**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three residents (Resident 1) reviewed for feeding assistance and weight loss was supervised during meals. This failure placed Resident 1 at risk for aspiration (inhaling food particles into the lungs), choking, and weight loss. Findings: During a record review on 1/16/25, Resident 1 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing) following cerebral infarction (stroke). During a record review on 1/16/25,the Minimum Data Set (MDS, an assessment tool) dated 11/20/24 indicated, Resident 1 had a BIMS (a tool to measure cognition) of 13, which indicated intact cognition. A review of the Interdisciplinary Progress Notes indicated on 11/20/24, At 8:30Am [sic], staff witnessed resident is coughing and started turning red. One staff went to notify the RN and another help [sic] resident with back thrust and encouraged him to cough, resident cleared his throat with cough and little tap on his back. Nothing had visibly come out but looked like resident chew [sic] food and swallow it again . A review of the In-House Referral dated 11/20/24 indicated, CONSULTANT'S COMMENTS: 11/20/24 Resident seen during skilled ST [Speech Therapy] session to discuss this episode of choking. Resident reported that he was eating quickly [and] taking larger bites of his eggs and a piece of egg went towards airway, causing expressive coughing . on 1/16/24 a review of the Interdisciplinary Progress Notes (IPN) was conducted. The IPN dated 12/18/24 at 2:26 P.M. indicated, Resident noted to have episode of choking during lunch time with [NAME] [sic] pasta and ground meat, noted with coughing and turning so red. Heimlich maneuver done and got relief . A review of Resident 1's Plan of Care effective 12/18/24 indicated At risk for choking/aspiration .with re-current choking episode during lunch time . The interventions indication, Follow Eating safe strategy at [facility's name] per facility policy .Do 1:1 supervision (one staff member dedicated to sit with/supervise the resident) during meals. On 1/16/25 at 12:54 P.M., an interview was conducted with Restorative Nursing Assistant (RNA) 1. RNA 1 stated Resident 1 is able to feed himself, and staff does not sit with Resident 1 during meals. RNA 1 stated, .we just watch him sometimes. He eats fast, he needs to slow down. Sometimes he coughs, but nobody sits with him. As far as I know nobody watches him during meals . On 1/16/25 at 1:08 P.M , an observation was conducted in the dining room during lunch. Resident 1 was sitting at a table with his lunch, by himself. Resident 1 picked up a spoon and took a bite of food. During an observation in the dining room on 1/16/25 at 1:23 P.M., Licensed Nurse (LN) 1 sat next to Resident 1, picked up a spoon and fed Resident 1 a bite of food. On 1/17/25 at 10:06 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 2. LN 2 stated .there's always a licensed nurse present during meals. Someone watches [Resident 1] but doesn't sit with him. We just do spot checks because he has episodes of choking. He tends to eat fast and cough . LN 2 stated she was unaware of Resident 1's care plan to have 1:1 supervision during meals. On 1/21/25 at 9:38 A.M., a telephone interview was conducted with the Speech Language Pathologist (SLP). The SLP stated Resident 1 required 1:1 supervision during meals, due to dysphagia and a history of choking while eating without assistance. The SLP stated, .he tends to eat fast. He has limited upper extremity movements and does require feeding assistance . The SLP stated Resident 1 was at risk for further choking because, .he doesn't want to comply with the diet orders [for mince and moist diet with mildly thickened liquids] .he enjoys .cookies, but doesn't have the lingual coordination or oral coordination to swallow it safely. The SLP stated Resident 1 required 1:1 supervision so staff could watch him eat, and to provide verbal cues when necessary. The SLP stated, From what I see with him I agree, someone should sit with him [during meals]. On 2/3/25 at 5:09 P.M., a telephone interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation for Resident 84 to receive 1:1 supervision if it was indicated in the care plan. The DON stated, .We have to be compliant on what the resident needs. Safety is our priority, so if the resident is 1:1 [supervision] he should be 1:1 [supervision] . A review of the facility's policy titled Assisting Residents With Eating/Dining/Feeding Techniques dated 10/19/23 indicated, .h. Trays are not placed in front of a resident who requires feeding help until help is available .l. Watch swallowing to determine if one bite is swallowed prior to offering another .m. Stop/slow down feeding if resident is having difficulty swallowing/coughing .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 126 was admitted to the facility on [DATE] with diagnoses which included weakness, per a Record of Admission. Findings: On 7/22/24 at 10:46 A.M., an interview was conducted with Resident 126 in her room. Resident 126 stated she had money but needed the facility to go purchase items for her. Resident 126 stated she did not get what she requested. Resident 126 stated she preferred a certain brand of shampoo and brand of sweatshirt but never got them. Resident 126 stated she requested pistachio nuts since October, and she did not get them. Resident 126 stated the facility had a checklist of items to purchase but it did not specify brands. Resident 126 stated she wrote in the specific brand she preferred, but she did not get the desired brand. Resident 126 stated she had hoped the staff would work with her regarding her preferences. Resident 126 stated, That is my right, right? On 7/23/24 at 4:24 P.M., an interview with CNA 11 was conducted. CNA 11 stated Resident 126 was alert, oriented and was able to express her needs. On 7/24/24 at 9:28 A.M., an interview with Social Services Aide (SSA) 11 was conducted. SSA 11 stated the facility had a process related to resident's request for purchase. SSA 11 stated there was an order form the residents would list their requests for purchase. SSA 11 stated that this was the residents' rights, but, We were told that we have to tell them (the residents) this is the policy and that those are wants, not needs. On 7/25/24 at 1:13 P.M., an interview with ADON was conducted. The ADON stated the staff would ask Resident 126's family if they could get Resident 126's preferred choice of supplies. The ADON stated, It is not a big deal. Per the facility's policy titled Resident Rights, dated 4/29/24, .Staff protect and promote resident rights as outlined in state and federal regulations .Staff recognize situations where it may be necessary to limit a right .Overview To ensure resident rights are not violated in this facility . Based on interview and record review, the facility failed to ensure three of 62 residents reviewed for Choices received: 1. Foods purchased from outside of the facility, stored and reheated when requested (Residents 119, 131), and, 2. Items requested were purchased in the brands or type requested (Resident 126). As a result, the resident's preferences and choices were not honored and respected, placing them at risk for psychosocial harm. Findings: 1a. Resident 119 was admitted to the facility on [DATE] with diagnoses to include weakness, and an amputation of the leg, per a Record of Admission. On 7/22/24 at 2:23 P.M., an interview was conducted with Resident 119. Resident 119 complained about the facility meals, stating she preferred to order foods from outside of the facility. Resident 119 stated she was not allowed to store any foods purchased outside of the facility in the unit refrigerator, and there was no microwave available for her to reheat the foods anyway. Per Resident 119, she used a microwave when she lived independently, and she felt it was her right to have access to a refrigerator and a microwave. On 7/23/24, a record review was conducted. Resident 119s Brief Interview of Mental Status (BIMS, an assessment tool) indicated Resident 119 had intact cognition. On 7/25/24 at 11:07 A.M., a follow up interview was conducted with Resident 119. Resident 119 stated she had again asked for food from outside to be saved in the refrigerator. Resident 119 stated the assigned Certified Nursing Assistant (CNA) had asked the charge nurse, who said no to the request. Resident 119 stated she was aware there was a microwave for staff use on the unit, and she did not understand why she was unable to use it. Resident 119 stated she would also like to buy frozen food, like ice cream, but had been told residents cannot use the freezer. 1b. Resident 131 was admitted to the facility on [DATE] with diagnoses to include injury to the spine, per a Record of Admission. On 7/22/24 at 3:40 P.M., an interview was conducted with Resident 131. Resident 131 stated he enjoyed buying food from the gas station or getting food delivery from restaurants. Resident 131 stated he did not always like the food served by the facility. Resident 131 stated he had asked his CNA to place the leftover food in the unit refrigerator, and she had said no, and said the food had to be sealed, or new from the store. Resident 131 stated he asked to have restaurant food reheated, and was told there was no microwave for residents to use. Per Resident 131, he had asked for a refrigerator and microwave for his room, to save and reheat food from outside the facility, but he was told no. Resident 131 stated he had been told he could never go to the kitchen to reheat food. Resident 131 stated, They are supposed to be here for us, I have been to many other nursing homes that allow us to save and reheat food, but not here. On 7/23/24, a record review was conducted. Resident 131's BIMS indicated intact cognition. On 7/24/24 at 9:45 A.M., an interview was conducted with CNA 1. CNA 1 stated the only foods she could put in the unit refrigerator was pre-packaged, sealed food containers. CNA 1 stated there was no microwave where residents could use it. CNA 1 stated at the end of a shift, the CNAs would check on resident rooms and remove and dispose any opened food per policy. On 7/24/24 at 10:26 A.M., a concurrent interview and record review of the unit refrigerator Personal Food Storage Guidelines was conducted with Nursing Supervisor (NS) 1. NS 1 stated the facility did not allow residents to store food in the unit refrigerator because of the risk of contamination. NS 1 stated if residents wanted to put food in the refrigerator, it could stay for 24 hours. NS 1 reviewed the Personal Food Storage Guidelines, and stated the Guidelines gave an expiration date of 48 hours, not 24 hours. Per NS 1, the Guidelines say no frozen food items could be stored but she was not aware of the reasons. NS 1 stated there was no microwave available for safety reasons. NS 1 stated, We do not reheat food. The unit microwave is for staff use only. On 7/24/24 at 3:30 P.M., an interview was conducted with the Assistant Director of Nursing (ADON). Per the ADON, We are supposed to accommodate preferences. Regarding leftover food, we should be able to label and date it, and store it safely, per policy. Per a facility document, reviewed 9/9/21 and titled Personal Food Storage Guidelines, .No frozen food items will be stored .Item: Pre-packaged, prepared food from outside the facility (un-opened) requiring refrigeration .Expiration date 48 hours from time accepted by staff . Per a facility policy, dated 10/19/20 and titled Outside Personal Food Storage-Reheating, .(Name of facility) provides residents a wide variety of food at mealtimes and between meals in an attempt to meet their food requirements in a healthy manner and accommodate some preferences and discourage the consumption of outside food within the facility .cannot guarantee the safety of food prepared outside the facility. 'Outside food' consumed .is done 'at your own risk' .staff will not assist in feeding or preparing outside food .staff do not reheat food for residents in facility microwaves .Residents who wish for special foods served or personal food items to be re-heated, can contact the Dietitian and/or the Nutrition Services Supervisor to consider storage, preparation and re-heating of food items .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment tool used to guide resident care) was accurately coded for one of 31 sampled residents (Resident 134) when the resident's diagnosis was not reflected on the initial MDS assessment and three consecutive MDS assessments. This failure had the potential for Resident 134's needs to be unmet. Findings: Resident 134 was admitted to the facility on [DATE], with diagnoses including long-standing schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), per the History and Physical (H&P), dated 8/31/23. A record review was conducted on 7/24/24. Resident 134's physician's orders, dated 8/31/23, indicated olanzapine (an antipsychotic medication) to be given every night at bedtime for schizophrenia. The resident's current medication orders for July 2024 included olanzapine every night at bedtime for schizophrenia. Resident 134's MDS assessment for cognitive pattern, dated 5/16/24, indicated a Brief Interview for Mental Status (BIMS, an assessment tool) score of 3 (severely impaired cognition). Resident 134's initial MDS, dated [DATE], under section I for active diagnoses, schizophrenia was not marked as an active diagnosis. Resident 134's MDS, dated [DATE], under section I for active diagnoses, schizophrenia was not marked as an active diagnosis. Resident 134's MDS, dated [DATE], under section I for active diagnoses, schizophrenia was not marked as an active diagnosis. Resident 134's MDS, dated [DATE], under section I for active diagnoses, schizophrenia was marked as an active diagnosis. During an interview with MDS Coordinator (MDS) 1 and MDS Coordinator (MDS) 2 on 7/25/24 at 1:35 P.M., MDS 1 stated the MDS was completed based on how the physician coded a diagnosis on the diagnosis list. MDS 1 stated if the doctor did not list the diagnosis for schizophrenia, it would not be included on the MDS. MDS 1 stated he did not recall if he questioned the doctor regarding schizophrenia not being listed on Resident 134's diagnosis list, despite an order for medication specifically for schizophrenia, and the resident's past psychiatric history of long standing schizophrenia on the H&P. During an interview with the Medical Director (MD), MDS 1 and MDS 2, on 7/25/24 at 1:56 P.M., the MD stated, the admitting physician probably coded psychosis instead of schizophrenia. The MD stated H&P on admission indicated Resident 134 had schizophrenia. The MD stated the initial MDS should have indicated schizophrenia as an active diagnosis. During an interview with the Assistant Director of Nursing (ADON) on 7/25/24 at 2:18 P.M., the ADON acknowledged the MDS needed to be coded accurately to drive the plan of care for the resident. During a review of the facility's policy and procedure titled MDS Assessments, dated 10/18/23, .It is the policy of (name of facility) to ensure that MDS assessments are completed and transmitted .according to the guidelines and requirements set .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 136 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) per a Record of Admission. Inside Resident 136's room an interview with Resident 136 was conducted on 7/23/24 at 8:36 A.M. Resident 136 stated he sometimes received help when he needed it, and sometimes he did not. Resident 136 stated, he uses the call light to ask for help. Resident 136 stated, he needed assistance to set up meals, get changed, or get on the wheelchair. During a concurrent observation and interview on 7/23/24 at 4:20 P.M. with Resident 136, Resident 136 was seen in his room. Resident 136's call light was placed beyond his reach. Resident 136 stated, They left the call light so far away that I can't call to ask for a drink. Resident 136 stated, he also needed to be cleaned. During an interview with Certified Nursing Assistant (CNA) 41 on 7/23/24 at 4:25 P.M., in Resident 136's room, CNA 41 acknowledged the call light was on the bed, and the resident could not reach the call light. CNA 41 acknowledged the call light should be within the resident's reach so the resident could call for help. On 7/24/24 a record review was conducted. Resident 136's care plan, dated 3/20/23, indicated Resident 136 was total care (needed assistance with all care), The care plan indicated an intervention including Be sure call light is within reach and respond promptly to all requests for assistance. During an interview with the Assistant Director of Nursing (ADON) on 7/25/24 at 2:18 P.M., the ADON acknowledged Resident 136's care plan related to call light should have been implemented to address the resident's needs. A review of the facility's policy and procedure titled, Care Plan Resident, dated 5/10/23, indicated .All residents at (Name of facility) will have a care plan developed .which will include a list of problems .and interventions specific to the individual needs of that resident . Based on observation, interview and record review, the facility failed to develop and/or implement: 1. An activities care plan for one resident (31), and 2. A call light care plan for one resident (136). This failure had the potential for the resident's needs to not be met. Findings: 1. Resident 31 was admitted to the facility on [DATE] with diagnoses that included traumatic subdural hemorrhage (bleeding in the brain) according to the facility's Record of Admission. A concurrent observation and interview with Resident 31 was conducted on 7/22/24 at 2:23 P.M. Resident 31 was walking in the hallway with his walker. Resident 31 stated that he was a former furrier (fur coat stylist) and tailor (a person who made clothing). Resident 31 stated he missed those activities and he would like to still be doing those things. Resident 31 further stated he was not able to do these things in the facility. On 7/23/24, a record review was conducted. Resident 31's care plan for activities, dated September 2023, indicated, . assist resident to activities of potential interest such as games, outdoor strolls and fresh air fit; introduce to Spanish speaking residents and staff; seat next to other Spanish speaking residents . There was no care plan for any other activities. An interview was conducted on 7/24/24 at 11:37 A.M. with the Director of Activities (DA). The DA stated, This resident (31) has mentioned his career was a furrier but we have not provided any activities related to sewing or design. His care plan does not reflect his interests. An interview was conducted on 7/25/24 at 2:51 P.M. with the Assistant Director of Nursing (ADON). The ADON stated, It is important to have a comprehensive care plan for staff to provide the best care for the residents. A review of the facility's policy, dated 7/11/23 and titled Care Plan Resident, indicated, I: Policy: All residents at (Name of facility) will have a care plan developed .based on the interdisciplinary assessments of team members which will include a list of problems, preferences, goals and interventions specific to the individual needs of that resident .C. a. Therapeutic Recreation .does their own care plans .G. Generally, care plan goals and interventions should be .specific and should reflect the goals/preferences of the resident .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an activity program to meet a resident's (31) preferences for one of one residents reviewed for activities. This failure had the potential to not support Resident 31's psychosocial well-being. Findings: Resident 31 was admitted to the facility on [DATE] according to the facility's Record of Admission. A concurrent observation and interview with Resident 31 was conducted on 7/22/24 at 2:23 P.M. Resident 31 was walking in the hallway with his walker. Resident 31 stated he was a former furrier (fur coat stylist) and tailor (a person who makes clothing). Resident 31 stated he missed those activities and he would like to still be doing those things. Resident 31 further stated he was not able to do those things in the facility. An interview was conducted on 7/24/24 at 11:37 A.M. with the Director of Activities (DA). The DA stated an activities assessment for residents was conducted on admission but it was not useful as it was mostly nursing based. The DA further stated, This resident has mentioned his career was a furrier but we have not provided any activities related to sewing or design. An interview was conducted on 7/24/24 at 11:39 A.M. with the Assistant Director of Activities (ADA). The ADA stated, He (Resident 31) has mentioned his career but we are not providing activities related to that. A review of the facility's Therapeutic Recreation Assessment for Resident 31, dated, 9/24/23 indicated, .individual interventions/recommendations: games, outdoor strolls, fresh air fit, introduce to Spanish speaking residents, praise and thank for participation efforts during groups . There was no reference to any other activities. An interview was conducted on 7/25/24 at 2:48 P.M. with the Assistant Director of Nursing (ADON). The ADON stated, It is important to provide meaningful activities to residents. A review of the facility's policy, dated 5/31/24, titled, Therapeutic Recreation Services, indicated, I. Policy: Therapeutic Recreation (TR) staff will complete a comprehensive assessment, and provide an ongoing program of activities in a therapeutic environment that promotes the resident's highest practicable degree of physical, cognitive, social and emotional well-being and functioning .III. Procedures .B. Activity Program-Requirements: a. the activity program consists of individual, small and large group activities which are designed to meet the needs and interests of each resident and which include but are not limited to .iii. creative activities .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure one of 31 sampled residents, (Resident 18), received the prescribed tube feeding volume according to facility policy. This failure had the potential to result in further functional and physical decline and increase the risk of infections, pressure sore, and death. Cross reference F692 Findings: During an observation on 7/22/24 at 9:22 AM of Resident 18, the resident was lying in bed, in a low position, with head of bed (HOB) elevated to 45 degrees, with some drooping in his left face, as well as drooling from mouth. There was an oxygen pump with humidifier, and gastric tubing from stomach established for tube feeding (TF). The TF pole and kangaroo pump machine had no bag or bottles hanging. The resident's eyes were half open and did not respond to questions and appeared non-verbal. During an observation of Resident 18 on 7/23/24 at 2:55 PM in Resident 18's room, the resident was lying in asleep in bed with the head of the bed elevated at a 45-degree angle. The Resident's left and right arms were bent and contractures on both hands. A kangaroo pump was on the left side of the bed, turned off, without formula or water hanging on it. During a review of Resident 18's Physician's Diet Orders dated 3/14/24 indicated Texture: NPO, Liquid: NPO, Enteric feeding: Jevity 1.5 (1.5 CAL/ML) VIA GT (gastric or stomach tube) FOR NUTRITION 24 HOUR TOTAL OF ENTERIC FEEDING 701 ML/1052 CALS. CONTINUOUS MAX RATE IS 100 ML/HOUR, WATER/HYDRATION: 1050 ML/24 HRS PER GT. During a review of Resident 18's Quarterly Nutrition assessment dated [DATE] completed by the Registered Dietitian (RD), the assessment indicated, .Wt. 169.5, IBW (ideal body weight): 160# (pounds) .Weight variance: .-4.9% x 6 months, 13.8# (pounds) x 1 year .Diet order: (9/7/22) NPO. On 3/23/23, Jevity 1.5 via GT 701 ml/1052 calories. Maximum rate 100 ml/hour. On 1/18/22, water/hydration 1050 ml/24 hrs per GT. On 12/30/22, Pro T Gold 30 ml via GT QD supplement .Labs reviewed: 10/3/23: Gluc 63 (Low), Creatinine (a waste product that comes from the digestion of protein in your food and the normal breakdown of muscle tissue)- 0.29 (Low), Albumin (the most abundant circulating protein in blood plasma)- 3.1 (Low) .Abnormal labs expected due to multiple medical diagnoses .Medications: .Remeron (appetite stimulant) .Nutrient Requirements using IBW .160# (pounds): Kcals (calories) .1241-1679 kcal/day, Protein 73-88 g/d (grams/day), Fluid (30 cc/167.6 pounds): 2190 cc/day .Assessment summary .1122 kcal, 62 grams protein, 2258 cc total approximate water per day .Pertinent information: Hospitalization 5/28-5/30/23 due to foley catheter complications. emergency room visit for shortness of breath likely due to 'acute episode of aspiration (difficulty breathing into lungs) per MD on 5/3/23' .Plan: Continue TF (tube feed) and water flush . Continue to update TF tolerance .and labs . During a review of Resident 18's Quarterly Nutrition assessment dated [DATE] completed by the RD, the assessment indicated .Wt. 166, IBW: 160 pounds .Nutrient requirements using IBW 160 pounds: KCALS 1241-1679 kcal/day, Protein .73-88 grams/day . During an observation and interview on 7/23/24 at 4:51 P.M. with Licensed Nurse (LN) 52 and LN 53, LN 52 stated she believed the kangaroo pump machine could store tube feed volume data for about 24 hours. LN 52 pressed the back button to review the previous tube feed amount received but the machine did not display the last formula volume from Resident 18's tube feeding. LN 53 also tried to turn on the kangaroo pump to check the last tube feed amount. LN 53 stated the kangaroo pump could store up to 72 hours of formula volume. LN 53 stated the nurses only run the daily volume from 4pm for 10 hours until the 701 mls are pumped. LN 53 stated the nurses do not document the daily intake amounts because they rely on the 72-hour kangaroo pump machine. LN 53 stated there could be potential concerns in the future if asked to provide formula intake amounts from months ago. During an interview on 7/23/24 at 4:38 P.M. with Licensed Nurse (LN) 51, LN 51 stated she typically starts the kangaroo pump machine for Resident 18's tube feeding at around 4 PM. LN 51 stated that she would press the on/off button to turn the machine 'on', then pressed 'start' to get the pump going. LN 51 then stated she makes sure the display reads 0 before she hangs a full bottle of the Jevity 1.5 formula. LN 51 stated she does not know how to fully check the kangaroo pump machine to determine how much formula Resident 18 had previously received because the machine is always off when she gets to work. LN 51 further stated she was a new employee that worked at the facility less than three months and had not received training on how to use the kangaroo pump. During a review of the facility's undated document titled Nutrition Service Tube Feeding and Supplement List indicated .[Resident 18] GT .cc's (cubic centimeters for liquid volume)/day- 701, Cals(calories)/day - 1052 . During a review Resident 18's G-Tube Feeding, Flushing, and Position Verification Record Form 334B, dated 2/1/23, for April-August 2024, indicated the nursing staff initials on each day for shifts 11-7 AM, 7-3 PM, and 3-11 PM by licensed nurses but does not include input or output fluid volume amounts. During an interview with LN 54 on 7/25/24 at 1:54 P.M., LN 54 stated when she does rounds on the residents, she checks all GT feedings and the history in the kangaroo pump for the last 24 hours. LN 54 also stated she checks to see if the total volume given was infused, and if not, then she will find the outgoing nurse to report it in the Medication Activity Record (MAR). LN 54 stated she initials the resident's tube feed report record each day. She said the intake/output record document is used if the resident is on antibiotics or fluid restricted. LN 54 further stated she doesn't think the machine can provide a history of infused volume for more than 72 hours. During an interview on 7/25/24 at 2:55 P.M. with the Assistant Director of Nursing (ADON), the ADON stated residents are weighed initially on admission, and monthly. Weight variances are referred to the RD so they could adjust the food, formula, calories, CC's, etc. The ADON stated GT kangaroo pumps have a total volume infused record, even for the water. The ADON stated if something is wrong with the machine or feeding, nurses will inform the MD. The ADON further stated The machine is not perfect, but it is important for the nurses to know how to operate the machine and to track the tube feeding formula volume. The ADON the nurses should be using the I&O (Input and Output) form to track the volume because the kangaroo pump only stores limited data up to a few days. Once they decide the appropriate weight for the resident, it is the duty of nurses to make sure the residents are getting the calories and volume they need. A review of the tube feed formula [Manufacturer's name] nutrient profile for Jevity 1.5 indicated a 1000 mL bottle provided 1500 calories, 63.8 grams of protein, and # 760 cc's of water. https://static.abbottnutrition.com/cms-prod/abbottnutrition-2016.com/img/Jevity%201.5%20Cal%20EN_tcm1310-73172.pdf A review of the facility's policy titled Intake and Output Measurement I-006, dated 3/2/2018, indicated .C. Measuring Enteral Feedings Intake- Licensed staff shall administer enteral food and fluids per Physician order and document volumes in the Intake and Output Record E-323 .E. Documentation- a. The Licensed Nurse will total the intake and output at the end of each shift and record on Intake and Output Record E323 .H. Resident Care Plans- Residents' Care Plans will be updated as necessary . A review of the facility's policy titled Enteral Tube Feeding for Gastrostomy (G-Tube or GT) ., dated 2/28/2022, indicated .Registered Dietitian will assess nutritional status and .makes recommendations for the diet order of formula and total volume/calories based upon the resident's: caloric requirements .current weight .overall nutrition status .Recommends hydration .Requests for laboratory data to aid in the assessment and monitoring of the resident .Monitors .resident progress .recommends changes in formula, nutritional adequacy of the formula .

Based on observation, interview and record review the facility failed to ensure a medication was administered as ordered by the physician for one of seven residents (Resident 13) reviewed during medication administration observation. This failure had the potential to result in adverse outcomes for Resident 13, who was diagnosed with iron deficiency anemia (low red blood cell count due to low iron levels). Findings: During a medication pass observation on 7/24/24 at 8:57 A.M., with Licensed Nurse (LN) 42, LN 42 prepared and administered five medications for Resident 13. A record review was conducted on 7/24/24. Resident 13's physician's orders for July 2024, medication orders included ferrous sulfate (iron) for iron deficiency anemia, daily. The ferrous sulfate was not prepared and administered to Resident 13 during the medication pass observation. During a concurrent interview and record review with LN 42 on 7/24/24 at 11:10 A.M., LN 42 acknowledged she did not give Resident 13's ferrous sulfate as ordered by the physician. LN 42 stated missing a medication dose can negatively affect the resident. Per a facility's policy titled Plan: Medication Safety Meds, dated 7/3/24, .It is the practice of this facility to prepare, administer, and document medications .in a timely, proper and accurate manner, in compliance with physician order and pharmacy recommendations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the call light was within reach for one of 32 residents (Resident 136) reviewed for call light accessibility. As a result, Resident 136 was not able to reach the call light to call for assistance in order for staff to address the resident's needs in a timely manner. Findings: Resident 136 was admitted to the facility on [DATE] with a diagnosis of hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body), per a Record of Admission. During an interview with Resident 136 conducted on 7/23/24 at 8:36 A.M. inside the resident's room, Resident 136 stated he sometimes received help when he needed it, and sometimes he did not. Resident 136 stated he used the call light to ask for help. Resident 136 stated he needed assistance to set up meals, get cleaned, or get in the wheelchair. A concurrent observation and interview on 7/23/24 at 4:20 P.M. was conducted with Resident 136. Resident 136 was seen in his room sitting on a Broda chair (a specialized wheelchair) in front of the television out of reach from the call light. Resident 136 stated, They left the call light so far away that I can't call to ask for a drink. Resident 136 stated he also needed to be cleaned. Resident 136 stated he had been sitting in his current position for about 20 minutes. Inside Resident 136's room, a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 41 on 7/23/24 at 4:25 P.M. CNA 41 stated Resident 136's call light was on the bed, and the resident could not reach the call light. CNA 41 stated the call light should be within the resident's reach so the resident could call for help. On 7/24/24, a record review was conducted. Per a Minimum Data Set (MDS - a patient/resident assessment tool), dated 5/15/24, Resident 136 had a Brief Interview for Mental Status (BIMS, an assessment tool) score of 13, which indicated intact cognition. The MDS indicated Resident 136 was dependent on staff assistance for transfers into and out of bed, to use the bathroom, and for personal hygiene care. Resident 136's care plan, dated 3/20/23 indicated Resident 136 was total care (needed assistance with all care) and dependent in all tasks. The care plan indicated an intervention including, Be sure call light is within reach and respond promptly to all requests for assistance. During an interview with Licensed Nurse (LN) 43 on 7/24/24 at 3:15 P.M., LN 43 stated the importance of the call light was for the resident to be able to ask for help and for staff to provide the assistance needed. During an interview with the Assistant Director of Nursing (ADON) on 7/25/24 at 2:18 P.M., the ADON acknowledged the call light should be within the resident's reach in order for the resident to call for help and get assistance from staff. A review of the facility's policy titled, Call Lights and Ascom Nursing Call light and Mobile Device System, dated 2/8/24, indicated .e. CNA staff and other staff interacting with residents will check to assure the call lights are placed within easy reach of the resident in bed or a nearby chair

Based on observation, interview and record review the facility failed to ensure the kitchen staff competently performed and carried out the functions of the Food and Nutrition Services department when: 1. A food services worker could not correctly operate the dishwashing machine. 2. A food services worker could not properly demonstrate how to calibrate a food thermometer. These failures had the potential for food contamination, resulting in food borne illnesses for all residents who consume food from the kitchen. Cross reference F812 Findings: 1. During the initial kitchen tour on 7/22/24 at 9:10 A.M., an observation and interview was conducted in the dishwashing room. Food Service Worker (FSW) 1 was at the dish machine station. FSW 1 stated the dish machine.Sanitizes the dishes and utensils. Surveyor asked FSW 1 to demonstrate how the kitchen staff ensures that the temperatures are accurate. The FSW 1 stated they use the, .Blue Screen on the wall- mounted digital controller on the wall to the left of the dish machine to verify accurate temperatures. FSW 1 proceeded to touch the screen, but the display did not read any change in temperatures. The buttons on the screen observed below and to the right of the screen indicated it was not a touch screen. During an observation and interview on 7/22/24 at 11:15 A.M. with the Chief of Nutrition Services (CNS), the CNS stated the dish machine sanitizer is tested using a test strip attached to a dish that goes through the machine. The CNS stated the test strip changes colors from light gray to dark gray to indicate it reached the correct sanitizer temperature of 160-165° (degrees) Fahrenheit (F) at the manifold. A review of the facility Job Description for Food Services Worker indicated the skills and abilities to include .Operate and maintain kitchen equipment in a safe and efficient manner According to the 2022 Federal Food and Drug Administration (FDA) Food Code, section 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures, (A) .in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 90°C (194°F), or less than: .(2) .180°F. A review of the facility policy titled Nutrition Services Infection Control indicated, .The dish machine is to be checked regularly throughout the day to ensure that the proper wash cycle temperature (150° F) and the proper rinse cycle temperature (180° F) are continuously maintained . 2. During a joint observation and interview on 7/22/24 at 12:35 P.M. with Food Services Worker (FSW) 2 and the Chief of Nutrition Services (CNS), the FSW 2 stated he used his own personal food thermometer to take food temperatures during food preparation. FSW 2 stated he does not use the facility's thermometer because he did not like the way it reads. The FSW 2 stated he did not know how to fully operate his thermometer but he has calibrated it before. FSW 2 further stated the battery in his thermometer was dead and therefore he was unable to demonstrate thermometer calibration. The FSW 2 stated he made the tuna salad earlier in the morning and used his own thermometer to take the temperature of the tuna salad. The CNS continued, stating the food thermometers provided to the kitchen staff several months ago were approved by the food and nutrition services department management for use in the kitchen. The CNS stated it was his expectation kitchen staff utilize the food thermometers provided by management and not their personal food thermometers. The CNS acknowledged it was important for staff to be trained on how to use the facility provided thermometers. The CNS further stated the kitchen staff were to avoid using personal food thermometers because they may not take accurate temperatures. A review of the Food Services Worker job description indicated Food Service Workers were expected to have, .Knowledge of: Safety practices as applied to food preparation and use of kitchen and cleaning equipment . According to the 2022 Federal FDA Food Code Annex 7-42, .Thermometers provide a means for assessing active managerial control of .food temperatures .Food thermometers must be calibrated at a frequency to ensure accuracy .

Based on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice when: 1. The ice machine had black debris inside the ice making parts of the tray and curtain. 2. Two (2) large onions in the refrigerator had mold on them. 3. Three (3) floor sinks had piping without an air gap of at least 1 (inch) between the pipe and drain. 4. Two (2) green cutting boards with deep cuts and food stains were stored in the clean area. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing foodborne illness. Cross reference F802 Findings: 1. During the initial kitchen tour on 7/22/24 at 8:26 A.M. an observation and interview with the Chief of Nutrition Services (CNS) and the Plant Operations Director (POD) was conducted. A Surveyor wiped the inside of the ice machine bin walls with a white paper towel and there was black debris on the paper towel. The POD opened the ice machine cover and there was tannish pinkish colored debris inside the area of the ice machine water pan and curtain. The CNS acknowledged the discolored debris and stated the kitchen staff was responsible for cleaning the storage bin and the maintenance plant operations department was responsible for cleaning/sanitizing the ice-machine's ice making parts. The POD stated the maintenance/plant operations department staff clean and sanitize the ice machine quarterly but they do not remove the baffle or the ice machine water tray underneath the ice making grid during the cleaning procedure. The manufacturer's cleaning/sanitizing instructions indicated, .1. Turn off the electrical and water supply to the ice machine. 2. Remove all ice from the bin. 3. Remove the water curtain and the components you want to clean or sanitize. 4. Soak the removed part(s) in a properly mixed solution. 5. Use a soft-bristle brush or sponge (NOT a wire brush) to carefully clean the parts .6. Use the sanitizing solution and a sponge or cloth to sanitize (wipe) the interior of the ice machine and the entire inside of the bin/dispenser. 7. Thoroughly rinse all of the parts and surfaces with clear water. 8. Install the removed parts According to the 2022 Federal FDA Food Code section 4-602.11, Equipment Food-Contact Surfaces and Utensils. Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold .Ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms . A review of the facility's undated policy and procedure titled Ice Machine Maintenance indicated, .cleaning and sanitizing of all internal water contact areas of all ice machines which shall be performed in accordance with manufacturer's recommendation . 2. During the initial kitchen tour conducted on 7/22/24 at 9:40 A.M., two floor sink drains next to reach-in refrigerators were observed with the PVC (polyvinyl chloride) white pipes extending into the floor drains. Also, a copper pipe that extended from a walk-in refrigerator was observed directly into a floor sink drain. The CNS acknowledged the three pipes going into the floor sinks and stated they should not extend into the floor drain without an appropriate air gap. According to the 2022 Federal FDA Food Code, section 5-402.11(A), .A direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment .are placed . A review of the facility policy titled Nutrition Services: Food Storage indicated, .Food storage areas will not be subject to sewage or wastewater backflow . 3. During the initial kitchen tour on 7/22/24 at 8:40 AM, an observation and interview was conducted with the CNS. A walk-in refrigerator containing produce was observed with an opened case of onions. One large onion was observed with a large moldy blackish-graying color on it. Another onion was observed with blackish grayish color on it. The CNS stated the staff usually checks the food deliveries received by the case. The CNS stated staff were assigned to check the produce every morning. The CNS stated, That one should've been pulled . and the onions were no longer good for consumption. According to the 2022 Federal Food Code, Annex 4 Table 2a, .Check condition at receiving; do not use moldy or decomposed food . A review of the facility's policy and procedure titled Nutrition Services: Food Procurement indicated, All fresh fruits and vegetables will be of good quality and freshness . 4. During a kitchen observation and interview on 7/22/24 at 2:55 P.M., a blue rubber cutting board was observed on the kitchen counter near the cold food prep area. The cutting board had multiple deep knife cuts and scratches. There were green colored stains visible inside the scratches and on the surface of the cutting board. The cutting board appeared to be in use by kitchen staff. There was a knife laying on the cutting board, with bits of food visible on the knife. On 7/23/24 at 9:30 A.M., an observation and interview was conducted with the Nutrition Services Supervisor (NSS) in the back of the kitchen. Two cutting boards, a blue and a green one, were observed on the clean storage shelf. The cutting boards had a large white discolored stain in the middle and several deep scratches on the surface, with green stains embedded in the scratches. The NSS stated the cutting boards were checked daily for wear, but the NSS stated the cutting board should be replaced. On 7/23/24 at 9:35 A.M., an interview was conducted with the CNS. The CNS stated his expectations were for the kitchen areas to be in compliance with standards of practice and the regulations. According to the 2022 Federal FDA Food Code, section 4-501.12, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces . A review of the facility's policy titled Nutrition Service Infection Control dated 3/30/23 indicated, .Cutting boards are inspected for stains, excessive wear, and deep cuts. Cutting boards that are deemed a safety concern are discarded .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: 1. The Centers for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBPs, an infection control intervention using protective gowns and gloves) were implemented for 26 of 29 residents, and, 2. A Licensed Nurse (LN 1) used appropriate Personal Protective Equipment (PPE - gloves, gown, masks and other equipment used to control the spread of infection) when administering tube feeding (a replacement food source, administered through a tube directly into the stomach or intestines) to Resident 88, whose room was posted as requiring EBP. These failures had the potential to result in the spread of Multiple Drug Resistant Organisms (MDROs, microorganisms, mainly bacteria, that are highly resistant to many types of antibiotics) throughout the facility. FINDINGS: 1. On 7/22/24 beginning at 8 A.M. observations were conducted of all nursing units. Of 156 residents, 29 residents were identified with indwelling medical devices, such as feeding tubes and urinary catheters (a tube used to empty the bladder and collect urine in a drainage bag). Of the 29 residents identified, 26 were not on EBP. During an interview on 7/22/24 at 1:45 P.M. with Supervisor Nurse (SN) 41, SN 41 stated not all residents met the EBP criteria. SN 41 stated the physician and the Infection Preventionist (IP) determined who will be placed on EBP. During an interview on 7/23/24 at 11 A.M. with Certified Nursing Assistant (CNA) 22, CNA 22 stated EBP meant a cabinet containing extra gowns and gloves would be placed outside of the resident room for staff to wear, but EBP was only for residents with COVID (a contagious disease). On 7/23/24 at 4:13 P.M., an interview with Licensed Nurse (LN) 11 was conducted outside Resident 106's room. LN 11 stated Resident 106 was not on EBP. Per LN 11, Resident 106 had recently been hospitalized , had an infection related to the feeding tube, and was on antibiotics (anti-infective medications). On 7/24/24 at 9 A.M., an interview with CNA 13 was conducted. CNA 13 stated the IP or charge nurse would place a sign by the resident's door if staff had to use PPE when providing resident care. On 7/24/24 at 11:08 A.M., an interview was conducted with LN 12. LN 12 stated the facility had a process using an assessment tool. Per LN 12, the assessment criteria for a resident to be placed in EBP included: returned from the hospital, had history of candida auris (fungal organism) or carbapenem resistant organism (an antibiotic-resistant infection), were hospitalized for a significant MDRO exposure and had a medical device. Per LN 12, the residents would have to meet the criteria before they were placed on EBP. During an interview on 7/24/24 at 2:47 P.M. with LN 43, LN 43 stated there were criteria that had to be met to place a resident on EBP. LN 43 stated the criteria included whether the resident came from a hospital or if the resident had any tubes. LN 43 stated a team, including the doctor, would decide if a resident should be on EBP. LN 43 stated the staff were in-serviced by the IP regarding EBP. On 7/24/24 at 3:17 P.M., an interview with IP was conducted. The IP stated the facility followed the CDC Guidelines on EBP. The IP stated she got information from the CDC, the California Department of Public Health (CDPH) and presented to the facility's leadership. The IP stated the leadership together with the primary physicians developed an assessment tool. The IP stated the facility was different from other facilities because residents were not as high risk as compared to the typical residents in other facilities. The IP stated the residents had no history of MDRO. The IP stated they placed the residents on EBP only when they came back from the hospital. The IP also stated 80 percent of their population had tubes and staff were PPE burned out (exhausted from excessive use of PPE) after COVID. The IP stated they, .May be incorrect . with their interpretation of the CDC guidelines. On 7/25/24 at 1:13 P.M., an interview with the Assistant Director of Nursing (ADON) was conducted. The ADON stated there was an assessment tool the facility used, and the residents had to meet the criteria before they were placed on EBP. Per ADON, the facility had to follow their policy. Per ADON, the IP was responsible for infection control concerns. During an interview on 7/25/24 at 2:18 P.M. with ADON, the ADON stated, the EBP criteria form was completed for new admission and when a resident came from the hospital. The ADON stated the criteria for EBP was taken from an AFL (All Facilities Letter, issued by CDPH). The ADON stated, What we are doing is CDC guidelines .it is subject to interpretation .it is controversial . During an interview on 7/25/24 at 5:59 P.M. with the Medical Director (MD), the MD stated the criteria was based on, .Our interpretation of the CDC guidelines. The MD stated they looked at the facility's infection rates, how much time it took for staff to use the PPE, and the federal regulation. The MD stated the facility has a modified assessment tool. The MD stated the facility was doing something different than other facilities. Per the facility's policy titled, Infection Prevention Program Plan, dated 4/24/23, .Procedures .c. Maintain compliance with regulatory and governmental regulations and standards . During a review of the facility's policy and procedure titled Enhanced Standard Precautions (ESP)/Enhanced Barrier Precautions (EBP) Quick Reference, dated 4/12/24, indicated, .(name of facility) implements enhanced standard precautions (ESP)/enhanced barrier precautions (EBP) through an individualized assessment of resident characteristics and risk in combination with risk assessment based on our unique facility characteristics, namely single rooms, high staffing, high air exchange, low admissions, almost no resident to resident transmission of infection, and with NO CDC-targeted Multidrug-resistant organisms (MDROs) in the history of the building operation . During a review of the CDC's guidelines, titled Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, indicated, .The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization .Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include .device care or use .Because Enhanced Barrier Precautions do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of the resident's stay in the facility or until .discontinuation of the indwelling medical device that placed them at higher risk .Enhanced Barrier Precautions applies to all residents with any of the following: .indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy .) regardless of MDRO colonization status Per the Center for Clinical Standards and Quality/Quality, Safety & Oversight Group publication QSO-24-08-NH Enhanced Barrier Precautions in Nursing Homes., dated March 20, 2024, with an effective date of April 1, 2024, .EBP recommendations now include use of EBP for residents with chronic wounds or indwelling devices during high-contact resident care activities regardless of their multidrug-resistant organism status . 2. Resident 88 was admitted to the facility on [DATE] with diagnoses to include pneumonitis (a lung infection), per a Record of Admission. On 7/23/24 at 9:30 A.M., an observation of Resident 88 was conducted in his room. Resident 88 was lying in bed, and did not respond to questions asked. A sign outside of Resident 88's door indicated he was on Enhanced Standard Precautions (also known as EBP). The sign indicated, Anyone participating in any of these six moments must also: [NAME] (put on) gown and gloves .Caring for devices & giving medical treatments . A plastic bin outside of the room contained isolation gowns, gloves, and other PPE. On 7/23/24 at 4:23 P.M., an observation of LN 1 was conducted in Resident 88's room. LN 1 connected a syringe to Resident 88's feeding tube, a medical device located on his abdomen. LN 1 was wearing gloves when touching the resident, and when connecting the syringe to the feeding tube. LN 1 was not wearing a gown. On 7/23/24 at 4:22 P.M., an interview was conducted with LN 1 as she exited Resident 88's room. LN 1 stated she should have been wearing a gown and gloves when using the feeding tube as she had been providing care through a medical device. LN 1 stated the use of the correct PPE was important to prevent the spread of infection to the resident. On 7/23/24 at 4:30 P.M., an interview was conducted with Charge Nurse (CN) 1. CN 1 stated LN 1 should have put on gloves and a gown when providing care for Resident 88. CN 1 stated all staff should review the signs prior to entering the room, and use the appropriate PPE to prevent the spread of infection. CN 1 stated more education may be necessary on the process. On 7/24/24 at 3:10 P.M., an interview was conducted with the ADON. Per the ADON, the nurse should have followed the instructions posted on the sign. The ADON stated this deficient practice had the potential to spread infection to other residents or staff. Per a facility policy, reviewed 4/12/24 and titled Enhanced Standard Precautions (ESP)/Enhanced Barrier Precautions (EBP), .A. Who receives Enhanced Standard Precautions .a .high risk residents, particularly those with wounds or tubes .B. What are Enhanced Standard Precautions/Enhanced Barrier Precautions? a. The use of a Gown and gloves .b. 6 moments: .caring for medical devices .E. How do we communicate about enhanced standard precautions? a. Each patient will have a sign placed outside their door .over a little drawer set of PPE .

Based on observation, interview, and record review, the facility failed to ensure kitchen equipment was in safe operating condition according to standards of practice when: 1. A dishwashing machine had temperatures below the sanitation level. 2. A reach-in refrigerator and a reach-in freezer had condensation. This failure had the potential to place residents at risk of developing foodborne illness. Cross reference F812 Findings: 1. During a kitchen observation and interview on 7/22/24 at 9:22 A.M. with the food services worker/dishwasher (DSW), the DSW stated dishes, utensils, and trays are placed in the dish machine to wash and sanitize. The DSW stated the machine sanitizes dishes when the on button on the wall mounted digital control pad is pressed. The Surveyor asked how the staff ensures the dish machine is sanitizing and the DSW stated, We run it (the machine), and we check the gauges . The DSW stated the dinnerware first goes through the power scraper and power wash cycles, then through the power rinse tank and final rinse. The DSW stated the dish machine wash goes up to 145° (degrees) but mostly stays between 140° and 145° Fahrenheit. The gauges on the dish machine read: Power scrapper= 109° Fahrenheit Power wash= 140° Fahrenheit Power rinse tank= 156° Fahrenheit Final rinse= 168° Fahrenheit During an observation and interview on 7/22/24 at 11:15 A.M. with the CNS, the CNS acknowledged the wash temperature on the dish machine was not reaching the appropriate temperature. The CNS stated the dish machine needed to be repaired to ensure the wash and sanitizing steps were operating correctly. According to the 2022 Federal FDA Food Code, section 4-501.110, .The wash solution temperature in mechanical warewashing equipment is critical to proper operation . A review of the facility policy titled Nutrition Services Infection Control indicated, .The dish machine is to be checked regularly throughout the day to ensure that the proper wash cycle temperature (150 degrees Fahrenheit) and the proper rinse cycle temperature (180 degrees Fahrenheit) are continuously maintained . A review of the facility policy titled Nutrition Services: Essential and Important Use Equipment indicated the dishwasher was, .Equipment identified as ESSENTIAL USE .Essential Use Equipment is essential .a non-working condition may necessitate notification to the CDPH due to, risk of detrimental impact on resident health and or safety . 2. During the initial kitchen tour on 7/22/24 at 9:10 A.M., a reach-in freezer was observed with condensation build-up inside. There was frozen liquid observed on the bottom shelf of the freezer. There was frozen condensation observed on the racks. A reach-in refrigerator in the cold food nourishments prep area was also observed with ice condensation build-up on the bottom shelf and on the inside of the door. According to the 2022 Federal FDA Food Code, section 4-204.11 .The dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms . A review of the facility's policy and procedure titled Nutrition Services: Essential and Important Use Equipment, dated 3/27/24 indicated it was the facility's policy to, .To establish repair categories for Nutrition Services equipment that is considered essential and important to the function of the Nutrition Services Department .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure E-Kits (emergency kits) contained Ativan (medication used for epilepsy control and anxiety emergencies) to provide safe and timely administration in the event of an emergency. Multiple E-Kit containers had a label indicating Ativan as part of the contents but were not available in the designated unit. Findings: On 10/20/21 at 10:15 A.M., an observation of the medication storage room in the Barona Unit was conducted. A review of the E-Kit lock box label indicated that Ativan injectable 2 mg(milligrams)/ml(milliliters) was stored in the E-Kit, located in the Santa [NAME] Unit. On 10/20/21 at 10:25 A.M., a concurrent observation and interview with licensed nurse (LN 1) was conducted to inquire why no Ativan was kept in each separate E-Kit on each unit of the facility. LN 1 indicated that Ativan was rarely used in the Barona Unit and the Pharmacist decided the quantity was not needed on units that had not used it for some time. On 10/20/21 at 10:40 A.M., an observation of the Santa [NAME] Unit medication storage room was conducted. The storage room E-Kit container did not have Ativan available as indicated by the label on the outside of the E-Kit container. In addition, the refrigerator that stored the Ativan had been not been functioning for six days due to a faulty temperature control. On 10/20/21 at 10:45 A.M., a concurrent observation and interview with LN 2 revealed the medication storage room had been without a refrigerator for six days. LN 2 indicated there was no refrigerator available for use in the medication storage room of the Santa [NAME] Unit for six days. The Ativan was to be obtained upstairs from the Sierra Unit's medication storage E-kit container. On 10/21/21 at 11:10 A.M., an interview with LN 3 was conducted. LN 3 stated she was not aware of why no Ativan was made available in the Santa [NAME] Unit's E-Kit container. An interview was conducted with the Director of Nurses (DON) on 10/21/21 at 10:45 A.M. The DON indicated that in an emergency situation, where Ativan was not kept in the E-Kit on a specific unit, the charge nurse of the unit would call the designated unit that had the Ativan. The charge nurse when then go to the designated unit to obtain the Ativan from that unit's E-Kit and bring it back to the unit that needed it. Due to the time of taking the elevator, the nurse would use the stairway to transport the Ativan to be more expeditious. When asked why the Ativan would not be kept in the unit E-Kit to be readily accessible in an emergency situation which could place a resident in jeopardy, the DON stated Ativan was rarely used in the Barona unit. The DON further indicated that the majority of the Ativan medication used was stored upstairs in the Sierra unit. The facility's plan was to keep the storage of emergency use Ativan in the center portion of the building units. This would enable the nurse to go to the designated unit quickly and obtain the medication. The DON was asked what the procedure would be in a situation where no Ativan was available in the nearest Unit, since this had been the situation in the Santa [NAME] Unit when the survey team did their observation. The DON indicated, the LN would call upstairs to the Charge Nurse to open the locked medication storage room and open the locked E-Kit and have the Ativan available. The LN would then take the stairs, obtain the medication and come back down to administer the medication. An interview was conducted with the facility's Pharmacist on 10/21/21 at 11:20 A.M. The Pharmacist indicated that Ativan was rarely used in the Barona Unit and if it were needed, it could be obtained by the Santa [NAME] unit. When asked what the procedure would be if no Ativan was available in the Santa [NAME] unit as was the case due to no refrigerator in the Santa [NAME] unit. The Pharmacist stated it would not have happened if the refrigerator had not broke. Although, rarely used on the Barona Unit, the procedure had the potential to place a Resident in jeopardy if and when it may have been needed and wasn't readily available. The Pharmacist acknowledged the potential hazard of not having the Ativan in each unit's E-Kit. An interview was conducted with the facility's Physician and ADM (Administrator) on 10/22/21 at 2:10 P.M. The ADM emphasized the locations of the units designated to have Ativan in the E-Kit was to be stored in Santa [NAME] Unit, for the Barona and Pico units use on the first floor. The Sierra Unit was to have Ativan stored for the [NAME] and Monte Vista's use on the second floor. There was no rationale provided to account for the potential issue of time to locate the charge nurse when she may not be readily available to open the medication storage room and open the E-Kit on the designated unit. A review of the facility's P&P (policy and procedure), titled, Emergency Drug Supply E-Kits Meds 007, dated 09/27/21, documented,Edgemoor provides supplies of drugs for use in medical emergencies. These drugs shall be immediately available at each nursing neighborhood or service as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure kitchen equipment was maintained in a safe operating and fully functioning manner when, the salad [NAME] had a chipped lid and the mechanical crank handle was held together with blue tape. This failure had the potential to impact the ability of dietary staff to prepare food in a safe and sanitary manner. Findings: On 10/19/21 at 8:45 A.M., a kitchen storage observation was conducted with the chief of nutrition services (CNS). At 9 A.M., the dishware and food storage containers section was observed. On the metal storage rack, there was a large salad [NAME]. The salad [NAME]'s lid was chipped and had missing pieces along the rim of the lid. The top of the lid had a metal crank and handle. The handle was secured to the crank with frayed blue tape. When the handle was lightly touched, it fell apart and pieces slipped down the crank. The CNS stated the salad [NAME] was still in circulation for use and that it should have been removed and fixed or replaced. On 10/21/21 at 11:10 A.M., an interview was conducted with the supervisor of dietary services (SDS) 4 and SDS 5 in the presence of the CNS. SDS 5 stated broken equipment was supposed to be given to the SDS for removal from circulation so it could be repaired or replaced. SDS 5 stated the salad [NAME] should have been removed from circulation as the tape or the handle could have fallen off and gone into the residents' food. On 10/21/21 at 3:20 P.M., an interview was conducted with the registered dietitian (RD). The RD stated broken equipment should have been removed from circulation and given to the SDS. The RD stated broken equipment was a safety hazard. The facility's policy titled Nutrition Services Employee Safety Guidelines 607, dated 3/19/18, indicated, . i. Ensure that all tools, including knives, etc. are adequate and are properly maintained

Based on observation, interview, and record review, the facility failed to ensure dietary staff were competent on the food cool-down process (bring food temperature down to 41 degrees °F [Fahrenheit] or below) for potentially hazardous foods [PHF] and the use of a cool-down log when preparing egg salad. This failure had the potential to place residents at risk of foodborne illness. Findings: According to the 1999 Federal Food and Drug Administration (FDA) Food Code, . 'Potentially hazardous food' means a food that is natural or synthetic and that requires temperature control because it is in a form capable of supporting: (i) The rapid and progressive growth of infectious or toxigenic microorganisms According to the 2009 FDA Food Code 3-501.14, Temperature and time control- Cooling: (1) Cooked Potentially Hazardous Food must be cooled: (a) Within two hours from 135 °F (57 °C) to 70 °F (21 °C); (b) Within a total of six hours from 135 °F (57 °C) to 41 °F (5 °C) or less On 10/21/21 at 2:42 P.M., an observation and interview was conducted with dietary staff (DS) 1, also present were the supervisor of dietary services (SDS) 2, SDS 3, and the chief of nutrition services (CNS). DS 1 described the process for making egg salad sandwiches. DS 1 stated after cooking the eggs he briefly placed them in an ice bath so he could remove the eggshells. DS 1 stated he then sliced the eggs and mixed them with the other ingredients and placed the egg salad mixture into the refrigerator. DS 1 stated he had placed the egg salad he had made into the refrigerator approximately 10 minutes ago. DS 1 stated he had not checked the temperature. DS 1 checked the temperature of the egg salad using the facility's thermometer. The temperature of the egg salad was 46 °F. DS 1 stated he made egg salad several times a week and has never done a cool-down. DS 1 stated he did not realize the cool-down process was required when making egg salad. SDS 2 stated there should have been a cool-down process performed when making egg salad because it was a PHF if the egg salad did not reach 41 °F or less within the appropriate timeframe. SDS 2 further stated the cool-down process had to be tracked and documented on the cooling record. On 10/21/21 at 2:30 P.M., an interview was conducted with the registered dietitian (RD). The RD stated egg salad was a PHF and should have gone through the cool-down process and the process should have been documented. The RD stated not doing the cool-down process when making egg salad could cause foodborne illness. On 10/21/21 at 3:35 P.M., an interview was conducted with SDS 2. SDS 2 stated the cool-down had not been implemented when making egg salad and there were no cool-down logs kept for egg salad. On 10/21/21 at 7:45 A.M., an interview was conducted with the CNS. The CNS stated the facility should have been doing the cool-down process when making egg salad and cool-down logs should have been kept. The CNS stated there had been no in-services provided to dietary staff on the cool-down process when making meat-based salads such as egg salad. The CNS stated there were no staff competencies done to ensure staff were knowledgeable on the cool-down process for egg salad. The CNS stated cool-down in-services and assessment of staff competency should have been done. The facility's policy titled Nutrition Services: Food Safety 614, dated 10/8/18, indicated, .e. For each potentially hazardous food (PHF) item that is cooked for later use (whether refrigerated or frozen), a cool down temperature graph shall be mandatory . h. All PHF items cooled must have a starting and ending temperature taken to determine if the cooling guidelines are met. Items which do not have either of these temperatures recorded shall be discarded The policy did not provide guidance related to inservices and competency assessment.

Based on observation, interview, and record review, the facility failed to ensure practices that mitigated the risk of resident food contamination were followed when: 1. Prepared egg salad was not cooled-down to ensure food safety. 2. Spoiled produce items were not removed from the refrigerated storage area. 3. Food items were not labeled and dated. 4. Washed food storage containers were stacked and stored wet. In addition, one of the food storage containers had a crack through it. These failures to mitigate potential food contamination may result in food borne illness. Findings: 1. According to the 1999 Federal Food and Drug Administration (FDA) Food Code, . 'Potentially hazardous food' [PHF] means a food that is natural or synthetic and that requires temperature control because it is in a form capable of supporting: (i) The rapid and progressive growth of infectious or toxigenic microorganisms According to the 2009 FDA Food Code 3-501.14, Temperature and time control- Cooling: (1) Cooked Potentially Hazardous Food must be cooled: (a) Within two hours from 135 °F (57 °C) to 70 °F (21 °C); (b) Within a total of six hours from 135 °F (57 °C) to 41 °F (5 °C) or less On 10/21/21 at 2:42 P.M., an observation and interview was conducted with dietary staff (DS) 1, also present were the supervisor of dietary services (SDS) 2, SDS 3, and the chief of nutrition services (CNS). DS 1 described the process for making egg salad sandwiches. DS 1 stated after cooking the eggs he briefly placed them in an ice bath so he could remove the eggshells. DS 1 stated he then sliced the eggs and mixed them with the other ingredients and placed the egg salad mixture into the refrigerator. DS 1 stated he had placed the egg salad he made into the refrigerator approximately 10 minutes ago. DS 1 stated he had not checked the temperature. DS 1 checked the temperature of the egg salad using the facility's thermometer. The temperature of the egg salad was 46 °F. DS 1 stated he made egg salad several times a week and has never done a cool-down. DS 1 stated he did not realize the cool-down process was required when making egg salad. SDS 2 stated there should have been a cool-down process performed when making egg salad because it was a PHF if the egg salad did not reach 41 °F or less within the appropriate timeframe. On 10/21/21 at 2:30 P.M., an interview was conducted with the registered dietitian (RD). The RD stated egg salad was a PHF and should have gone through the cool-down process and the process should have been documented. The RD stated not doing the cool-down process when making egg salad could cause foodborne illness. On 10/21/21 at 3:35 P.M., an interview was conducted with SDS 2. SDS 2 stated the cool-down had not been implemented when making egg salad and there were no cool-down logs kept for egg salad. On 10/21/21 at 7:45 A.M., an interview was conducted with the CNS. The CNS stated the facility should have been doing the cool-down process when making egg salad and cool-down logs should have been kept. The facility's policy titled Nutrition Services: Food Safety 614, dated 10/8/18, indicated, .e. For each potentially hazardous food (PHF) item that is cooked for later use (whether refrigerated or frozen), a cool down temperature graph shall be mandatory. f. Manual temperatures shall be recorded at a minimum of every two hours (but preferably every hour) . h. All PHF items cooled must have a starting and ending temperature taken to determine if the cooling guidelines are met. Items which do not have either of these temperatures recorded shall be discarded 2. On 10/19/21 at 8:45 A.M., a kitchen storage observation was conducted with the chief of nutrition services (CNS). The CNS stated the produce inside the walk-in refrigerator was ready to be used in resident meals. Inside the walk-in produce refrigerator, there were: -A jalapeno pepper with a soft, circular area covered with fuzzy gray material resembling mold. -A green bell pepper that was soft and misshapen. The top half of the pepper was discolored and covered in fuzzy gray and black material resembling mold. -An orange that was soft and dented inward when gently pressed. The orange was discolored and had a section of smooth gray material on it that resembled mold. -A large plastic bin containing fresh parsley leaves. The green parsley leaves had several other leaves that were wilted and yellow and black in color. -A large bag of spinach with several areas in the bag where the spinach was wilted, slimy, and had produced an orange liquid in the bag. -A large box of approximately 100 limes. Approximately 50 of the limes were yellow in color and were covered in soft brown spots. The CNS stated it was his expectation that the produce inside the walk-in refrigerator was checked daily for spoiled items. The CNS stated there should not have been spoiled produce mixed in with non-spoiled produce. On 10/21/21 at 11:10 A.M., an interview was conducted with the supervisor of dietary services (SDS) 4 and SDS 5 in the presence of the CNS. SDS 4 stated there should not have been any spoiled produce in the walk-in produce refrigerator. SDS 4 stated the refrigerators were assigned to dietary staff to check for any spoiled food at the start of their shift. SDS 4 stated the dietary staff signed a form each day that indicated the refrigerator had been checked. SDS 4 and SDS 5 both stated the supervisors of dietary services were responsible for ensuring that the refrigerators had been checked by dietary staff. On 10/21/21 at 11:58 A.M., an interview was conducted with dietary staff (DS) 2. DS 2 stated she had been assigned to check the walk-in produce refrigerator on 10/19/21 for cleanliness and to make sure the produce was fresh. DS 2 stated this was to be done at the start of her shift at 6:30 A.M. DS 2 stated she did not check the walk-in produce refrigerator on 10/19/21 and stated she was aware that she should have. DS 2 stated she also did not sign the log for performing refrigerator checks. On 10/21/21 at 2:17 P.M., a joint interview and record review was conducted with SDS 2 and SDS 3 in the presence of the CNS. The logs for the refrigerator and food storage checks titled Positions Responsible for Noted Storage Areas were reviewed. SDS 2 stated he reviewed all the logs from 10/17/21 through 10/21/21 and that there were missing logs and incomplete entries on the logs that were turned in. SDS 2 stated food storage checks to include the walk-in produce refrigerator had not been consistently done. On 10/21/21 at 3:20 P.M., an interview was conducted with the registered dietitian (RD). The RD stated the refrigerators should have been checked daily, and any spoiled food should have been promptly removed. The RD stated this was done to prevent foodborne illness. The facility's policy titled Nutrition Services: Food Safety 614, dated 10/8/18, indicated, .To prevent food borne illnesses, food and beverages are to be received, stored, prepared and served under sanitary conditions The facility's policy titled Nutrition Services: Food Storage 610, dated 4/23/18, indicated, . M. Food items are rotated with stock on hand using FIFO (first in, first out) principle 3. On 10/19/21 at 8:45 A.M., a kitchen storage observation was conducted with the chief of nutrition services (CNS). Inside the walk-in refrigerator, there were: - A large package of approximately 24 dinner rolls. They were not labeled or dated. -A large package of approximately 24 hamburger buns. They were not labeled or dated. -A large plastic bin containing fresh parsley leaves. The green parsley leaves had several other leaves that were wilted and yellow and black in color. It was not labeled or dated. -A large bag of spinach with several areas in the bag where the spinach was wilted, slimy, and had produced an orange liquid in the bag. It was not labeled or dated. -A plastic bag filled with approximately 12 large zucchinis. They were not labeled or dated. Inside the walk-in freezer, thawing section, there was a food storage container with what resembled cooked ground meat that had been covered with plastic wrap. On top of the plastic wrap, was a gallon sized zip lock bag with what resembled uncooked pink ground meat inside. The zip lock bag had caused the plastic wrap to cave-in so that the zip lock bag was directly on top of what looked like cooked ground meat. The zip locked contents were not labeled or dated. The CNS stated that the contents of the zip locked bag were cooked ground ham. The CNS stated all food items in the walk-in refrigerators or freezers should have been appropriately labeled and dated. On 10/19/21 at 9:15 A.M., an interview was conducted with cook (CK) 1. CK 1 stated all food items in the refrigerators or freezers had to be labeled and dated. CK 1 stated there had been ground cooked ham in the gallon sized zip lock bag. CK 1 stated he threw it away because it was not labeled or dated and he could not determine how long it had been in the thawing section of the freezer. CK 1 further stated the ground ham should not have been stored directly on top of the ground turkey in the same container. The undated signage posted on nourishment refrigerator (R4) indicated, .All food must be covered, labeled, dated On 10/21/21 at 11:10 A.M., an interview was conducted with the supervisor of dietary services (SDS) 4 and SDS 5 in the presence of the CNS. SDS 4 stated all food items should have been labeled and dated so everyone could tell what the item was and how long it had been in the refrigerator. SDS 4 stated food was kept for specific amounts of time depending on what the food was, and the food had to be labeled and dated so staff would know when to dispose of it. On 10/21/21 at 3:20 P.M., an interview was conducted with the registered dietitian (RD). The RD stated food items should have been labeled and dated in order to ensure food could be accurately identified and it would be safe to serve to the residents. The RD stated thawed meat items were generally kept for three days, and if they were not dated, staff would not know when to remove them. The facility's policy titled Nutrition Services: Food Storage 610, dated 4/23/18, indicated, . a. Stored items should be covered, labeled and dated when received, opened, or when leftover 4. On 10/19/21 at 8:45 A.M., a kitchen storage observation was conducted with the chief of nutrition services (CNS). At 9 A.M., the dishware and food storage containers section was observed. A metal rack held several plastic food storage containers that were stacked in groups, one container fitting tightly into the other container. The CNS stated this rack of food storage containers were clean and ready to be used. A stack of approximately 10 plastic food storage containers were stored wet. The CNS stated the containers were clean and should not have been stored wet. One of the food storage containers had an approximate two inch long crack from the rim down. The CNS stated the crack in the food storage container could not be effectively cleaned or sanitized and could possibly harbor bacteria. The CNS stated all cracked food storage containers or dishware had to be removed from circulation. On 10/21/21 at 11:10 A.M., an interview was conducted with the supervisor of dietary services (SDS) 4 and SDS 5 in the presence of the CNS. SDS 5 stated all broken or cracked dishware or food storage containers had to be given to the SDS so they could remove them and reorder new items to replace them. Both SDS 4 and SDS 5 stated storing food storage containers while wet could contribute to food contamination. On 10/21/21 at 3:20 P.M., an interview was conducted with the registered dietitian (RD). The RD stated clean dishware and food storage containers should not have been stored wet. The RD stated cracked dishware or food storage containers had to be removed from circulation. The RD stated storing food storage containers wet and keeping cracked containers in use could lead to bacterial growth and contamination. The facility's policy titled Nutrition Services Employee Safety Guidelines 607, dated 3/19/18, indicated, .viii. Discard chipped and/or cracked dishes

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to allow one of 35 sampled residents (64) to attend a scheduled activity of their choice. This failure had the potential to affect Resident 64's quality of life. Findings: On 1/14/20, a record review was conducted. According to the facility's Record of Admission, Resident 64 was admitted to the facility on [DATE]. On 1/14/20 at 8:57 A.M., an observation was conducted. Resident 64 was seated in her manual wheelchair, slowly propelling herself down the main hall. On 1/15/20 at 9:09 A.M., an observation and interview was conducted with Resident 64. Resident 64 stated, yesterday (1/14/20) she had a bowel movement after lunch that required her brief to be changed. Resident 64 stated, staff put her back to bed in order to change her. Resident 64 stated, she did not want to remain in bed as she had planned to attend the mind, body, and soul activity that was scheduled for 2:30 P.M. (on 1/14/20). Resident 64 stated she was not a religious person and attending the mind, body, and soul activity was spiritual for her and made her feel better. Resident 64 stated, she was not allowed out of bed to attend the activity. Resident 64 stated, there was a facility rule according to her care plan that when she was in bed after lunch she had to stay in bed until the next shift came on. Resident 64 stated, I'm not okay with those rules. Resident 64 stated, her certified nursing assistant (CNA) 1 and a nurse told her she had to remain in bed until the P.M. shift came on (3:30 P.M.) as this was part of her care plan. Resident 64 was tearful and stated, I'm very upset. Resident 64 stated she felt punished for having had a bowel movement. A review of Resident 64's MDS (minimum data set-an assessment tool) dated 10/30/19, indicated, the resident scored 12 on the BIMS (brief interview of mental status) and was cognitively intact. The MDS further indicated, Resident 64 was totally dependent and required two staff for transfers between bed and wheelchair, and required extensive assistance from two staff for toileting. On 1/15/20 at 9:42 A.M., an interview was conducted with CNA 1. CNA 1 stated, Resident 64 had a bowel movement after lunch on 1/14/20 around 1 P.M., and asked to have her brief changed. CNA 1 stated Resident 64 was dependent on staff help for toileting and required two staff for the mechanical lift, to transfer the resident from wheelchair to bed. CNA 1 further stated, Resident 64 could not change her own brief and had to be changed in bed. CNA 1 stated, after changing Resident 64's brief, she told the resident she had to stay in bed between 1 P.M. and 3:30 P.M. as it was part of her care plan. CNA 1 stated she did not ask for extra staff assistance to get the resident up and into her wheelchair because the care plan required the resident to stay in bed at that time. CNA 1 stated, Resident 64 told her she did not want to stay in bed and had planned to attend an activity at 2:30 P.M. CNA 1 stated, the unit was busy after lunch and there were not enough staff to take Resident 64 in and out of bed. CNA 1 stated, Resident 64 cried when she told her she had to stay in bed and would miss the activity. CNA 1 stated, she did not think it was fair Resident 64 had to stay in bed after having a bowel movement. CNA 1 stated, making Resident 64 stay in bed bothered her and she decided to speak to the charge nurse (CN) 1 and nursing supervisor (NS) 1 about it. CNA 1 stated NS 1 told her to follow the care plan and keep Resident 64 in bed. On 1/15/20 at 12:01 P.M., a joint interview and record review was conducted with CNA 1 of the electronic charting for CNAs. The care plan for ADLs (activities of daily living) indicated, Resident 64 was to stay in bed following a brief change after 1:30 P.M. CNA 1 stated, she had followed this care plan for ADLs on 1/14/20. On 1/15/20 at 12:07 P.M., an interview was conducted with the recreational therapist (RT). The RT stated, the activity mind, body, and soul was held on 1/14/20 at 2:30 P.M. The RT stated Resident 64 regularly attended the mind, body, and soul activity, and really gets into the exercise and voices the steps out loud. The RT stated, Resident 64 did not attend the activity on 1/14/20. The RT stated she was aware of the care plan for the resident to stay in bed at certain times and around staff shift change. The RT stated, the resident had the right to be changed when soiled and the right to choose to go to the activity of her choosing. The RT stated, the care plan should not have deprived the resident of being able to get out of bed and attend activities. The RT stated, keeping Resident 64 in bed was not okay especially since attending the class had such a positive effect on the resident's mood and behavior. On 1/15/20 at 1:09 P.M., an interview was conducted with NS 1. NS 1 stated, some residents on the unit had care plans indicating times they were required to stay in bed in order to benefit the unit. NS 1 stated, staff cannot meet all residents' needs at certain times. NS 1 stated, Some residents are going to be disappointed they have to stay in bed and miss something. NS 1 stated, I take responsibility for not allowing her (Resident 64) to get out of bed. I told the CNA (CNA 1) she (Resident 64) was to stay in bed. NS 1 stated, she did not realize keeping the resident in bed prevented the resident from exercising her right to participate in activities. NS 1 stated, perhaps we should have more staff around shift change. On 1/16/20 at 9:44 A.M., an interview was conducted with NS 2. NS 2 stated, a resident who required toileting in bed should be placed back in their wheelchair if requested after being changed. NS 2 stated, making a resident remain in bed when they wanted to attend an activity was not right and was disrespectful. NS 2 stated, resident care plans should allow for incontinence (unable to control bowel or bladder) episodes and should not prevent residents from exercising their rights to choose to attend activities. On 1/16/20 at 10:24 A.M., an interview was conducted with the director of nursing (DON). The DON stated, resident needs were attended to before resident wants. The DON stated Resident 64 was cleaned after having a bowel movement and was expected to wait until staff could attend to her desire to go to activities which was considered a want. The DON stated, the needs of the unit come before a resident's wants. A review of the written statement, dated 1/17/20, and signed by CN 1, indicated, .The CNA approached me last 1/14/2020 around 2:30 pm stating that the resident wanted to be up right away and CAN [sic] felt pulled between a careplan with restrictions and her other responsibilities and the added pressure of being in survey. The CNA went to the Nursing Supervisor [NS 1] in her office, but she was busy and she told the staff to follow the Care Plan . I went to the resident [Resident 64] and spoke to her regarding her concern. And I told her, she will be up as soon as we get help and next shift is coming in 30 minutes to help. She told me she was being punished, but this is common for her. I told her 'it is not about you' It is about the other residents to assure they get the proper care in the time available A review of Resident 64's Care Plan Request and Facility Response Form 6858, dated 12/9/19, indicated, . Pt (patient) likes many activities AM + PM. Heavy voider. Takes 2 staff for care. Have to accommodate needs of other residents. Cannot change in WC (wheelchair) . Can go back to bed for change up to 130 (1:30 P.M.) - 230 (2:30 P.M.) or wait until PM shift. If back to bed, day shift will not get her up again . The document further indicated, Resident 64 refused to sign. On 1/17/20 at 8:17 A.M., a joint interview and record review was conducted with Resident 64. Resident 64 reviewed the Care Plan Request and Facility Response Form 6858, dated 12/9/19. Resident 64 stated the care plan request was not her idea and she did not request it, but she did attend the meeting. Resident 64 stated, the care plan request was the facility's idea because she required too much help from the staff and could not toilet herself. Resident 64 stated I take too much of their time because I'm too big. Resident 64 stated I did not sign that (Care Plan Request and Facility Response Form 6858) because I didn't agree with it. Resident 64 further stated, staff came during the P.M. shift to offer to get her up (on 1/14/20) and she refused. Resident 64 stated, at that time there were no more activities that interested her and she had no more reason to be up in her wheelchair. On 1/17/20 at 3:35 P.M., an interview was conducted with the DON. The DON stated, I'm satisfied as DON based on my root cause analysis that the CNA (CNA 1) and CN (CN 1) tried their best and followed the expectation by explaining to the resident (Resident 64) why she couldn't get up at that time . The facility's policy titled Resident Rights 106, dated 5/24/17, did not provide guidance regarding a resident's right to make choices. Per the facility's policy titled Dignity Guideline 1148, dated 4/8/19, [facility name] residents will be treated with consideration, respect, and full recognition of dignity and individuality,