctor's order. During a concurrent interview and record review on 12/8/24 at 11:52 a.m., with Director of Nursing (DON), Resident 8's O2 Sats were reviewed. The O2 Sats indicated, 95% at room air on 12/8/24 at 5:42 a.m., and 96% at 3 liters per minute on 12/8/24 at 10:51 a.m. DON did not answer why Resident 8 was on O2 at this time when asked. During a concurrent interview and record review on 12/10/24 at 1:43 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 8's clinical records were reviewed. LVN 1 stated, There is none unfortunately why they increased it when asked why they applied O2 at 3.5 liters per minute to Resident 8 on 12/8/24 after O2 Sat 95% at room air on 12/8/24 at 5:42 a.m. During an interview on 12/12/24 at 9:47 a.m., with DON, DON acknowledged, O2 at 3.5 liters per minute was a bit of high amount for COPD (For residents with COPD, high oxygen levels is generally considered not recommended and can be harmful, as the target oxygen saturation level for most COPD residents should be between 88% and 92% to avoid complications like oxygen-induced hypercapnia- a condition that occurs when supplemental oxygen increases blood carbon dioxide (CO2) levels in residents with COPD or other conditions that cause chronic hypercapnia), and RN 1 should have followed the doctor's order. Review of Resident 8's care plan indicated, . Monitor oxygen saturation via pulse oximetry (a painless, noninvasive test used to measure the oxygen saturation of the blood) . Review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered dated March 2022 indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is . implemented for each resident . Review of the facility's policy and procedure (P&P) titled, Oxygen Administration dated 2001 indicated, . 1. Verify that there is a physician's order for this procedure. Review the physician's order .

Based on observation, interview and record review, the facility failed to ensure communication services were provided for one of 6 sampled residents (Resident 38) who spoke in his native language when there were no interpreter services for Resident 38 on Sunday (12/8/24). This failure has the potential for Resident 38 not to understand and carry out activities of daily living (ADL) to attain the resident's highest practicable well-being. Findings: Review of Resident 38's clinical record indicated, Resident 38 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of left femur (broken left thigh bone), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hyperlipidemia (high cholesterol). Review of Resident 38's Minimum Data Set (MDS, resident assessment tool) dated 10/2/24 indicated, Resident 38 was cognitively intact. During an interview on 12/8/24 at 11:58 a.m., with Son of Resident 38 via phone, Son stated, Resident 38 speaks Cantonese, Mandarin, and Chinese and does not speak English well. Son stated, Resident 38 had abdominal discomfort. During a concurrent observation and interview on 12/8/24 at 12:09 p.m., with Resident 38 in front of his room in hallway, he pointed to his abdomen while speaking in Chinese when asked if he had a pain. During a concurrent interview and record review on 12/8/24 at 12:11 p.m., with Registered Nurse (RN) 1, RN 1 stated, they are using Chinese-speaking staff or a Chinese-translated book when asked how they can communicate with Resident 38. RN 1 stated, the Chinese speaking staff was off today (Sunday) and she did not know where the book was when asked if interpreter service was available for Resident 38 today which was Sunday. During an interview on 12/9/24 at 2:06 p.m., with Business Office Manager (BOM), BOM stated, Resident 38 speaks Cantonese, and she helps translate when Resident 38 uses Cantonese. BOM stated, Resident 38's abdominal discomfort was due to bowel movements. BOM stated, she works from Monday to Friday. BOM stated, she did not know when asked whether staff use interpreter services on Sundays or nights for Resident 38. During a concurrent interview and record review on 12/9/24 at 2:15 p.m., with RN 1 and BOM, CHINESE COMMUNICATION BINDER was reviewed. The binder indicated, images of health issues, home assist/items, food, utensil, appliances, etc. RN 1 acknowledged, she did not use the binder because she did not know where it was. During an interview on 12/9/24 at 2:21 p.m., with Resident 38, with translation assistance from BOM, Resident 38 stated, he did not like the new binder titled, CHINESE COMMUNICATION BINDER because he was not used to it and the binder had so many pages. Resident 38 stated, he prefers the old binder because that was simple. During an interview on 12/12/24 at 9:45 a.m., with Director of Nursing (DON), DON stated, they should use another Chinese-speaking CNA, binder, or Google interpreter services when asked what to do with Chinese speaking residents on Sundays or at night. DON stated, it is important for residents to communicate in their own language. Review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, dated March 2021 indicated, . 1. The resident's individual needs and preferences are accommodated to the extent possible .

Based on interview, and record review, the facility failed to ensure Resident 25 was free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic [a type of psychiatric medication which are available on prescription to treat psychosis]; (ii) Anti-depressant [prescription medicines to treat depression]; (iii) Anti-anxiety [drugs used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress]; and (iv) Hypnotic [a class of drugs that induce or prolong sleep in people with sleep disorders and are intended to improve the overall quality of sleep]) when: 1.There was no evidence of non-pharmacological intervention for Aripiprazole (antipsychotic), Bupropion (antidepressant), Lorazepam (antianxiety), and Mirtazapine (antidepressant) for Resident 25 2. There was no targeted behavior of Lorazepam for Resident 25. 3. There was no evidence of specific behavioral monitoring for Lorazepam for Resident 25. 4. There is no specific indication for Mirtazepine for Resident 25. These failures could result in unnecessary use of, ineffective and/or lack of monitoring or interventions for psychotropic medications that could negatively affect the residents' highest practicable mental, physical and psychosocial well-being. Findings: Review of Resident 25's clinical record indicated, Resident 25 was admitted to the facility with diagnoses including low back pain, depression (mental health condition that involves a low mood or loss of interest in activities for a prolonged period of time), and PTSD (Post Traumatic Stress Disorder, an anxiety problem after seeing or having a traumatic event). Review of Resident 25's Minimum Data Set (MDS, resident assessment tool) dated 11/6/24 indicated, Resident 25 was cognitively moderately impaired. Review of the document titled, Resident Matrix (a form used by the facility to list all current residents and to note pertinent care categories) dated 12/9/24 indicated, Resident 25 was on antianxiety, antidepressant, and antipsychotic medications. Review of Resident 25's doctors order titled, Order Details dated 11/4/24 indicated, . ARIPiprazole (an antipsychotic medication) Oral Tablet 20 MG (Milligram) . Give 1 tablet by mouth one time a day . Review of Resident 25's doctors order titled, Order Details dated 11/4/24 indicated, . buPROPion (an antidepressant medication) . Oral Tablet Extended Release 24 Hour 300 MG . Give 1 tablet by mouth one time a day . Review of Resident 25's doctors order titled, Order Details dated 11/4/24 indicated, . Mirtazapine (an antidepressant medication) Oral Tablet 15 MG . Give 1 tablet by mouth at bedtime . Review of Resident 25's doctors order titled, Order Details dated 12/4/24 indicated, . LORazepam (an antianxiety medication) Tablet 0.5 MG . Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 Days . During a concurrent interview and record review on 12/10/24 at 10:02 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, No when asked if there was the evidence of non-pharmacological intervention for Resident 25 regarding Aripiprazole, Bupropion, Lorazepam, and Mirtazapine. LVN 1 stated, Unfortunately we don't have a target behavior when asked if there were targeted behaviors for Resident 25 regarding Lorazepam. LVN 1 stated, No. There was not when asked if there was the evidence of behavioral monitoring for Lorazepam for Resident 25. LVN 1 stated, Not in the order when asked if there were the specific indications for Mirtazepine for Resident 25. Review of the facility's policy and procedure (P&P) titled, Psychotropic Medication dated December 2019 indicated, . The facility supports the goal for using psychotropic medications appropriately . 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications . 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident .

Based on observation, interview, and record review, the facility failed to follow disinfection protocols for reusable items which includes durable medical equipment (DME - equipment that is used for a medical purpose, is used in the home, and is expected to last at least three years) for three out of three residents (Residents 18, 29, and 41). This failure puts residents at risk for cross contamination and the possible spread of infection among residents. Findings: During a continuous observation on 12/8/24 from 8:55 a.m. to 9:25 a.m. on unit B, with Registered Nurse 1, (RN1) was observed taking Resident 29's blood pressure, then Resident 41's blood pressure, and finally Resident 18's blood pressure. Each time, RN1 did not disinfect the blood pressure cuff prior to taking the residents' blood pressures. During an interview on 12/09/24 at 1:50 p.m., with RN1, she was unclear about the facility's policy and procedure (P&P) regarding disinfecting resident care equipment, and offered no explanation. RN1 stated she would have to check with the Director of Nursing (DON) & check the P&P. During concurrent interview and record review on 12/10/24 at 2:30 p.m. with the Executive Assistant, the facility policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated July 2014, indicated 1. d. Reusable Items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). The Executive Assistant stated that DME includes bp cuffs

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide, one of three sampled residents (Resident 1), Resident 1's representative with the 7-Day Bed-hold written notice at the time of transfer or within 24 hours of Resident 1's emergency transfer to a higher level of care on [DATE]. This failure resulted in a facility-initiated discharge on [DATE] for Resident 1. Findings: During a review of Resident 1's Summary for Providers, the Summary indicated that Resident 1 had an emergency transfer to the hospital on [DATE], due to a change of condition (COC). During a review of Resident 1's face sheet (FS), the FS indicated that Resident 1 was admitted to the facility on [DATE] and discharged on [DATE] (7 days after an emergency transfer due to a COC). During a concurrent interview and record review on [DATE] at 4:20 PM with Executive Assistant (EA), the EA was unable to locate documented evidence to show Resident 1's representative was provided with the 7-Day Bed-hold written notice at the time of transfer on [DATE] or within 24 hours. The EA verified that Resident 1 was discharged from the facility on [DATE]. The EA stated the facility's social worker should have provided the 7-Day Bed-hold written notice at the time of transfer on [DATE] or within 24 hours. During a concurrent interview and record review on [DATE] at 9:33 AM with Director of Nursing (DON), DON stated that Resident 1's representative was not provided with the 7-Day Bed-hold written notice at the time of transfer on [DATE] or within 24 hours. Review of facility policy and procedure titled Bed-Holds and Returns, dated [DATE], indicated that, 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalizations or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g. in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) . 3. Multiple attempts to provide the resident representative with notice 2 should be documented in cases where staff were unable to reach and notify the representative timely . 7. Residents who seek to return to the facility after the state bed-hold period has expired . are allowed to return . provided that the resident: a. still requires the services provided by the facility; and b. is eligible for Medicare skilled nursing facility or Medicaid nursing facility services . 9. If the facility determines that a resident cannot return, the facility must comply with the requirements for facility-initiated discharges .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services provided meet professional standards for one of 13 sampled residents (Resident 43) when there was no order for the use of oxygen for Resident 43. This failure could potentially prevent staff from providing Resident 43 with appropriate treatment and care which could jeopardize the resident's health and safety. Findings: Resident 43 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - lung disease that cause airflow blockage and breathing related problems), and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred, as it worsens, become progressively more short of breath). During a concurrent observation and interview on 10/2/23 at 11:00 AM with Resident 43 in the resident's room, Resident 43 was on oxygen at 2L/min (liters/minute) via nasal cannula (device that delivers extra oxygen through a tube and into the nose that help people who are having difficulty breathing). Resident 43 stated, My nose is stuffed. During a concurrent interview and record review on 10/4/23 at 3:32 PM with Registered Nurse (RN) 2, Resident 43's Order Summary Report (OSR) with active orders as of 10/4/23 was reviewed. RN2 verified that Resident 43 uses oxygen and stated, He's on oxygen 24/7 via nasal cannula at 2L/min for shortness of breath. RN2 acknowledged that the OSR did not reflect an order for the use of oxygen for Resident 43. RN2 stated, I don't believe there's an order for oxygen. I don't see it. RN2 further said, Yes, there should be an order, so we know how much to give/administer per MD (doctor of medicine). Review of facility policy titled, Oxygen Administration revised October 2010, indicated, .Preparation .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident's (Resident 10) nutritional status was maintained when poor intake, significant weight loss, and insidious weight loss were not monitored and assessed. This failure had the potential to result in avoidable weight loss from inadequate nutrient intake for one resident out of a facility census of 51. Findings: A professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014 showed, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1. A professional reference review of BSN (Balance Senior Nutrition) Solutions, titled, Weight Loss in the Elderly: When Should You Be Concerned? dated March 19, 2018, showed, According to the Centers for Medicaid and Medicare services (CMS), weight can be a useful indicator of nutritional status when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. Insidious weight loss refers to a gradual, unintended, progressive weight loss over time. (https://www.bsnsolutions.net/weight-loss-in-the-elderly-when-should-you-be-concerned-clone#:~:text=%E2%80%9CInsidious%20weight%20loss%E2%80%9D%20refers%20to,progressive%20weight%20loss%20over%20time). The standard of practice in medical nutrition therapy is the implementation of The Nutrition Care Process (NCP) which is a framework for systematic problem-solving. It is used by nutrition and dietetics professionals to critically think and make decisions when providing safe and effective quality nutrition care. The NCP consists of four distinct, interrelated steps: Nutrition Assessment and Reassessment; Nutrition Diagnosis; Nutrition Intervention; Nutrition Monitoring and Evaluation (Academy of Nutrition and Dietetics) Review of the policy and procedure titled Weight Assessment and Intervention revised March 2022, showed the threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater than 5% is severe; 3 months - 7.5% weight loss is significant and greater than 7.5 percent is severe. In addition, undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: the resident's target weight range, the resident's calorie, protein, and other nutrient needs compared with the resident's current intake, and whether and to what extent weight stabilization or improvement can be anticipated. Interventions for undesirable weight loss are based on careful consideration of the following including but not limited to: resident choice and preferences, nutritional needs of the resident, medications that may interfere with appetite, etc. Review of the policy and procedure titled Calorie Counts revised April 2007, showed resident food intake will be monitored and recorded by direct care staff on a daily basis. Direct care staff will notify nursing staff of any poor intake, defined as consumption of 25 percent or less of a meal or snack. Nursing staff will document poor intake in progress notes. Three or more episodes of poor intake in a two-day period will be reported in writing to the dietitian. Verbal communication will be confirmed in writing. A record review for Resident 10 showed he was originally admitted to the facility on [DATE] with diagnoses including but not limited to congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease stage 3 (when kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood), severe obesity, depression, and pulmonary edema (a condition caused by excess fluids in the lungs). The MDS (Minimum Data Set, an assessment tool) dated September 9, 2023, showed Resident 10 with a BIMS (Brief Interview for Mental Status) score of 12 showing moderate cognitive impairment. Section K of the MDS showed Resident 10 was not on a physician-prescribed weight-loss regimen. On 10/4/23 at 12:21 p.m., an observation and interview with Resident 10 showed Resident 10 was in his room sitting up in bed with his lunch tray in front of him. The food on the plate, which consisted of beef, noodles, and vegetables, appeared untouched. The juice was partially consumed, and the ice cream cup was opened and partially consumed. Resident 10 stated he did not like the food and that it tasted flat. He said he did like ice cream and juice and these items had a lot of flavor. Resident 10 also had an unopened Glucerna supplement shake (Glucerna is a low sugar nutritional supplement typically meant for diabetic patients) on his bedside table. He stated facility staff provided the Glucerna, but he was afraid to drink it because it was different from what was provided to him in the hospital. He stated the supplement he received in the hospital said for people with kidney disease on the container, but the Glucerna did not say that on the container, so he did not know if it was safe for him to drink given his diagnoses. He also stated sometimes when he did not eat his meals, staff provided him a sandwich as a substitute, but he did not like the sandwiches. A record review, for Resident 10 showed weights were recorded on the document titled Weights and Vitals Summary. Weights from 8/15/23 to 10/3/23 and were as follows: 8/15/23 286 lbs 8/22/23 282 lbs: 8/29/23 273 lbs: a loss of 13 pounds (4.5%) in 2 weeks, which is considered significant. 9/6/23 269.4 lbs: 9/12/23 269.8 lbs: 9/18/23 266.8 lbs: a loss of 19 pounds (6.7) in 6 weeks, which is considered severe. 9/21/23 263.2 lbs: 9/28/23 265 lbs: a loss of 21 pounds in 2 months (7.3%), which is considered severe. 10/3/23 260.4 lbs: a cumulative loss in 26 pounds in 9 weeks, or 9% which is considered severe. According to the parameters provided in the policy and procedure titled Weight Assessment and Intervention revised March 2022, Resident 10 consistently exhibited either significant or severe weight loss from 8/15/23 through 10/3/23. Record review for Resident 10 showed various care plans created related to nutrition status: A care plan initiated on 8/14/23 showed Resident 10 was at risk for malnutrition. The goal for this plan was to maintain adequate nutritional status as evidenced by stable weight. The interventions included but were not limited to cater to food preferences initiated on 8/14/23. A Nutritional Risk Assessment completed by RD2 on 8/15/23. In this assessment RD2 documented interventions including but not limited to, monitor po (by mouth) intake, weight . The next RD documentation for Resident 10 was a Nutritional Risk Assessment dated 9/7/23 after Resident 10 was readmitted from the hospital (Resident 10 was away from the facility from 9/1/23-9/6/23). RD2 documented interventions including but not limited to monitor po intake, weights . There was no evaluation of Resident 10's nutrient needs in comparison to his reported intake. There was no target weight range documented. There was no documentation to show to what extent weight stabilization or improvement could be anticipated. An IDT (Interdisciplinary Team) Weight Variance note written by RD2 on 9/7/23 showed Resident 10 had a 14.2 pound (4.9%) weight loss in one month and po intake was 25-75% of diet. Interventions included but were not limited to . monitor weekly weights. There was no evaluation whether Resident 10's nutrient needs were met in comparison to his reported intake. There was no target weight range documented. There was no documentation to show to what extent weight stabilization or improvement could be anticipated. A revised care plan on 9/7/23 confirmed Resident 10 was at nutritional risk. The goal created was for Resident 10 to receive adequate calories and nutrition for stable weight. The interventions included but were not limited to for the RD to reassess as indicated. An additional care plan for unplanned/unexpected weight loss . was initiated on 9/7/23 and revised on 9/16/23. The goals created included the resident will regain lost, and the resident's weight will return to baseline range. Interventions for this care plan included but were not limited to, Alert dietitian if consumption is poor for more than 48 hours (initiated 9/16/23), If weight decline persists, contact physician and dietitian immediately (initiated 9/16/23), and Offer substitutes as requested or indicated. The resident prefers: (Resident 10's preferences were not indicated on the care plan, initiated 9/16/23). An IDT Conference Note was created on 9/29/23. The Nutrition and Eating section was documented by Dietary Supervisor 2 (DS2). The note indicated intake by mouth was variable. The IDT conference note did not reflect an RD assessment to address Resident 10's poor intake, insidious weight loss and no new interventions were recommended. This IDT note did not show an RD evaluation of nutrient needs in comparison with intake, a target weight range or documentation to show to what extent weight stabilization or improvement could be anticipated. The next documented RD note was three and a half weeks later which was a progress note written by RD2 on 10/2/23. This note read weekly weights were stable and intake by mouth had declined to 25 to 75% of diet. Interventions included but were not limited to update food preferences. There was no evaluation of Resident 10's nutrient needs in comparison to his reported intake. There was no target weight range documented. There was no documentation to show to what extent weight stabilization or improvement could be anticipated. There was no target weight range documented. There was no documentation to show to what extent weight stabilization or improvement could be anticipated. During a record review for Resident 10, the document for amount eaten showed from 8/14/23-8/23/23, 11 of 53 meals 0-25% intake, and for 18 of 53 meals 26-50% intake. From 9/6/23-9/30/23, 40 of 73 meals 0-25 % intake, and 23 of 73 meals 26-50% intake. From 10/1/23 - 10/3/23, three of eight meals showed 0-25% intake and 3 of eight meals showed 26-50% intake. The documentation also showed 2 meals were refused during this time frame in October. In addition, documentation showed Resident 10 ate 25% or less for the following dates: 4 meals from 8/29/23-8/30/23; 4 meals from 9/7/23-9/8/23; 4 meals 9/11-9/12; 4 meals 9/13-9/14; 5 meals 9/18-9/19/23; 4 meals 9/21-/9/22/23; 4 meals 9/26-9/27; from 10/2-10/3/23 Resident 10 ate 25 percent of 2 meals and refused 2 meals. Record review for Resident 10 showed on the document titled 50% or less meal consumption and/or refusal (Alternate meal/nourishment), showed in a look back of 30 days from 10/6/23, an alternate meal was provided on 9/23/23 at 2:30 p.m. There was no other documentation of an alternate provided in the 30 day look back. In an interview on 10/5/23 at 11:24 a.m., Registered Dietitian 1 (RD1) stated Resident 10's weight loss was triggered to assess when he was readmitted from the hospital on 9/6 and an IDT meeting was held and documented on 9/7/23. RD1 stated an RD assessment would be completed for residents with significant weight loss, for example weight loss of 5% in one month and/or 2% in a week. Resident 10's weight documentation was reviewed with RD1. RD1 stated his weight was not stable and he had gradual weight loss since admission. RD1 further stated Resident 10's weight loss was not significant therefore an RD assessment was not completed. RD1 stated insidious weight loss was defined as gradual continuous weight loss. RD1 stated weight loss would be considered insidious if there was a continuous downward trend of weights two weights in a row. When RD1 was asked if Resident 10 had insidious weight loss, RD1 would not confirm if Resident 10 had insidious weight loss. The interview continued with RD1 on 10/5/23 at 11:40 a.m., and Resident 10's electronic medical record was reviewed. RD1 confirmed Resident 10's food preferences were documented on August 14, 2023. RD1 was unable to confirm resident 10's food preferences were updated after August 14, 2023. RD1 added if a resident experienced weight loss, staff from the kitchen should update resident food preferences. RD1 also stated the documentation in the electronic medical record showed Resident 10 refused his bedtime snack. RD1 stated a resident had the right to refuse the snack. In an interview on 10/5/23 at 1:57 p.m., Dietary Services Supervisor 2 (DS2) stated when a resident experienced weight loss, the RD would notify her and ask her to obtain resident food preferences. DS2 confirmed there was no documentation Resident 10's food preferences were updated since his initial admission in August 2023. In an interview on 10/5/23 at 3:50 p.m., RD1 stated if a resident had insidious weight loss, an RD would assess the resident and discuss the resident in the weekly weight variance meeting. During an interview on 10/6/23 at 10:45 a.m., with the Director of Nursing (DON), she reviewed Resident 10's electronic medical record (EMR). The DON confirmed cater to food preferences documented as an intervention in Resident 10's care plan, meant the facility would provide the resident's food preferences. The DON also confirmed Alert dietitian if consumption is poor more than 48 hours which was also documented in Resident 10's care plan, meant if CNA documented poor consumption of food for more than 48 hours, the CNA reported this to the nurse and the nurse reported the poor intake to the RD. In an interview on 10/6/23 at 11:51 a.m., the DON confirmed there was no documentation by nursing of Resident 10's poor intake nor notification of poor intake by nursing to the RD. The DON also confirmed there was no documentation Resident 10's weight loss was beneficial or planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the manufacturer's recommendations and specifications for installing and maintaining bed rails when the bed of Resident 10, one of 13 sampled residents, had a left sided bed rail that would fall down periodically when used by resident. This failure of the facility had the potential to injure the resident resulting from an accidental fall from the bed. Findings: Resident 10 was admitted to the facility on [DATE] with diagnoses including, ulcers of both lower extremity's (legs), severe obesity (excessive body fat), depression and anxiety, gait (walking disorder) and mobility abnormalities, kidney failure, pulmonary edema (accumulation of liquid in lungs), congestive heart failure (inability of heart to pump sufficient blood flow), and generalized muscle weakness. Resident 10's Minimum Data Set (MDS, an assessment tool) indicated moderately impaired cognition (thinking), required two staff assist to turn and reposition in bed, resident did not walk or use wheelchair. Wears a Life Vest Cardiac Monitor (delivers a shock treatment to restore normal heart rhythm). During an interview at the initial tour on 10/2/23, at 9:40 AM, Resident 10 was sitting up in bed with head of bed up and both side hand rails up. He stated that his left sided hand rail had fallen down twice, this past month, when attempting to use it. And he was afraid he might get hurt when it happened. As he began to describe and demonstrate the left hand rail fell down. He stated the hand rail had been fixed once but the problem still occurred. He stated he told staff about it each time. Review of Maintenance Request Log, dated 9/15/23, indicated, Repairs/Services Needed: room [ROOM NUMBER]-A Side rail is not working. It was signed and dated, 9/15/23, Work/Services Performed. Review of facility's policy on Bed Safety, revised August, 2022, indicated, Policy Statement: Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. Policy Interpretation and Implementation: 1. The resident's sleeping environment is evaluated by the interdisciplinary team. 2. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. 3. Bed dimensions are appropriate for the resident's size .6. The maintenance department provides a copy of inspections to the administrator and report results to the QAPI committee for appropriate action. Copies of the inspection results and QAPI committee recommendations are maintained by the administrator and/or safety committee. 7. Any worn or malfunctioning bed system components are repaired or replaced using components that meet manufacturer specifications. 8. Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit . 11. The staff shall report to the director of nursing and administrator any accidents or incidents associated with a bed or related equipment including the bed frame, side or bed rails, and mattresses. The administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Devices Act. Review of Falls Care Plan for Resident 10, .Focus: Falls: Resident is at risk for falls with or without injury related to recent hospitalization, acute CHF, sepsis, urinary tract infection, bilateral lower extremeties venous stasis ulcers, atrial fibrillation, depression, anxiety, morbid obesity, impaired mobility. Goals: Will minimize risk for falls to extent possible. Interventions: .Side rails up while in bed to aid in bed mobility and repositioning . During an interview on 10/2/23, at 11 AM, with Maintenance Supervisor (MS). He stated he would replace resident's bed now (temporary) and order a new bed for resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe storage and proper labeling of medication when an unlabeled loose white round tablet and cherry colored liquid were found on Resident 19's over bed table. This deficient practice had the potential for Resident 19 to self-administer or receive incorrect medication that may cause harm or death, and the unattended medication had the potential for drug diversion. Findings: Resident 19 was admitted on [DATE] with diagnoses including alcoholic cirrhosis of liver with ascites (chronic liver damage from a variety of causes leading to scarring and liver failure with buildup of fluid in the abdomen) and traumatic brain injury (brain dysfunction caused by an outside force usually by a violent blow to the head). During a concurrent observation and interview on 10/2/23 at 9:32 AM with Resident 19 in the resident's room, there was an unlabeled loose white round tablet in a medication cup and another medication cup filled with cherry colored liquid found on Resident 19's over bed table without supervision by a licensed nurse. Resident 19 stated, That's my water pill (white round tablet) and that's my protein supplement (cherry colored liquid). I like to take it after I eat because it doesn't taste good. During an interview on 10/2/23 at 9:51 AM with the Director of Staff Development (DSD), the DSD said that the licensed nurse is not supposed to leave the medication until the resident takes it. DSD stated, You'll never know whether he's going to take it or not. Wait until they take it. It will defeat the purpose of having it. They will not get well. During an interview on 10/5/23 at 11:25 AM with the Director of Nursing (DON), the DON said that medications should not be left at bedside without licensed nurse supervision. DON stated, Give medication with the license nurse, wait until medication is taken by the patient, for patient's safety. During a review of Resident 19's Order Summary Report (OSR), the OSR indicated, Resident 19 had active orders as of 10/4/23, Lasix (used to reduce extra fluid in the body caused by liver disease and other medical conditions) Oral Tablet 80 mg (milligram) give 1 tablet by mouth one time a day and Prostat (a ready-to-drink concentrated liquid protein medical food) 30 ml (milliliter) three times a day. During a review of Resident 19's Medication Administration Record (MAR), the MAR had a check mark and initials of the licensed nurse on the box dated 10/2/23 to indicate that, Lasix Oral Tablet 80 mg scheduled at 8:00 AM and Prostat 30 ml scheduled at 9:00 AM were administered. During a review of Resident 19's Medication Admin Audit Report (MAAR), with schedule date of 10/2/23, the MAAR indicated, Lasix 80 mg and Prostat 30 ml were administered at 8:04 AM, with documented time of 8:07 AM. Review of facility policy titled, Administering Oral Medications revised October 2010, indicated, .Steps in the Procedure .21. Remain with the resident until all medications have been taken .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 19) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when Resident 19 received Trazodone (an antidepressant) without adequate monitoring. This failure had the potential for Resident 19 to receive unnecessary psychotropic medication and be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being. Findings: Resident 19 was admitted on [DATE] with diagnoses including alcoholic cirrhosis of liver with ascites (chronic liver damage from a variety of causes leading to scarring and liver failure with buildup of fluid in the abdomen), traumatic brain injury (brain dysfunction caused by an outside force usually by a violent blow to the head), and major depressive disorder. During a review of Resident 19's Order Summary Report (OSR), the OSR indicated, Resident 19 had active orders as of 10/4/23, .Trazodone HCl (Trazodone Hydrochloride - used to treat depression) Oral Tablet 100 mg (milligram) give 1 tablet by mouth at bedtime for insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or both) .monitor hours of sleep daily from 3-11 and 11-7 with the use of (specify drug and diagnosis) document hours of sleep every evening and night shift for Trazodone . with a start date of 9/8/23. During a concurrent interview and record review on 10/4/23 at 11:05 AM with Registered Nurse (RN) 2, Resident 19's Medication Administration Record (MAR) for October 2023 was reviewed. The MAR indicated, on 10/1/23 to 10/3/23, there was a check mark and a licensed nurse initials in the box for monitor hours of sleep. There was no documentation on the MAR to demonstrate that the number of hours of sleep was monitored daily from 3-11 and 11-7 on 10/1/23 to 10/3/23 for Resident 19. RN2 acknowledged that the MAR didn't reflect the number of hours and stated, Should record the number of hours of sleep. RN2 said that Resident 19 should be monitored for sleep to see if medication is effective. During a review of Resident 19's MAR for September 2023, the MAR showed a check mark and initials of the licensed nurse in the box on 9/8/23 to 9/30/23, under Monitor hours of sleep daily from 3-11 and 11-7. Document hours of sleep every evening and night shift for Trazodone, indicating the order was carried out. The number of hours of sleep was not recorded on both shifts. During an interview on 10/4/23 at 11:27 AM with Medical Records Director (MRD), the MRD said that with only a check mark in the MAR, they would not be able to determine if Resident 19 slept well. MRD stated, It should reflect the number of hours of sleep to know if medication is working or effective. Review of facility policy titled, Psychotropic Medication revised December 2019, indicated, .6. Psychotropic medications include anti-anxiety/hypnotic, antipsychotic and antidepressant classes of drugs .a. Monitoring, Follow-up, and Oversight: The interdisciplinary team will review and update accordingly to ensure that the approaches and interventions are current and effective .

Based on observation, interview and record review the facility failed to ensure Resident 31 was served the correct food texture according to her physician prescribed therapeutic diet. This failure to serve Resident 31 the prescribed texture of food had the potential to result in one resident not being able to tolerate food texture resulting in decreased nutritional intake and/or choking. Findings: Review of Resident 31 face sheet indicated, Resident 31 was admitted with diagnoses of: dysphagia (a medical term for swallowing difficulties), muscle weakness, and lack of coordination. Her brief interview for mental status (BIMS - an evaluation tool to test cognitive skills) was 8 indicating moderate cognitive impairment. During meal observation on 10/4/23 at 12:09 p.m., in the dining room, observed Resident 31 quietly eating her lunch. On her plate was noodles with pieces of meat that resembled chicken, and green and yellow chopped vegetables. The pieces of meat were varied in length between two to three inches long. Resident 31 moved her food around her plate with her eating utensil. She placed a long piece of meat, over 2 inches in length, into her mouth. Resident 31 had a tray ticket on her plate with her name on the ticket. Also printed on the tray ticket was Mechanical Soft, Regular, Thin Liquids. In an interview with Dietary Supervisor 2 (DS2) on 10/4/23 at 12:11 p.m., DS2 stated for a mechanical soft diet, chicken should not be two to three inches long and that the meat should be chopped into smaller pieces. In an observation and interview with the Director of Staff Development (DSD), the Speech Language Pathologist (SLP), and DS2 on 10/4/23 at 12:15 p.m., the DSD stated she checked food trays before they were served. The DSD looked at the lunch tray of Resident 31 and confirmed the pieces of chicken on Resident 31's plate were over 2 inches long. SLP stated the size of the pieces of chicken on Resident 31's plate was too big for a mechanical soft diet. The surveyor pressed the vegetables with a fork, and the vegetables were hard and could not be mashed with the fork. SLP also pressed the pieces of vegetables with a fork and stated the vegetables were too hard for a mechanical soft diet. DS2 confirmed the pieces of chicken were too large for a mechanical soft diet and the vegetables were too hard for a mechanical soft diet. In an interview on 10/4/23 at 1:27 p.m. the DSD stated she looked at all resident food trays in the dining room before they were served to residents. DSD stated she verified residents were getting the correct diet according to the tray ticket. She stated she mainly verified the texture and consistency of the food was correct according to the tray ticket. The DSD stated if the meat was soft enough, it was okay for a resident on a Mechanical Soft diet to have larger pieces of meat. The DSD stated, to know if the meat was soft enough, she observed a resident to verify the resident could break the piece of meat up into smaller pieces. The DSD stated she received training on diet texture about 20 years ago in nursing school. She stated she did not receive training regarding diet texture from the facility Food and Nutrition Services staff. The DSD stated the Infection Preventionist (IP) also checked the trays when they came out of the kitchen before they were served to residents. During an interview with the IP on 10/4/23 at 1:34 PM, the IP stated, when food carts came out of the kitchen, she checked the food to ensure the texture was correct according to the residents' diets. She stated, mechanical soft texture should be sliced or chopped. The IP stated pieces of chicken two inches or more in length was not okay for a mechanical soft diet. She stated she must have missed Resident 31's meat texture. The DSD stated if she saw meat pieces that were too large for a mechanical soft diet, she would send it back to the kitchen. During a concurrent interview and document review with the SLP on 10/6/23 at 9:11 AM, SLP reviewed the Evaluation and Plan of Treatment for Resident 31 dated 10/26/2022. He stated, Resident 31 complained about the texture of the regular textured food, so he did an evaluation on her. SLP stated he recommended a Mechanical Soft food texture due to the resident was missing teeth and did not have dentures. The Food & Nutrition Services Diet Manual dated 2017, was also reviewed with SLP. He stated the highest level of mechanically altered/soft food was appropriate for Resident 31. He verified the meat size should be ¼ inch as shown in the diet manual for a Mechanically Altered diet. Review of the Speech Therapy SLP Evaluation and Plan of Treatment signed and dated by SLP on 10/26/22, showed under Clinical Impressions, that Resident 31 was missing dentition resulting in prolonged mastication (chewing) and reported difficulty of masticating regular texture. Patient demonstrates adequate oral motor structures appropriate for accepting and manipulating textures of mechanical soft and thin liquids, which is patient's baseline as reported by [family member]. Review of the document titled Oral Health Care dated 7/31/23, showed Resident 31 did not want dentures. Review of an order document showed a Mechanical Soft Diet was ordered for Resident 31 on 10/25/22 and the order was signed by a Medical Doctor on 11/28/22. Review of the policy and procedure titled Food and Nutrition Services revised October 2019, showed Food and Nutrition Services staff will inspect food trays to ensure that the correct meal is provided to each resident. If the incorrect meal is provided to a resident, nursing staff will report it to the Food Service Manager so that a new food tray can be issued. Review of the Food & Nutrition Services Diet Manual dated 2017 showed mechanically altered diets consists of foods that are soft and easy to chew and swallow and excludes foods that are very hard, and meats should be moist and chopped into bite size pieces (1/4 inch or smaller) or ground to small curd cottage cheese size. The diet manual also showed vegetables are to be cooked to a soft and tender texture and should be easily mashed with a fork.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for four of 13 sampled residents (Residents 18, 19, 43, and 31) when: 1. The CP for Resident 19 did not have specific interventions for the use of Trazodone (medication used to treat depression). 2. No individualized person-centered CP was developed for the management of peripherally inserted central catheter (PICC - a long thin tube that's inserted through a vein in an arm and passed through a larger vein near the heart) line for Residents 18 and 43. 3. No individualized person-centered CP was developed for the management of the urinary catheter (a tube left in the bladder to carry urine from the bladder to outside the body) for Resident 43. 4. No individualized person-centered CP was developed for the use of oxygen for Resident 43. 5. No individualized person-centered CP was developed for Resident 31 to include her lack of teeth and dentures. This failure had the potential for not meeting the residents' nursing needs and goals to attain their highest practicable well-being. Findings: 1. Resident 19 was admitted on [DATE] with diagnoses including alcoholic cirrhosis of liver with ascites (chronic liver damage from a variety of causes leading to scarring and liver failure with buildup of fluid in the abdomen), traumatic brain injury (brain dysfunction caused by an outside force usually by a violent blow to the head), and major depressive disorder. During a review of Resident 19's Order Summary Report (OSR), the OSR indicated, Resident 19 had active orders as of 10/4/23, .Trazodone HCl (Trazodone Hydrochloride - used to treat depression) Oral Tablet 100 mg (milligram) give 1 tablet by mouth at bedtime for insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or both) .monitor hours of sleep daily from 3-11 and 11-7 with the use of (specify drug and diagnosis) document hours of sleep every evening and night shift for Trazodone . with a start date of 9/8/23. During a concurrent interview and record review on 10/4/23 at 11:05 AM with Registered Nurse (RN) 2, Resident 19's CP for the use of Trazodone was reviewed. RN2 acknowledged that the CP did not include monitor hours of sleep. RN2 stated, It's not individualized. It doesn't reflect the intervention for monitoring of sleep to see if medication is effective. 2a. Resident 18 was readmitted to the facility on [DATE] with Pneumonia (Lung infection). During a concurrent observation and interview on 10/4/23 at 9:10 AM, Resident 18 had two separate tubing and two cap PICC line, with dressing clean, dry, intact, and dated. Resident 18 stated Today is the last day of my antibiotics. During review of Resident 18's OSR. Resident 18's OSR had active orders as of 10/5/23, .Ceftriaxone Sodium (medication that kills bacteria and prevents its growth) Injection Solution Reconstituted 2 gm (grams) IV every 24 hours for Right Lower Extremity (RLE) hardware infection .Flush the PICC line 10 ml (milliliters) NS (Normal Saline) before and after medication administration in the morning . Flush the PICC line 10 ml NS for patency every dayshift . Assess length of external catheter and upper arm circumference in cm (centimeters) every shift . PICC line dressing change every 7 days. During a concurrent interview and record review on 10/5/23 at 3:41 PM with the DON, the DON verified that there was no CP developed for the management of Resident 18's PICC line and stated, There should be a CP. I didn't see a CP for PICC line. I thought I was sure of it that this resident has PICC line CP, but there's none. The DON said that a CP is important to monitor the condition of the PICC line site. 2b. Resident 43 was admitted on [DATE] with diagnoses including malignant neoplasm of lung (lung cancer), and secondary malignant neoplasm of brain (caused by cancer cells spreading to the brain from a different part of the body). During a concurrent observation and interview on 10/2/23 at 11:00 AM with Resident 43 in the resident's room, Resident 43 had a PICC line on his left upper extremity, which was capped, with dressing dry and intact. Resident 43 stated, It's used for my chemotherapy. During a concurrent interview and record review on 10/5/23 at 3:13 PM with the Director of Nursing (DON), Resident 43's CP was reviewed. The DON said that Resident 43 has a PICC line used for chemotherapy (type of cancer treatment) and for intravenous antibiotics (medications delivered into a vein). The DON acknowledged that there was no CP developed for the management of Resident 43's PICC line and stated, There should be a CP, I didn't see a CP for PICC line. The DON said that a CP is important to monitor the condition of the PICC line site, for any changes, and address it with the primary care physician. The DON further stated, For patient safety. 3. During an observation on 10/2/23 at 11:00 AM, Resident 43 had a urinary catheter hanging below the right side of the bed, no kinks, bag covered, and was off the floor. During a concurrent interview and record review on 10/4/23 at 3:00 PM with RN2, Resident 43's CP was reviewed. RN2 said that Resident 43 had a foley catheter for urinary incontinence (the loss of bladder control). RN2 acknowledged there was no CP developed for the management of Resident 43's foley catheter. RN2 stated, There's no care plan for the foley catheter. Care plan is important to see what goals and interventions they have. Review of an undated facility policy titled, Care Plans, Comprehensive Person-Centered indicated, .Interpretation and Implementation .1. A Comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative .6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible . 4. During a concurrent observation and interview on 10/2/23 at 11:00 AM with Resident 43 in the resident's room, Resident 43 was on oxygen at 2L/min (liters/minute) via nasal cannula (device that delivers extra oxygen through a tube and into the nose that help people who are having difficulty breathing). Resident 43 stated, My nose is stuffed. During a concurrent interview and record review on 10/4/23 at 3:32 PM with RN2, Resident 43's CP was reviewed. RN2 verified that Resident 43 uses oxygen and stated, He's on oxygen 24/7 via nasal cannula at 2L/min for shortness of breath. RN2 acknowledged there was no CP developed for Resident 43's use of oxygen and stated, None for administering oxygen. Review of facility policy, Oxygen Administration revised October 2010, indicated, .Preparation .2. Review the resident's care plan to assess for any special needs of the resident . 5. A record review showed Resident 31 was admitted on [DATE]. The MDS 3.0 Nursing Home Quarterly dated July 28, 2023, showed Resident 31 with a BIMS (Brief Interview for Mental Status) score of 8 showing moderate cognitive impairment. On 10/4/23 at 12:09 p.m., Resident 31 was observed in the dining room eating her lunch. The tray ticket on her tray indicated Resident 31 was on a Mechanical Soft textured diet (a diet designed for people who have trouble chewing and/or swallowing). Resident 31 ate pieces of chicken that were too large for a mechanical soft diet. In addition, her plate of food contained vegetables that were too hard for a mechanical soft diet (cross-reference F805). In an interview on 10/6/23 at 9:25 a.m., Speech Language Pathologist (SLP) stated he recommended mechanical soft textured food for Resident 31 because she was missing teeth and did not have dentures. Review of the Speech Therapy SLP Evaluation and Plan of Treatment signed and dated by SLP on 10/26/22, showed under Clinical Impressions that Resident 31 was missing dentition resulting in prolonged mastication (chewing) and reported difficulty of masticating regular texture. Patient demonstrates adequate oral motor structures appropriate for accepting and manipulating textures of mechanical soft and thin liquids, which is patient's baseline as reported by [family member]. Review of the document titled Oral Health Care dated 7/31/23, showed Resident 31 did not want dentures. In an interview on 10/6/23 at 12:27 p.m., the Director of Nursing and Dietary Supervisor 1 (DS1) verified there was no care plan initiated for Resident 31 regarding dental issues prior to 10/6/23. The DON stated there should be a care plan for a resident with dental issues such as missing teeth and/or no dentures. Review of the undated document titled Care Plans, Comprehensive Person-Centered showed a comprehensive, person-centered care plan should include measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs. The care plan should be developed by the interdisciplinary team, with input from the resident, and his/her family or legal representative. The care plan should be developed within 21 days of admission and the care plan should be reviewed and updated by the interdisciplinary team when there is a significant change in the resident's condition, and at least quarterly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to: 1. Provide food preferences to one resident (Resident 10); and 2. Provide an appealing option of similar nutritive value for milk when 39 residents chose not to drink milk. These failures had the potential for residents to not receive the amount of nutrients provided by the planned menu and/or the Registered Dietitians recommended nutrient needs leading to nutrient deficiency, weight loss, and/or malnutrition out of a census of 51. Findings: 1. A record review for Resident 10 showed he was originally admitted to the facility on [DATE] with diagnoses including but not limited to congestive heart failure ((a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease stage 3 (when kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood), severe obesity, depression, and pulmonary edema. The MDS (Minimum Data Set, an assessment tool) dated September 9, 2023, showed Resident 10 with a BIMS (Brief Interview for Mental Status) score of 12 showing moderate cognitive impairment. It was identified during the recertification conducted from 10/2/23 to 10/6/23 that Resident 10 did not like the food he was served, documentation showed he had poor intake continuously, he was losing weight, and food preferences were not updated since his original admission. (Cross-reference F692) Review of the policy and procedure titled Food and Nutrition Services revised October 2019, showed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide care) will assess food likes, dislikes, and eating habits. Reasonable efforts will be made to accommodate resident choices and preferences. Review of the policy and procedure titled Food Preferences dated 2018, showed updating food preferences will be done as residents' needs change. Review of the policy and procedure titled Food Substitutions for Residents Who Refuse the Meal dated 2018, showed the FNS [Food and Nutrition Services] Director is to document on the resident's profile and tray card what menu items are disliked and, if necessary, re-interview the resident or staff for food preferences. In an interview on 10/5/23 at 1:57 p.m., Dietary Services Supervisor 2 (DS2) stated when a resident had weight loss, the RD notified her and asked her to get resident food preferences. DS2 confirmed there was no documentation for Resident 10's food preferences since his initial admission in August 2023. 2. Review of the Daily Cook's Menu dated Fall 2023 10/2, showed all diets received milk except for Renal diets (a diet typically prescribed to a person with kidney disease). An observation and concurrent interview with RD1 and DS2 on 10/02/23 at 12:15 a.m., showed trays were prepared for lunch food service. Drinks were placed on the trays. Milk was not observed on many trays. RD1 stated residents did not receive milk unless milk was printed on the tray ticket as a standing order, even when milk was on the menu. She stated it was a resident's preference if they did not want milk. She stated many residents were [of certain ethnic origin] and they did not like milk. She said resident did not get a substitute for milk to make up for the nutrients they were missing in relation to the planned menu. DS2 confirmed residents did not receive a substitute for milk. Review of the lunch meal tickets showed 39 tray tickets did not have milk printed on them as a standing order and did not indicate the resident should not receive milk due to an allergy or preference (renal diet meal tickets were not included). Review of the Policy and Procedure titled Food Preferences dated 2018, showed Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. Review of the policy and procedure titled Menus revised October 2017, showed menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established guidelines for nutritional adequacy.

Based on observation, interview, and facility document review, the facility failed to have a full-time, qualified, and competent person to supervise food and nutrition services when: 1. The registered dietitian (RD) and the qualified dietary supervisor were at the facility less than full-time defined as 35 hours per week; 2. Food and Nutrition Services (FNS) supervisory staff did not ensure: a resident received food preferences; FNS staff were competent to carry out job duties and tasks they performed; the planned menu was followed; a resident received the appropriate texture food according to the diet order; there was an effective system to maintain food and nutrition services in a safe and sanitary manner; and the kitchen was pest free; and 3. The dietary supervisor did not ensure chicken potstickers were cooked to an appropriate temperature. These failures had the potential to compromise the safety and nutritional status of residents through the potential transmission of foodborne illness, the provision of inadequate nutrients, the provision of food texture that did not meet resident needs, and ineffective interventions for 51 residents who received food from the kitchen out of a facility with a census of 51. Findings: 1. 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 undated job description titled Dietary Supervisor, showed the Dietary Supervisor must be a graduate of an approved dietary managers course that meet the state and federal regulations. In an interview on 10/2/23 at 9:20 a.m. Dietary Supervisor 2 (DS2) stated she was not a not a qualified supervisor. She stated the Certified Dietary Manager (CDM) for this facility worked at two facilities. DS2 also stated there were two registered dietitians for the facility, Registered Dietitian 1(RD1) who was the kitchen RD and Registered Dietitian 2 (RD2) who was the clinical RD. Dietary Supervisor 1 (DS1) stated she was the CDM and was at the facility about three days a week. DS1 also stated RD1 was the RD for the kitchen and was at the facility one day a week. In an interview on 10/2/23 at 12:35 p.m., RD1 stated she was not the regular dietitian for this facility and did not usually come to this facility. She stated she was covering for RD2 for a few days while RD2 was out of state at a conference. In an interview on 10/3/23 at 11:35 a.m., DS1 provided a certificate that showed she was qualified as a Dietary Services Supervisor (DSS). She stated there was no documentation of her hours to show how many hours she came into the facility because she was salary. She stated sometimes she came into the facility for 32 hours a week but mostly she came to the facility 3 days a week for around six to eight hours a day. The Administrator (ADM) stated DS1 came into the facility about 24 hours a week. When the surveyor informed ADM the requirement for a full-time supervisor for Food and Nutrition Services, he stated, but she [DS1] is here 32 hours a week. ADM stated he thought fulltime was defined as 32 hours a week. ADM confirmed there was no documentation of hours for DS1. He also confirmed there was not a full-time RD for the facility. 2. Multiple issues were identified in the kitchen including not providing a resident with food preferences; not ensuring staff competency; not ensuring the planned menu was followed; not ensuring the appropriate texture of food was served according to the diet order; not ensuring food safety and sanitation; and not ensuring the kitchen was free of pests (cross-reference F692, F802, F803, F805, F812, and F925). Review of the undated job description titled Dietary Supervisor, showed the general purpose of the Dietary Supervisor (DS) role was providing supervision to the Dietary Department. The DS was responsible for directing and assisting the preparation and service of regular meals and therapeutic diets, ordering food and supplies, and maintaining the area and equipment in a sanitary condition. Essential duties for this position included, directing and participating in food preparation and service of food that was safe and appetizing and was of quality and quantity to meet each resident's needs in accordance with physicians order in compliance with approved menus; directs and supervises all dietary functions and personnel; trains dietary employees; assures handling of food and supplies complies with current state and federal guidelines; receives resident food preferences; maintains kitchen and food storage areas in a safe, orderly, clean and sanitary manner; transmits orders for appropriate food and supplies; checks trays for accuracy before they are delivered. Review of the undated job description titled Registered Dietitian, showed essential duties included to monitor food services operations to ensure conformance to nutritional, safety, sanitation, and quality standards, as well as state and federal regulations; and to monitor food control systems such as food temperatures, portion control, preparation methods to ensure food was prepared and presented in an acceptable manner. 3. An observation and interview on 10/2/23 at 12:05 p.m., showed DS1 measured the temperature of foods placed on the trayline for food service. A pan of chicken potstickers were removed from the oven. The pan had foil over the top. DS1 placed the probe of a thermometer through to foil to measure the potstickers. Because the probe was placed through the foil covering the pan, it could not be identified where the probe was inserted into a potsticker. The thermometer showed 170 degrees Fahrenheit (F) and DS1 stated they were okay and ready to serve. The surveyor pulled back the foil that covered the pan and measured the temperature of the center of two potstickers with a calibrated thermometer and the temperatures were 106.3 degrees F and 129.0 degrees F. Then DS1 stated the potstickers had to be heated more. When DS1 was asked how she knew her thermometer was inside the potsticker toward the center when she stuck the thermometer probe through the foil, she stated she did not know. When she was asked how many potstickers she should measure temperatures of to ensure they were hot enough, she stated she should take the temperature of at least three potstickers. She also stated the potstickers had to be heated to at least 165 degrees F before serving them. Review of the recipe titled Pot Stickers dated 8/3/23, showed to cook frozen pot stickers to an internal temperature of 165 degrees F. Review of the policy and procedure titled Food Preparation and Service revised 2022, showed poultry was to be cooked to at least 165 degrees F to kill or sufficiently inactivate pathogenic microorganisms. Also, previously cooked food that was to be reheated to an internal temperature of 165 degrees F. In addition, ready to eat foods that require reheating were to be cooked to at least 135 degrees F for holding for hot service.

Based on observation, interview, and facility document review, the facility failed to ensure the competency of Food and Nutrition Staff when: 1. A cook did not know the steps for cooling Time Temperature Control for Safety (TCS, foods more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) food; 2. A cook did not follow recipes when preparing food for the planned menu; 3. A diet aide did not know how long to submerge items in the sanitizer solution when washing manually using the 2-compartment sink; 4. A diet aide did not follow manufacturer's instructions for a sanitizer test strip when testing the surface sanitizer. These failures had the potential to compromise the safety and nutritional status of residents through the transmission of foodborne illness and the provision of inadequate nutrients and/or decreased quality of food for 51 residents who received food from the kitchen out of a census of 51. Findings: 1. Review of the Cooldown Temperature Log dated October 2023, showed instructions which read Food must be cooled from 140 degrees Fahrenheit (F) to 70 degrees F within first 2 hours, 70 degrees F to 41 degrees F within next 4 hours . In addition, the directions showed potentially hazardous foods (also known as TCS food) prepared from room temperature ingredients such as salads and sandwich fillings, including tuna salad, are to be cooled to 41 degrees F within 4 hours. Documentation on this log dated 10/2/23 showed salad start temperature was 140 degrees F at 10 a.m. and 68 degrees F at 11 a.m. These documented temperatures were the same as the example provided on the log for the cooling of potato salad. During the recertification survey from 10/2/23-10/6/23, it was identified Food and Nutrition staff were not documenting cooling of TCS food which was cooked and stored for later use (Cross-reference F812). In an interview and observation with [NAME] 1 on 10/4/23 at 9:32 a.m., the October cooldown log was reviewed. [NAME] 1 confirmed he documented green salad on the cooldown log on 10/2/23. He stated he did not know why he documented green salad on the log, and he stated the temperatures of 145 degrees Fahrenheit at 10 a.m., and 68 degrees at 11 a.m., were mistakes. He also stated food should be cooled from 135 degrees F to somewhere around 68 to 72 degrees F in two hours and between 41 and 45 degrees F for an additional four hours. In an interview with DS2 on 10/4/23 at 1:22 p.m., she stated she did not know tuna salad made from room temperature ingredients had to be cooled and she did not expect it to be documented on the cooldown log. Review of the policy and procedure titled Food Preparation, Cooking and Holding Time/Temperatures revised 2019, showed potentially hazardous foods (also known as time temperature control for safety (TCS) foods, foods more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) are to be cooled rapidly from 135 degrees Fahrenheit (F) to 70 degrees F within two hours and then to a temperature of 41 degrees F or below within the next four hours. The total cooling time between 135 degrees F and 41 degrees F is not to exceed 6 hours. 2. Review of the Daily Cook's Menu dated 10/2, showed Beef and Broccoli was served to regular textured diets and the pureed diet received pureed Beef and Broccoli. Review of the recipe titled Beef and Broccoli dated 8/3/23, showed directions on how to prepare the Beef and Broccoli. The recipe showed to prepare the pureed texture Beef and Broccoli, to place prepared portion of Beef and Broccoli into a blender and blend until a smooth consistency. During an observation and concurrent interview with Registered Dietitian 1 (RD1) on 10/2/23 at 1:06 p.m., a regular texture and puree texture test tray was tasted. The regular texture Beef and Broccoli was a mixture of beef and broccoli in a sauce. The pureed test tray showed a scoop of pureed beef and a scoop of pureed broccoli. When tasted, the regular Beef and Broccoli mixture had a different flavor to the separate pureed beef and broccoli. RD1 stated the pureed beef and broccoli should not be separate and the cook should have pureed portions of the prepared Beef and Broccoli mixture. Review of the Daily Cook's Menu dated 10/3/23, showed the entrée for lunch that day was steamed fish and the vegetable was stir-fried Peking cabbage. An observation and concurrent interviews with [NAME] 1, Dietary Supervisor 1 (DS1), and the RD1 on 10/3/23 at 10:30 a.m., showed [NAME] 1 preparing food for the lunch meal. DS1 told [NAME] 1 to make sure to follow the recipes. [NAME] 1 opened the recipe binder to the nutritional analysis page which was a spreadsheet of the nutrient provided for the weekly menu. [NAME] 1 looked at the nutrient analysis then placed a one teaspoon of chicken base into a container of water. [NAME] 1 stated he looked at the nutrient analysis to find out how much sodium use to make the broth. [NAME] 1 stated the broth was for the pureed cabbage. [NAME] 1 filled a blender with a cooked cabbage mixture and added two, 6-ounch ladles of broth. He blended the cabbage and the broth for about 3 seconds and added another ladle and a half of broth and blended the mixture more. He poured thin mixture into a pan. Review of the recipe titled Cabbage Stir-fry, Peking dated 10/3/23 showed directions for preparing the stir-fry. The directions for the pureed stir-fry showed to place the number of portions needed of prepared stir-fry in a blender and gradually add 1 -1/2 teaspoons of thickener for each portion. Blend until smooth until pudding like consistency is met. In a concurrent observation and interview with [NAME] 1 on 10/3/23 at 10:40 a.m., a pan containing fish and water was on the stove. [NAME] 1 removed the fish from the pan and placed it in the blender. Then he removed water from the pan using a 6-ounce ladle. He blended the mixture and poured the mixture into a pan. The texture was runny and [NAME] 1 added thickener using a half cup measuring cup. [NAME] 1 stated he followed the recipe for the pureed because he used the same ingredients as the regular fish which he baked in the oven. The recipe titled Fish, steamed dated 10/3/23, showed to prepare the fish by added ingredients and steaming the fish in a steam pan. For the pureed steamed fish, the directions showed to add prepared portions of steamed fish to a blender and add one tablespoon of milk or vegetable broth for each portion, then blend until smooth. Review of the policy and procedure titled Standardized Recipes revised April 2007, showed standardized recipes shall be developed and used in the preparation of foods. 3. In an observation, interview, and document review on 10/3/23 at 11:05 a.m., Diet Aide 1 (DA1) demonstrated how to use the two-compartment sink for manual dish washing. She stated the last sink filled with a sanitizer solution to sanitize items. She stated the sanitizer used was dispensed from a hose above the two-compartment sink. The label on the sanitizer container connected to the hose showed it was a Quaternary Sanitizer. She stated items had to be in the sanitizer for 10 seconds. The directions posted above the sink titled 2-Compartment Sink Procedure showed to fully submerge service ware in sanitizer solution for 1 Minute. Review of the manufacturer's instructions located on the quat sanitizer container, showed for food contact surfaces, to immerse items in a sanitizer solution for 60 seconds. 4. In an observation, interview, and review of manufacturer's instructions on 10/3/23 at 11 a.m., Diet Aide 1 (DA1) demonstrated how she prepared and tested the food contact surface sanitizer. She filled a red bucket with a quaternary ammonia sanitizer solution that was dispensed from a hose above the two-compartment sink. She removed a test strip from a container and dipped it in the solution for three seconds. DA1 stated the solution was 200 ppm (parts per million). She was asked to test the sanitizer again this time dipping the test strip in the sanitizer solution for 10 seconds. After 10 seconds, she removed the strip and it was darker than the strip she held in the solution for three seconds. She stated the strip she held in the solution for 10 seconds was between 200-300 ppm. The manufacturer's instructions for the test strips located inside the container of the sanitation test strips showed to dip the paper in the quat solution for 10 seconds.

Based on observation, interview and record review, the facility failed to follow the planned menu when: 1) The incorrect serving size of the main entrée was served according to the menu for a lunch meal; 2) Pureed melon was not served according to the menu for a lunch meal. 3) Pureed salad was not served according to the menu for a lunch meal. 4 ) Fresh strawberry and ice cream were not served according to the menu for a lunch meal. This failure to follow the planned menu had the potential to result in residents not receiving the nutrients the menu was intended to provide leading to decreased nutrient intake and further compromising residents' medical status for 51 residents who received food from the kitchen. Findings: Review of the policy and procedure titled Menus revised October 2017, showed menus are developed and prepared following established national guidelines for nutritional adequacy. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. The dietitian reviews and approves all menus. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. Review of the policy and procedure titled Purchasing Food and Supplies dated 2018, showed the Food and Nutrition Services Director is responsible for specifying quantity of food desired when ordering food from an appropriate vendor. Proper procedures are to be followed in purchasing food and seeing that food is delivered. Food purchasing begins with a planned menu. Supplies shall be appropriate to meet the requirements of the menu and therapeutic diets ordered. 1. Review of the document titled Daily Cook's Menu dated Fall 2023, 10/2, showed the serving size for the regular textured Beef and Broccoli entrée was ¾ of a cup. The menu showed all regular textured diets received ¾ of a cup except for small portions. On 10/2/23 at 12 p.m., an observation and concurrent interview with Dietary Supervisor 2 (DS2) and Registered Dietitian 1 (RD1), showed [NAME] 1 plated food for residents' lunch meal. For the main entrée, Beef and Broccoli, [NAME] 1 used a spoodle (a cross between a ladle and a spoon) that had a label marked on the handle showing the spoodle was 4 ounces (1/2 cup). DS2 and RD1 referred to the cook's spreadsheet and confirmed the portion for the beef and broccoli was ¾ of a cup and [NAME] 1 was using the incorrect size spoodle and was serving a portion that was less than indicated on the menu. 2. Review of the document titled Daily Cook's Menu dated Fall 2023, 10/2, showed regular textured diets received cubed fresh melon and pureed diets received pureed fresh melon. During tray line observation and interview with DS2 on 10/2/23 around 12:15 PM in the kitchen, food for resident lunch was placed on trays. The trays with a tray ticket that specified the resident was on a pureed diet received a small bowl of a light colored pureed substance. DS2 stated the pureed substance was pureed pears and there was no pureed melon for the pureed diets., DS2 stated she only received one box of melons. She stated she ordered five melons but she just received three. On 10/2/23 at 3 p.m., the food invoice dated 10/2/23 was reviewed with DS2. The invoice showed 1 case of cantaloupe was ordered and 1 case of cantaloupe was shipped. When DS2 was asked how many melons came in a case, she stated 3. DS2 confirmed she did not order enough melon to meet the needs of the menu for lunch today (10/2/23). 3. Review of the document titled Daily Cook's Menu dated Fall 2023, 10/2, regular textured diets received Asian Cucumber Salad, and pureed diets received pureed Asian Cucumber Salad. The menus also showed the entrée for pureed diets was pureed Beef and Broccoli. An observation and interview with [NAME] 1 on 10/2/23 at 12:10 p.m., showed food was placed on to trays for resident lunches. Trays with tray tickets that indicated residents were on a pureed diet, did not have pureed salad on their trays. [NAME] 1 stated there was no pureed salad for pureed diets today. [NAME] 1 stated he gave pureed diets broccoli instead of salad. 4. Review of the document titled Daily Cook's Menu dated Fall 2023, 10/42, showed all diets received fresh strawberries and ice cream except for residents on a renal diet (a diet typically prescribed to a person with kidney disease). During dining observation on 10/4/23 at 12:15 PM, residents had small containers of strawberry ice cream on their lunch tray. There were no fresh strawberries on resident trays. In an interview and document review on 10/4/23 at 12:11 p.m., DS2 stated confirmed strawberry ice cream was served for lunch today (12/4/23) not fresh strawberries and ice cream. DS2 retrieved the recipe titled Standard A Fall 2023 Strawberries & Ice Cream and stated the recipe showed the ingredients were vanilla ice cream and fresh strawberries. DS2 stated the residents should have received vanilla ice cream and fresh strawberries but she did not order strawberries.

Based on observation, interview and record review, the facility failed to ensure food safety requirements in accordance with professional standards for food service safety when: 1. Staff did not ensure food was cooled safely. 2. Pans and bowls were not dried appropriately. 3. Frying pans were in poor condition. 4. A large mixer was not clean and in poor condition. 5. An industrial can opener was not clean and in poor condition. 6. Refrigerator and Freezer door rubber gaskets (a rubber strip surrounding the perimeter of the inside of the cooler door to seal the door when it is closed so air cannot go in or out) were not clean. 7. Staff did not handle clean dishes appropriately to prevent contamination of the dishes. 8. There was no airgap (a gap between the sink drains and the drain that leads to sewage drain. This gap prevents a back-up of non-potable water and/or bacteria into the sink) for the food preparation sink drain. 9. Nursing staff who monitored food refrigerator temperatures did not know appropriate refrigerator temperatures to store food safely. 10. Refrigerated food belonging to residents were not labeled to show who the food belonged to. 11. Expired tube feedings (liquid nutrition provided through a tube when a person is not able to eat on their own by mouth) were stored expired and available for use; and 12. Perishable food at resident's bedside (Resident 19) was beyond the amount of time that was considered safe for consumption. The failure to store, prepare, serve, and distribute food in a safe and sanitary manner had the potential to put residents at risk for foodborne illness leading to severe illness and even death for 51 residents who consumed food by mouth and through tube feeding. Findings: 1. A concurrent observation and interview with Dietary Supervisor 1 (DS1), and Dietary Supervisor 2 (DS2) on 10/2/23 at 10:05 AM in the kitchen, showed cooked rice dated 10/1/23-10/3/23 in a closed container in the refrigerator. DS1 stated rice was cooked almost every day. DS2 stated rice should be documented on the cool down log. The cool down logs for the months of September and October were checked and were both blank. DS1 and DS2 confirmed there was no cooldown documented for any foods for September and October 2023. DS1 stated the rice had to be discarded because she did not know if it was cooled appropriately. On 10/3/23 at 11:28 a.m., an observation showed tuna salad in the refrigerator in a plastic container dated 10/3/23-10/6/23. In an interview on 10/4/23 at 12:36 p.m., [NAME] 2 stated she made the tuna salad yesterday that was stored in the refrigerator dated 10/3/23. She stated she used packaged tuna that was stored in the dry storeroom at room temperature to prepare the tuna salad. She stated she did not document cooldown for the tuna salad. Review of the policy and procedure titled Food Preparation, Cooking and Holding Time/Temperatures revised 2019, showed potentially hazardous foods (also known as time temperature control for safety (TCS) foods, foods more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) are to be cooled rapidly from 135 degrees Fahrenheit (F) to 70 degrees F within two hours and then to a temperature of 41 degrees F or below within the next four hours. The total cooling time between 135 degrees F and 41 degrees F is not to exceed 6 hours. Review of the Cool Down Temperature Log dated October 2023, showed directions which read potentially hazardous foods prepared from room temperature ingredients such as salads and sandwich fillings, including tuna salad, are to be cooled to 41 degrees F within 4 hours. 2. During a concurrent observation and interview with the DS1 on 10/2/23 at 9:30 a.m. in the kitchen, showed a storage rack that held metal pans and mixing bowls of various sizes. The mixing bowls and pans were stacked within one another and were wet. The DS1 acknowledged the observation and stated, they should have been air dried completely. During a review of the facility's policy and procedure titled 3 compartment procedure for manual dishwashing dated 2018 indicated all items are air-dried, which means no water droplets are present. According to the 2022 Federal Food Code, after cleaning and sanitizing, equipment and utensils are to be air-dried before storing. According to the annex, wet nesting occurs when dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. 3. A concurrent observation and interview with the DS1 on 10/2/23 at 9:30 a.m., in the kitchen, showed frying pans hanging above the two-compartment sink. During observation three pans were examined. Three frying pans (two large and one small) had thick black, hard, and solidified residue. The flat cooking surface of the frying pans were scratched and had a rough surface. DS 1 stated the pans were used to cook eggs and confirmed the pans had a coating that was scratched, and the pans had to be replaced. Review of the policy and procedure titled Sanitization dated 2001, showed all equipment and utensils shall be kept clean, and maintained in good repair. According to the 2022 Federal Food Code, food-contact surfaces are to be smooth and free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. In addition, the food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulations. 4. A concurrent observation and interview with DS1 and DS2 on 10/2/23 at 9:32 a.m. in the kitchen, showed a large mixer covered with a plastic. DS1 stated, the mixer was used to prepare cakes and when it was covered with plastic, it was supposed to be clean. The flat beater attached to the mixer had a silver coating on the surface that had partially come off. Also, there was white, greasy to the touch residue where the flat beater attached to the mixer, and also white residue on the safety shield. DS1 confirmed the coating was coming off the flat mixer and there was residue on the mixer, and it had to be cleaned. During a review of the facility policy and procedure titled: Electrical Food Machine, 2018, indicated, keep, and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slicers, and toasters. According to the 2022 Federal Food Code, food-contact surfaces are to be smooth and free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Equipment food contact surfaces and utensils are to be clean to sight and tough. In addition, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 5. An observation and concurrent interview on 10/2/23 at 9:44 a.m., showed an industrial can opener on a food preparation table. [NAME] sticky residue was embedded on the blade around the seem where the blade was screwed on to the can opener. A white paper was used to wipe the can opener blade and dark brown dirt came off onto the paper towel. In addition, the silver coating on the can opener blade was rubbed off. The facility's document titled: can opener and base, 2018 indicated, proper sanitation and maintenance of the can opener is important to sanitary food preparation. The can opener must be cleaned thoroughly each work shift, and more frequently when necessary. According to the 2022 Federal Food Code, food-contact surfaces are to be smooth and free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Equipment food contact surfaces and utensils are to be clean to sight and tough. In addition, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 6. During a concurrent observation and interview with DS1 and DS2 on 10/2/23 at 10:06 a.m. in the kitchen, showed the rubber gaskets (a rubber strip surrounding the perimeter of the inside of the cooler door to seal the door when it is closed so air cannot go in or out) for the doors of one reach-in refrigerator and one reach-in freezer had black residue embedded in the surface of the gaskets. DS1 confirmed the gaskets were dirty and had to be cleaned. During a review of the facility policy and procedure titled, Refrigerator and Freezer (2018), it indicated, maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. The procedures showed refrigerator and freezers should be on a weekly cleaning schedule and to wipe down gaskets with soapy water. According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 7. During a concurrent observation and interview with DS1 on 10/4/23 at 10 a.m. in the kitchen, showed DA1 handled washed dishes on the clean side of the dish machine with her bare hands and placed the dishes in the plate warmer next to the tray line. When she handled the plates, she touched the food contact surface of the plate. DS1 confirmed DA1 touched the food contact of the plates with her bare hands and stated only the underside or the side of the plates should be handled with bare hands, not the food contact surface. According to the 2022 Federal Food Code, sanitized utensils are to be handled so that contamination of food and lip-contact surfaces is prevented. 8. During a concurrent observation and interview with DS1 and DS2 on 10/2/23 at 10 a.m., showed a food preparation sink in the kitchen with a drain that was plumbed directly into the wall. The Maintenance Supervisor (MS) stated there was no air gap (a gap between the sink drains and the drain that leads to sewage drain. This gap prevents a back-up flow of non-potable water and/or bacteria into the sink). He also confirmed drain was attached to the wall, and it went straight to the ground and was connected to the sewer. According to the 2022 Federal Food Code, a direct connection may not exist between the sewage system and the drain originating from equipment in which food, portable equipment, or utensils are placed. 9. In an interview on 10/2/23 at 2:40 p.m., Registered Nurse 1 (RN1) stated he monitored and documented the temperature of the resident food refrigerator located in the medication room. He stated the proper temperature for the food refrigerator was on the log. The log was reviewed with RN1, and he confirmed the log showed 36-46 degrees as the appropriate temperature. At the top of the log it showed If the temperature is not between 36 and 46 degrees, notify Maintenance. RN1 stated it was okay for the food refrigerator to go up to 46 degrees Fahrenheit (F). In an interview on 10/5/23 at 10:22 a.m., RN1 stated he thought he had training regarding food refrigerator temperatures from the DSD, but he could not remember when. He stated during the training the DSD reviewed the refrigerator temperature log sheet. In an interview on 10/5/23 at 10:24 a.m., the DSD stated she trained nurses on the food refrigerator temperature according to the log sheet that showed 36-46 degrees F. She stated she did not receive training from Food and Nutrition staff regarding proper food/refrigerator temperatures. During a review of the facility policy and procedure titled, Procedure for Refrigerated Storage dated 2019, showed the refrigerator was to be 41°F or lower. 10. During a concurrent observation and interview on 10/2/23 at 2:15 p.m., a resident food storage refrigerator located in the medication room contained foods that were not dated and that was not labeled with resident names. This food included two packages of shredded cheese, a package of deli meat ham, a container of mustard, a container of strawberry preserves, and two tubs of butter. The Director of Staff Development (DSD) confirmed the food belonged to residents and stated the food should be dated and labeled with the resident names to show who it belonged to. Review of the policy and procedure titled Foods Brought by Family/Visitors revised March 2022, showed food brought by family/visitors and left for the resident to consume later are to be labeled with the resident's name. 11. During a concurrent observation and interview with DS1 and DS2 on 10/2/23 at 10:28 a.m. in the dry food storage room, 27 expired plastic bottles of tube feedings (TF) were found. The 27 expired bottles included: 15 bottles of Nepro [Therapeutic nutrition to help meet the nutritional needs of dialysis patients] with expiration date of September 2023, and 3 bottles with expiration date of May 2023; and 2 plastic bottles of Jevity [a complete balanced nutrition with fiber] with expiration date of June 2023 and 7 bottles with expiration date of August 2023. The DS1 confirmed the tube feedings were expired and they had to be discarded. During an interview with the Medical Records Director (MRD) and the [NAME] Clerk (WC) on 10/4/23 at 1:52 p.m., WC stated the [NAME] Clerks monitored the inventory of the tube feedings every Tuesday. The MRD stated expired tube feedings should not be in the storeroom. 12. During a concurrent observation and interview on 10/2/23 at 9:32 AM with Resident 19 in the resident's room, a sandwich was on the over bed table. The sandwich was covered with a plastic wrap and dated, 10/1/23. Resident 19 stated, That's from last night. During an interview on 10/2/23 at 9:51 AM with the Director of Staff Development (DSD), the DSD acknowledged that the sandwich was dated 10/1/23. DSD stated, It's not supposed to be here. It's not refrigerated, not good anymore. It's from yesterday. During an interview on 10/5/23 at 11:09 AM with the Registered Dietitian (RD) 1, when queried regarding the sandwich, RD1 stated, That should be consumed within two to four hours or as soon as possible after it has left the kitchen. It should be thrown away. Review of facility policy titled, Food and Nutrition Services revised October 2019, indicated, .Food and nutrition services staff will inspect food trays to ensure .it is served at a safe and appetizing temperature .b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded .

Based on observation, interview, and facility document review, the facility failed to maintain the outside compost bin in a clean manner. This failure had the potential to attract pests resulting in pest related illness for 51 residents out of a census of 51. Findings: An observation and interview with Dietary Supervisor 2 (DS2) on 10/3/23 at 12:51 p.m., showed a compost bin stored outside with other waste receptacles directly next to the facility's outside side wall. The compost bin had a significant amount of thick dark brown and black residue on the outside surface and sides of the inside surface of the bin also covered with a thick black and brown residue. DS2 stated the black and brown residue was food residue. In an interview on 10/3/23 at 2:54 p.m., the maintenance supervisor confirmed the outside compost bin was dirty. Review of the document titled Miscellaneous Areas dated 2020, showed each time the garbage is emptied, containers must be cleaned thoroughly. In addition, the trash collection area is a potential feeding ground for vermin and rodents and must be clean. According to the 2022 Federal Food Code, soiled receptacles and waste handling units for refuse shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.

Based on observation, interview, and facility document review, the facility failed to maintain the kitchen free of pests. This failure had the potential to result in contamination of food and utensils used by residents leading to pest related disease and/or illness for 51 residents who received food from the kitchen out of a facility census of 51. Findings: An observation and concurrent interview with Dietary Supervisor 1 (DS1), Dietary Supervisor 2 (DS2), and the Maintenance Supervisor (MS) on 10/2/23 at 9:50 a.m., showed a small fly on the wall above the food preparation sink and adjacent to the knife storage area on the wall. Below the food preparation sink was an open cabinet where the sink drain was plumbed into the wall. There were more than 30 alive flies in inside the cabinet space. In addition, two long pieces of sticky tape over four inches in length and 1.5 inches wide were in the cabinet space and were covered with dead flies stuck to the tape. DS1 and DS2 stated they were not aware of the flies. MS stated the flies were not reported to him. In a phone interview with the pest control service technician (PCST) on 10/3/23 at 1:26 p.m., he stated he was called to the facility yesterday and arrived at 7:30 p.m. PCST stated he saw drain flies under the food preparation sink cabinet. He also stated usually when a couple drain flies are observed, there was actually a lot more. He stated his recommendation to the facility was to lift up the floor cabinet to look for a leak or standing water since drain flies were usually attracted to standing water. Review of the policy titled Pest Control revised May 2019, showed the facility shall maintain an effective pest control program. An on-going pest control program will be maintained to ensure the building is kept free from insects and rodents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 1:1 assistance during meal was provided as per physician's order and Registered Dietician's recommendation for one of 13 sampled residents (Resident 21). This deficient practice contributed to Resident 21's weight loss. Findings: Resident 21 was readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) and protein-calorie malnutrition. Review of Resident 21's quarterly Minimum Data Set (MDS-an assessment tool), dated 9/5/21, indicated, Resident 21 was cognitively impaired. Under functional status for activities of daily living (ADL) indicated Resident 21 required assistance for eating including supervision, oversight, encouragement or cueing. During a dining observation on 10/12/21 at 12:21 PM, Resident 21 was eating in her room by herself. No staff aided Resident 21 with meals. During a follow-up observation on 10/12/21, at 12:37 PM, Resident 21 has finished eating her meal. Then, the Certified Nursing Assistant (CNA) entered Resident 21's room. During a concurrent interview, CNA acknowledged that Resident 21 consumed 50 percent (%) of her meal and required 1:1 assistance with meals. CNA explained the resident needed feeding assistance from start to end of meal. CNA further stated, Resident 21 eats less, about 25-50% as the reason why resident required an assistance. During record review and concurrent interview on 10/13/21 at 2:22 PM, the Registered Nurse (RN) stated, She can eat independently. Then the RN proceeded to review Resident 21's medical record. RN verified the physician's order as 1:1 assistance with meals. RN stated, Resident 21 needed 1:1 assistance during meals for encouragement due to poor oral intake and poor appetite. During an interview on 10/14/21, at 1:19 PM, the Registered Dietitian (RD) stated, 1:1 assistance with meals is provided for encouragement because of poor oral intake. RD stated, Her (Resident 21) meal intake is usually 25%, mostly right now it's 51-75%. RD further said that Resident 21 has complications of dysphagia and protein-calorie malnutrition, had a weight loss of 5.1% from July to August. Review of Dietary Note dated 8/10/21, indicated, .Rt (Resident 21) with very poor po (oral) intake of meals - 0-50% . Review of Resident 21's Task: Amount Eaten record, dated 10/8/21 through 10/14/21, amount eaten record indicated, the following: On 10/9/21 at 13:09 PM, 10/10/21 at 21:40 PM, and 10/12/21 at 22:09 PM, 0-25% of the meal was eaten. On 10/8/21 at 9:01 AM and 14:02 PM, 10/9/21 at 8:08 AM and 18:48 PM, 26-50% of the meal was eaten. On 10/8/21 at 20:39 PM and 10/13/21 at 13:04 PM, resident refused. All other times, 51-75 percentage of the meal was eaten. Review of Resident 21's Weights and Vitals Summary dated 10/14/21, indicated, Resident 21 weighed 71 lbs (pounds) on 6/23/21 and weighed 65 lbs on 9/15/21, a 6-lb weight loss in three months. Review of facility document titled, Order Summary Report with active orders as of 10/14/21, indicated, .1:1 Assistance with meals .order date: 8/24/21 . Review of Resident 21's Quarterly Nutritional Risk Review, dated 9/3/21, indicated the following: Physical and Mental Functioning: Assist with feeding; Food Intake: Intake 26-74% of Meals; Further review of the risk review under Nutrition Goals/Monitoring and Evaluation indicated, Resident had a significant weight loss over the quarter .Resident is also on 1:1 feeding. Recommend to continue with all these interventions with the goal of continued wt (weight) stability . Review of Resident 21's care plan, indicated, .Focus .Resident at risk for altered nutrition and hydration status .Interventions .Assist as needed .Date Initiated: 2/16/18 . The care plan did not reflect 1:1 Assistance with meals as ordered by the physician. Review of facility policy and procedure (P&P) titled Assistance with Meals revised on July 2017, indicated, .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident .Dining Room Residents: 1. All residents will be encouraged to eat in the dining room [ROOM NUMBER]. Facility Staff will serve resident trays and will help residents who require assistance with eating . Review of facility P&P titled Food and Nutrition Services revised on October 2017, indicated, .5. The food and nutrition staff will be available and adequately staffed to assist residents with eating as needed. Nurse aides and feeding assistants will provide support to enhance the resident experience .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store medications according to standard of practice when: 1. Two injection needles with damaged packaging, 12 expired syringes of saline (a mixture of salt and water) and a box containing 100 expired syringes were kept in the medication room. 2. Three opened insulin (medication that allows your body to use sugar) vials and three opened and used insulin vials after 28 days were kept inside the medication cart. These failures had the potential to subject residents to sub-therapeutic medications, non-sterile needles, and use of expired syringes. Findings: During medication room observation on [DATE] at 9:01 AM, with the Director of Nursing (DON), the following were found: a. Two sterile injection needles had damaged packaging. Their paper backing had two small linear tears (approximately 1/4 inch long); b. Twelve syringes of saline dated [DATE] and c. A box containing 100 syringes with expiration date of 11/2019. During medication cart observation on [DATE] at 10:00 AM, with Licensed Vocational Nurse (LVN), the following items were found in the medication cart: a. Three opened and undated insulin vials and b. Three insulin vials were opened, dated, and not discarded after 28 days. During a concurrent interview, LVN 1 stated, insulin vials should be dated when open so staff could discard them after 28 days. LVN 1 also acknowledged the dated insulin vials should have been discarded after 28 days. During a review of the facility's policies and procedures regarding insulin and medication labeling found no information regarding dating the insulin vial when opened and found no information regarding discarding insulin after 28 days. According to the Center for Disease Control and Prevention (CDC) website accessed on [DATE] at https://www.cdc.gov/injectionsafety/providers/provider_faqs_multivials.html, .the United States Pharmacopeia (USP) General Chapter 797 [16] recommends the following for multi-dose vials of sterile pharmaceuticals: If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days .

Based on observation, interview and record review, the facility failed to ensure the Physician ordered therapeutic diet was followed for four of four residents on renal diet (Resident 153, 22, 27 and 11). The deficient practice had the potential to compromise the health of the residents on therapeutic diets. Findings: Review of the facility document titled Diet Type Report dated 10/13/21, indicated, Resident 153, 22, 27 and 11 had a physician ordered renal diet. During dining observation and concurrent interview on 10/13/21, at 12:45 PM, Resident 11's meal ticket indicated, Regular, Consistent Carbohydrate Diet (CCHO), Renal, small portions, thin liquids. Resident 11's meal tray consisted of tandoori chicken with tandoori sauce, rice and zucchini. Resident 11 stated, she never liked sauce on her food because it made her food sweeter. During an interview on 10/13/21, at 2 PM, DC 1 was asked how he would determine which food to plate for renal diet. DC 1 stated, therapeutic diets such as renal diet have the same food meal content as the regular diet. DC 1 stated, the only difference was if the diet was ordered with different texture. DC 1 confirmed, the tandoori sauce was given to the residents with renal diet. DC 1 added, he asked DC 2 ahead of time to state only the ordered texture and not the type of diet ordered during the tray line distribution. During an interview on 10/13/21, at 2:15 PM, the Dietary Supervisor (DS) described the tray line process as reviewing the meal texture, the diet ordered, ensuring there was a main entrée, dessert and beverages. The DS also stated, during tray line, the assigned dietary staff reads and states what was in the meal ticket to ensure the texture, dislikes and the ordered diet to be plated correctly. The DS acknowledged the current method of checking resident trays did not ensure physician order for renal diet was followed. DS also acknowledged the spread sheet for therapeutic diets should be available during tray line for staff guidance. During an interview on 10/14/21, at 3 PM, the Registered Dietician (RD) stated, dietary staff should have the diet spread sheet available during tray line as reference and guidance for the therapeutic diet menu. Review of 10/13/21 Daily Cook's Menu indicated, noon meal consisted of chicken tandoori and tandoori sauce, brown rice, zucchini stir fry, pumpkin cake, and cream cheese frosting. It also indicated, tandoori sauce should not be given to the residents with renal diet. It also indicated, RENAL DIET: Same as LIBERAL DIALYSIS DIET, average calories 2000-2300 calories, 80-110-gram protein, < (less than) 3 gm potassium, < 3 gm sodium, < 2-gram phosphorus. Verified and acknowledged by the DS. Review of facility document titled Liberal Dialysis/Renal Diet (undated), indicated, The Liberal Dialysis diet is designed for pre-end stage renal failure or chronic renal failure The goal is to slow the progression of the disease, maintain optimal nutritional status, minimize uremic toxicity, and prevent protein catabolism .

Based on observation, interview and record review, the facility failed to ensure safe food practices when: 1. The water heater has build up of grease and dirt. 2. A green bucket placed on top of water heater contained sponges, a scrubber and three unidentifiable tools were kept on top of the water heater. 3. The hair of the kitchen staff was not properly restraint. These deficient practices had the potential to expose residents to food borne illness. Findings: During kitchen observation and interview with the Dietary Supervisor, on 10/12/21, at 10:15 AM, the following were observed: 1. There was noticeable buildup of grease and dirt on the top and front surfaces of the water heater located under the dishwasher's clean dish table. 2. A green bucket contained two dried sponges, one silver colored metal scrubber with embedded particles of food, and three metal tools were stored on top of the water heater. The DS verified and acknowledged the water heater surfaces needed to be cleaned. The DS stated he was not sure where to keep the green bucket containing the items mentioned. Review of the facility's policy and procedure (P&P) titled Sanitization revised date 10/2008, indicated, .The food service area shall be maintained in a clean and sanitary manner . 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . 3. During meal preparation observation on 10/13/21, at 11 AM, the Dietary [NAME] (DC) 2 was wearing a hairnet not fully covering the hair on both sides and back of her head. During an interview on 10/14/21, at 3 PM, the RD acknowledged the kitchen staff should wear hair restraints that cover the entire hair while in the kitchen. Review of the facility's P&P titled, Food Preparation and Service revised date 4/2019, indicated, .Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices . Food and nutrition services staff wear hair restraints (hair net, hat, beard restrain, etc.) so that hair does not contact food .