**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide two out of eight sampled residents (Residents 80 and 92) with dignity and respect when: 1. Resident 80's bed was not made every day. 2. Resident 92 stated, facility staff spoke in a manner, that led her to believe, facility staff did not want to provide care to Resident 92 and had overheard staff talking disrespectfully about her just outside of the door. This failure had the potential to impact resident well-being and cause psychosocial harm. Findings: A review of the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity, dated 11/1/23, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. The P&P indicated, staff would speak with respect and would have conversations regarding residents in an area that residents could not overhear. A review of the undated admission Record, indicated, Resident 80 was admitted to the facility on [DATE] with the diagnoses of hypertensive heart disease without heart failure (heart problems that were caused by high blood pressure), anxiety (feelings of fear), and a history of falling. Resident 80 was her own responsible party (RP, made own decisions). A review of the quarterly Minimum Data Set (MDS, an assessment tool), dated 10/17/24, Section C, indicated, Resident 80 had a Brief Interview for Mental Status (BIMS, an assessment that tested a resident's ability to recall information and memory. The test was scored from 0-15 where 0 meant the resident was not able to remember and 15 meant the resident had intact memory) and scored a 14. During an interview on 11/19/24 at 3:44 p.m., Resident 80 stated, not every day, but often, Resident 80 had to ask facility staff to make the bed. Resident 80 stated, inability to make own bed anymore due to being [AGE] years old, a fear of falling again, and stated feeling upset because Resident 80 was not able to perform activities of daily living for herself like she used to. Resident 80 stated, when the bed was left unmade, it bothered her. During an interview on 11/19/24 at 4:03 p.m., Certified Nurse Assistant (CNA) B stated, it was the responsibility of the CNA on the morning shift to make resident's beds. CNA B confirmed Resident 80's allegations that the bed was left unmade and stated, CNA B would come to work in the afternoon and find Resident 80's bed unmade all the time. During an observation on 11/22/24 at 8:57 a.m., Resident 80's room was observed. Resident 80 was not in the room, and the bed had been stripped of all the linen (bed did not have sheets, blanket, or pillowcase). During a concurrent observation and interview on 11/22/24 at 9:18 a.m., Resident 80 was observed standing next to the stripped bed holding on to a walker (metal frame on wheels used by residents that had difficulty walking or were at risk for falls). Resident 80 stated, she had just had a shower. During a concurrent observation and interview, on 11/22/24 at 9:40 a.m., Resident 80's room was observed. Resident 80's bed was stripped of linen. The Director of Staff Development (DSD) was observed walking past Resident 80's room. DSD confirmed Resident 80's bed was stripped of linen and stated, after the CNA provided Resident 80 with a shower, the CNA was expected to make the bed. DSD stated earlier in the week, it was brought to DSD's attention that Resident 80's bed had been left unmade and had planned to re-educate the CNA assigned to Resident 80. During the concurrent observation and interview with the DSD, a request was made to interview Resident 80's CNA. The CNA agreed to an interview after providing resident care. The CNA completed resident care, walked out of the room, and quickly walked down the hall into another resident room and closed the door. 2. A review of the undated Admissions Record, indicated, Resident 92 was admitted to the facility on [DATE] with the diagnoses of hypertension (high blood pressure), anxiety, and need for assistance with personal care (bathing, using bathroom, and rolling in bed). Resident 92 was her own RP. A review of the admission MDS, dated [DATE], Section C, indicated, Resident 92 had a BIMS assessment score of 13 (able to recall and remember information). A review of the undated admission Record, indicated, Resident 6 was admitted to the facility with the diagnoses of muscle weakness and major depressive disorder (a sad mood). Resident 6 was her own RP. A review of Resident 6's quarterly MDS, dated [DATE], Section C, indicated, Resident 6 had a BIMS assessment score of 14. During a concurrent observation and interview on 11/20/24 at 10:17 a.m., Resident 92 was observed lying in bed and maintained good eye contact during the interview. Resident 92 stated, I hear staff talking about me in the hallways all the time. Resident 92's roommate, Resident 6, joined the interview and stated, Resident 6 was treated differently than Resident 92. Resident 6 stated, facility staff treated her with dignity and respect and when facility staff spoke to Resident 92, they were short and sharp. Resident 6 and 92 described short and sharp as not having time and not wanting to care for Resident 92. Resident 92 began to cry and stated being afraid to say anything for fear staff would treat her worse. During an interview on 11/21/24 at 3:05 p.m., the Director of Staff Development (DSD) stated, it had been brought to the DSD's attention, at the end of last week, that two staff members had talked badly and mean to Resident 92. DSD stated one staff member had been identified and one staff member was unknown. DSD stated, DSD had not had an opportunity to follow up with facility staff regarding Resident 92's statements and DSD had previously counseled the identified staff in the past regarding how they spoke to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents environment was clean, safe, comfortable, and homelike when: A drain in the kitchen was observed to have missing tile with exposed wood. Two tub and shower rooms used by residents were observed to contain excessive brown stains resembling rust on a handrail and on metal baskets used to hold soap and wash cloths. Doors in residents' rooms bathrooms were observed with scrapes, and gouges of exposed wood. One resident's wall next to his bed had multiple scrapes with exposed drywall. These findings had the potential for injuries to residents and an un home like environment. Findings: A review of a Safe and Homelike Environment policy dated 1/24/24 indicated the facility would provide a safe, clean and homelike environment to ensure residents can receive care and services safely. The policy additionally instructed that the facility maintenance and housekeeping would provide services as needed to maintain a safe, orderly, and comfortable environment. 1.During an observation on 11/19/24 at 11:00 am, in the kitchen during the walk through, the sink drain on the floor was missing tile with bare, water damaged wood exposed. During a concurrent interview and observation on 11/21/24 at 3:00 pm, with Dietary Manager (DM), and Registered Dietician (RD) 2 in the kitchen, DM stated, That drain really needs to be fixed with tiles, maintenance has ordered tiles and is in the process of starting to fix it, and RD 2 concurred in agreement that the drain needed to be fixed. 2. During a concurrent observation and interview on 11/20/24 at 8:55 am, with LN B in the Tub/Shower Room in the hall of the locked unit across from the nurse's station and utility room. Extensive rust was observed on metal baskets with plastic coating used for holding items such as soap and resident's wash cloths, also observed substantial rust on and in a floor drain with capped off spickets entirely coated in corrosion and rust which appears to not be in current use. LVN B concurred that rust and corrosion were evident, and this did not appear to be a satisfactory environment for someone's home. 3. During an observation on 11/20/24 at 9:15 am, in the Tub/Shower Room across from room [ROOM NUMBER] in the locked unit, observed rust on metal plastic coated baskets, rusted washers on shower safety handlebars, and 3 circular spackled areas in the shower exposed to water. During a concurrent observation and interview on 11/21/24 at 2:00 pm, with Admin in the Administrator's Office. Pictures recently obtained of the kitchen drain, and Tub/Shower Rooms with apparatus' observed with rust and corrosion issues were reviewed. Admin concurred the items were not in good shape and needed to be fixed. Admin stated we are in the process of fixing them. During a concurrent observation and interview on 11/21/24 at 4:30 pm, with MS, in the hall outside the Theatre Room. Pictures recently obtained of the kitchen drain, and Tub/Shower Rooms with apparatus' observed with rust and corrosion issues were reviewed. MS concurred he has been made aware of the issues and is in the process of fixing them. There is only one person in maintenance with a part time person recently hired. MS concurs many things need to be fixed. 4. On 11/19 24 at 11:30 am, room [ROOM NUMBER]-bathroom door was observed to have a long gouge of exposed wood measuring approximately 9 inches by 1 inch long above the door handle. Concurrently, on the same day room [ROOM NUMBER]c bed wall next to his bed was observed to have scrapes with exposed drywall the length of his bed. At 11:40 am, the bathroom door of room [ROOM NUMBER] was observed to have exposed wood gouges by the doorknob measuring one foot in length by 1 inch in length. The inside door of this room also had wood gouges observed by the door knob measuring approximately 15 inches in length by 1 inch in width. On 11/21/24 at 4:15 pm, the above rooms and disrepair was observed with the Maintenance Supervisor (MS). He acknowledged at this time the findings and the measurements. MS stated these areas needed to be repaired. He stated sometimes the staff tell him about needed repairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) for one out of eight sampled residents (Resident 92) when Resident 92 notified Licensed Nurse (LN) A that facility staff working the night shift provided rough care (too much force, not careful or gentle). This failure had the potential for allegations of abuse to go unrecognized and placed residents at risk for abuse. Findings: A review of the facility's policy and procedure titled, Abuse-Reporting & Investigating, revised 11/1/16, indicated, when an allegation of abuse was made, the facility would notify CDPH. A review of the undated admission Record, indicated, Resident 92 was admitted to the facility on [DATE] with the diagnoses of hypertension (high blood pressure), anxiety (feelings of fear), and need for assistance with personal care (bathing, using bathroom, rolling in bed). Resident 92 was her own responsible party (made own decisions). A review of the admission Minimum Data Set (MDS, an assessment tool), dated 10/17/24, Section C, indicated, Resident 92 had a Brief Interview for Mental Status (BIMS, an assessment that tested a resident's ability to recall information and memory. The test was scored from 0-15 where 0 meant the resident had poor memory and 15 meant the resident had good memory) and scored a 13. During a concurrent observation and interview on 11/20/24 at 10:17 a.m., Resident 92 was observed in bed and maintained good eye contact during the interview. Resident 92 stated, One night, the nurses were really rough turning me and changing me. Resident 92 was observed to lower her head, broke eye contact, and began to cry. During an interview on 11/21/24 at 12:26 p.m., LN A stated, Resident 92, came to me with concerns about rough care provided by NOC [nighttime] shift on last Friday and had reported to the Director of Staff Development (DSD). During an interview on 11/21/24 at 2:29 p.m., with the facility's Administrator (ADMIN), Resident 92's allegations of potential abuse were discussed. ADMIN confirmed, there was no report of Resident 92's allegations of potential abuse made to CDPH and stated, ADMIN was not notified of Resident 92's statements. During an interview on 11/21/24 at 3:05 p.m., DSD stated, last Friday, LN A notified DSD that Resident 92 alleged the NOC shift staff was rough while providing care, the Director of Nursing (DON) was aware, and it wasn't abuse. During an interview on 11/21/24 at 3:21 p.m., DON stated, LN A notified DON that Resident 92 alleged something happened a while ago, and the night shift didn't seem nice. DON stated, asking LN A what had happened and if Resident 92 was abused. DON confirmed, Resident 92's allegation of potential abuse was not reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to include nail care to one sampled residents comprehensive care plan (Resident 8). Resident 8 was observed to have long dirty fingernails, and was observed eating with his fingers. This deficient practice led to unidentified need for nailcare, and the potential for injury (scratches), and poor hygiene. Findings: On 11/19/24 at 12:38 pm Resident 8 was observed eating his lunch in the Dining Room with his fingers. His nails on his fingers were observed long with black particles in the nails. A review of Resident 8's record indicated he was admitted to the facility on [DATE] with diagnoses that include dementia (a progressive state of decline in mental abilities), diabetes (disorder characterized by difficulty in blood sugar control and poor wound healinge), and the need for assistance with personal care. A review of a Minimum Data Set (MDS, an assessment tool) dated 8/30/24, indicated Resident 8 was severely impaired for decision making and dependent on staff for personal hygiene. On 11/20/24 at 8:45 am, Resident 8 was observed with Licensed Nurse (LN) C. Resident 8's fingernails on all of his nails were approximately one inch in length with brown substance under the nails. LN C confirmed the findings stating nail care is usually done on a weekly basis during their showers and with activities. LN C acknowledged all Resident 8's nails were at least one inch long on all fingers and dirty. On 11/20/24 at 9 am, LN D was interviewed while reviewing Resident 8's record. LN D confirmed a care plan for refusal of ADLS (Activities of Daily Living) was present in the record but nothing about his refusal or need for nail care. On 11/21/24 at 7:35 am the Director of Nurses (DON) stated during an interview that nail care should have been included in Resident 8's ADL care plan. During an interview with the Activity Director (AD) on 11/22/24 at 10 am, she stated she usually does rounds to observe the residents. She stated Resident 8 is usually resistant to care, and she did not know his nails were a concern. A review of a facility policy titled, Care Planning / Interdisciplinary Team Care Planning Conference dated 9/2016, indicated the purpose of resident care plans were to assure resident care needs are identified through continuous assessment with measurable objectives and adequate interventions. The policy additionally indicated care plans would be reviewed, evaluated and updated as necessary by nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain personal hygiene to one sampled resident that was unable to carry out his activities of daily living (Resident 8). Resident 8 was observed to have long dirty fingernails. This deficient practice led to unidentified need for nailcare, and the potential for injury (scratches) and poor hygiene. Findings: On 11/19/24 at 12:38 pm, Resident 8 was observed eating his lunch in the Dining Room with his fingers. His nails on his fingers were observed long with black particles in the nails. A review of Resident 8's record indicated he was admitted to the facility on [DATE] with diagnoses that include dementia (a progressive state of decline in mental abilities), diabetes (disorder characterized by difficulty in blood sugar control and poor wound healinge), and the need for assistance with personal care. A review of a Minimum Data Set (MDS, an assessment tool) dated 8/30/24, indicated Resident 8 was severely impaired for decision making, and dependent on staff for personal hygiene. On 11/20/24 at 8:45 am, Resident 8 was observed with Licensed Nurse (LN) C. Resident 8's fingernails on all his fingers were approximately one inch in length with brown substance under the nails. LN C confirmed the findings stating nail care is usually done on a weekly basis during their showers and with activities. LN C acknowledged all Resident 8's nails were at least one inch long on all his fingers and dirty. During an interview with the Activity Director (AD) on 11/22/24 at 10 am, she stated she usually does rounds to observe the residents. She stated Resident 8 is usually resistant to care and she did not know his nails were a concern. A review of a facility policy titled, Activities of Daily Living (ADLs) dated 1/24/24, indicated grooming and personal hygiene would be provided to residents who are unable to carry out activities of daily living. Additionally the policy directed it would identify resident triggers and inform the resident or his representative about the benefit verses benefit of the proposed treatment, and offer an alternative action if the resident refusals continue.

Based on interview and review of Resident Council Minutes the facility failed to act promptly to resolve resident grievances in a timely manner and demonstrate their response and rationale for their response. This action had the potential to violate residents' rights. Findings: A review of a facility policy titled, Resident and Family Grievances dated 1/24/24, indicated grievances may be voiced verbally during resident or family council meetings. Under procedure, the policy included the following directions: The staff person receiving the grievance would record the nature and the specifics of the grievance. Steps would be taken to resolve the grievance, and record information about the grievance and actions taken on the grievance form. All staff involved in the grievance investigation should make prompt efforts to resolve the grievance. The Social Service Designee (SSD) would keep residents appropriately appraised of the progress and the resolution of the grievance. The SSD would issue a written decision on the grievance and a conclusion of the investigation. The facility would make prompt efforts to resolve grievances. During an interview with the Activities Director (AD) on 11/20/24 at 4:35 pm she stated there was one missing follow up from a resident council meeting grievance. She provided six months of Resident Council Minutes minutes from June to November 2024. A review of the six months of Resident Council minutes from June to November 2024 indicated during a Resident Council meeting on September 17, 2024, there was one complaint about noise in the facility. There was no follow up documentation of who made the complaint, or a documented effort to resolve the grievance or a conclusion of the investigation. The Resident Council minutes from June to November 2024 did not have any documented food complaints. During an interview with the Administrator (Admin) on 11/20/24 at 4:45 pm she stated the facility is supposed to have follow up on all concerns brought up by Residents Council members. She stated the concerns are to be brought up to the Department Managers. She also stated this was part of their grievance process which included being discussed with their Interdisciplinary Team (IDT, a group of professionals that meet and plan care and services for the residents). During a confidential interview on 11/21/24 at 10:30 am, five residents stated the food in the facility was not good. Residents stated, the hot food was not hot, the cold food was not cold, and the meat was tough and hard to chew. One resident stated the meat was hard to swallow due to how tough it was. The residents stated this had been an ongoing problem and had been brought up at previous council meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. A review of the undated admission Record, indicated, Resident 72 was admitted to the facility on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease (affected the lungs and made breathing difficult). Resident 72 was her own responsible party (RP, could make own decisions). During an interview on 11/19/24 at 11:58 a.m., Resident 72 stated, the hot foods were not always hot, the cold foods were not always cold, and the meat was tough and over cooked. 9. A review of Resident 80's undated admission Record, indicated, Resident 80 was admitted to the facility on [DATE] with the diagnosis of type 2 diabetes (body was not able to control blood sugar levels). Resident 80 was her own RP. During an interview on 11/19/24 at 3:44 p.m., Resident 80 stated, the dietary department had served tomato soup the other day. Resident 80 had tears in her eyes and stated, I had my heart set on that hot tomato soup, on a cold evening, and it was stone cold. A review of the facility's weekly meal menu, titled Good for Your Heart Health Menus, dated 11/18/24 through 11/24/24, indicated, on 11/18/24, the residents received tomato soup with dinner. 10 - 14. During a confidential interview on 11/21/24 at 10:30 a.m., five residents stated the food in the facility was not good. Residents stated, the hot food was not hot, the cold food was not cold, and the meat was tough and hard to chew. One resident stated the meat was hard to swallow due to how tough it was. Based on observations and interviews, the facility failed to ensure the facility food was an appetizing temperature and palatable texture when 14 of 21 sampled residents (Residents 17, 9, 51, 70, 16, 36, 85, 72, 80, and five confidential residents), who received food prepared in the facility kitchen were not satisfied with the facility food temperature and texture. This failure had the potential to result in residents not obtaining appropriate nutritive intake, unplanned weight loss, increased health issue complications, and diminished emotional well-being. Findings: A review of the facility's policy and procedure (P&P) titled, Food Preparation Guidelines, dated February 2023, Revision, indicated, Food shall be palatable attractive, and at a safe and appetizing temperature. 1. A review of Resident 17's medical record indicated that Resident 17 was admitted on [DATE] with diagnoses that included Dementia with mood disturbance (loss of memory, language, problem solving, and thinking ability with mood issues such as depression, anxiety, and apathy), Hypertension (HTN, high blood pressure), and Syncope and Collapse (fainting). The Minimum Data Set (MDS, Tool for evaluating and implementing a standardized assessment) Brief Interview for Mental Status (BIMS, Section C assessing cognitive function) score dated 9/19/24, indicated Resident 17 rates 14/15, which equates to having cognition intact. During an interview on 11/20/24 at 12:40 pm, with Resident 17 while in the dining room, Resident 17 stated, Food is bland, mostly cold, and veggies are mushy. 2.A review of Resident 9's medical record indicated that Resident 9 was admitted on [DATE] with diagnoses that included Diabetes Mellitus (DM), Chronic Kidney Disease (Progressive damage and loss of function to the kidneys), and Cerebral Infarction (Stroke, blockage of blood flow to the brain). The MDS BIMS, Section C score dated 11/20/24, indicated Resident 9 rates 10/15, which equates to having moderately impaired cognition. During an interview on 11/20/24 at 12:40 pm, with Resident 9 while in the dining room, Resident 9 stated, Food is cold. 3.A review of Resident 51's medical record indicated that Resident 51 was admitted on [DATE] with diagnoses that included Alzheimer's Disease (brain disease which causes brain to shrink and brain cells to die) , Chronic Obstructive Pulmonary Disease (COPD, ongoing lung condition causing damage to the lungs and difficulty to breathe), and Heart Failure. The MDS BIMS, Section C score dated 10/24/24, indicated Resident 51 rates 5/15, which equates to having severely impaired cognition. During an interview on 11/21/24 at 12:35 pm, with Resident 51 while in the dining room, Resident 51 stated, Food is cold. 4.A review of Resident 70's medical record indicated that Resident 70 was admitted on [DATE] with diagnoses that included Neurocognitive disorder with Lewy Bodies (progressive damage to the brain with build-up of Lewy body cells which are clumps of proteins causing the brain to have symptoms of hallucinations, lack of focus and attention, and movement tremors), Parkinsonism (Neurologic condition that causes movement abnormalities such as tremor and impaired speech), and Generalized Muscle Weakness. The MDS BIMS, Section C score dated 11/7/24, indicated Resident 70 rates 2/15, which equates to having severely impaired cognition. During an interview on 11/19/24 at 1:35 pm, with Resident 70 while in the resident's room, Resident 70 stated, I am picky, the Food isn't to my taste, I get food out from my daughter. 5.A review of Resident 16's medical record indicated that Resident 16 was admitted on [DATE] with diagnoses that included Alzheimer's Disease , DM, and HTN. The MDS BIMS, Section C score dated 10/2/24, indicated Resident 16 rates 14/15, which equates to having intact cognition. During an interview on 11/19/24 at 2:00 pm, with Resident 16 while in the resident's room, Resident 16 stated, Food is cold, not good, I just have to eat it. 6.A review of Resident 36's medical record indicated that Resident 36 was admitted on [DATE] with diagnoses that included Cerebral Vascular Accident (Stroke, Blood flow to the brain is cut off and can lead to brain cell death, and neurologic damage), Monoplegia to Left Lower Limb (paralysis to one leg), and DM. The MDS BIMS, Section C score dated 10/30/24, indicated Resident 36 rates 7/15, which equates to having severely impaired cognition. During an interview on 11/20/24 at 12:40 pm, with Resident 36 while in the resident's room, Resident 36 stated, Food is cold. 7.A review of Resident 85's medical record indicated that Resident 85 was admitted on [DATE] with diagnoses that included Dementia with Behavioral Disturbances, Heart Failure, and Cardiomyopathy (disease of the heart muscle causing the heart to have a difficulty pumping blood to the body). The MDS BIMS, Section C score dated 9/23/24, indicated Resident 85 rates 8/15, which equates to having severely impaired cognition. During an interview on 11/21/24 at 12:35 pm, with Resident 85 while in the dining room, Resident 85 stated, Food does not taste good and is cold. During an interview on 11/21/22 at 3:00 pm, with DM in the DM and RD office, DM stated, I understand the food must meet the resident's tastes.

Based on Observation, Interview, and Record Review the facility failed to ensure federal regulations related to the certification qualification requirement of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with resident assessment accuracy, meal distribution accuracy, safe food handling, and sanitation guidelines. Findings: According to the HSC 1265.4 (a) Shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. According to the HSC 1265.4, (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association and maintains this certification. A record review of the facility's job description titled, Dietary Manager, dated 2022, indicated, Minimum requirements include .Certification as a dietary manager .Must also meet State requirements for food service managers or dietary managers. During a concurrent interview and record review on 11/19/2024 at 11:00 am with Dietary Manager (DM) and Registered Dietician (RD) 1 in the office of DM and RD. DM's education certificates were observed hanging on the wall with a passing date of April 12, 2023. The actual Dietary Manager Certificate was not observed, thus requested. DM stated, I am not certified yet. I have not passed the test. I am scheduled to take the test on 1/3/24. I have been performing duties of the position for three (3) years. RD 1 stated, I am here at the facility one (1) time a month, I only started two (2) months ago, so I have only been here twice, and I have four (4) other facilities that I oversee. I am always available for DM if needed. During an interview on 11/21/2024 at 2:00 pm with Administrator (Admin) in the Administrator office, Admin stated, we know the DM does not have the certificate and is working on getting it, the test is scheduled for January. We thought we were covered with our RD in place and the other Certified Dietary Manager (CDM) with a current certificate in the building now serving as the Medical Records Director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) dignity was honored when Certified Nursing Assistant C (CNA C) provided personal cares with the window covering open which exposed Resident 3 to an outside courtyard accessible to staff and residents. This failure had the potential to negatively affect Resident 3 ' s physical and mental well-being. Findings: A review of the facility ' s policy titled Promoting/Maintaining Resident Dignity dated 11/2023, indicated It is the practice of this facility to protect and promote residents ' rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident ' s quality of life by recognizing each resident ' s individuality. Compliance Guidelines 11. Maintain resident privacy. A review of Resident 3 ' s admission Record (undated) indicated that Resident 3 was admitted to the facility on [DATE] with diagnoses including Alzheimer ' s Disease (a disease that destroys memory and other important mental functions), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), chronic (ongoing) pain, need for assistance with personal care. A review of Resident 3 ' s Quarterly Minimum Data Set (MDS, a complete clinical assessment) dated 9/10/24, indicated a Brief Interview for Mental Status (BIMS, an evaluation of cognition [thinking, recalling, and making decisions]) was done with results indicating her cognition was severely impaired. Section GG indicated Resident 3 was dependent on staff for toileting needs. Section H indicated Resident 3 was always incontinent with urination and bowel movements. During an observation on 11/15/24 at 1:33 pm, Resident 3 ' s room was observed. Resident 3 was in bed and the right side of her bed was against an outside wall. There was a window alongside the lower half of her bed that looked outside onto a courtyard (grassy area and a sidewalk). The window shade was completely open. CNA C was observed entering Resident 3 ' s room and pulling a privacy curtain around Resident 3 ' s left side of the bed and the end of the bed but stopped a foot short of the wall. The window shade was all the way up and Resident 3 was in full view of the outside. CNA C was observed changing Resident 3 ' s brief (incontinent product worn like a diaper that collects bowel and urine). Resident 3 ' s peri area (resident ' s private area) was exposed to the outside area through the uncovered window. During a concurrent observation and interview with Licensed Vocational Nurse A (LVN A) on 11/15/24 at 1:35 pm, in Resident 3 ' s room. LVN A entered the room and when it was pointed out by the surveyor that the window shade was up and Resident 3 was having personal cares done, LVN A immediately pulled the window shade down. During a concurrent observation and interview with the Activity Director (AD) on 11/15/24 at 1:40 pm, the outside courtyard was observed. The AD indicated this area was accessible to staff and residents. The AD confirmed that she was able to see in the windows when the shades were up. The AD indicated it would be a dignity issues to do personal cares for a resident with the window shades up exposing private areas of a resident. During an interview on 11/15/24 at 1:45 pm, CNA C indicated she should have pulled the window shade down before she started to give cares and it was a dignity issue that she had not. During an interview on 11/15/24 at 2:59, the Administrator and Director of Nursing both concurred that window shades should be closed to maintain privacy when doing personal cares with a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was free from physical restraints (any manual method, physical or mechanical device that the individual cannot remove easily that restricts movement or normal access to one ' s body) when a staff member (unknown) put two pillows under Resident 1 ' s mattress which tilted the mattress up and prevented him from getting out of bed. This failure had the potential for Resident 1 to be unable to move freely increasing the risk for the decline of physical functioning, injury, and mental harm from being restricted to his bed. Findings: A review of the facilities policy titled Restraint Free Environment dated 11/2023, indicated that It is the policy of this facility that each resident shall attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience Falls do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraints. A review of Resident 1 ' s admission Record (undated), indicated Resident 1 was admitted on [DATE] with diagnoses that included Parkinson ' s disease (a movement disorder that may cause stiffness, slowing of movement and trouble with balance that raises the risk of falls), diabetes (high blood sugar levels), Chronic Obstructive Pulmonary Disease (lung disease), history of falling, difficulty in walking, and cognitive communication deficit. A review of Resident 1 ' s Quarterly Minimum Data Set (a complete clinical assessment) dated 10/2/24, indicated Resident 1 required supervision by staff when transferring in and out of the bed and the chair. Resident 1 was able to walk with supervision. Resident 1 ' s Brief Interview of Mental Status (BIMS, an evaluation of cognition [thinking, recalling, and making decisions]) indicated his cognition was moderately impaired. A review of Resident 1 ' s Fall Care plan dated 12/29/24, indicated an intervention to use the safest, least restrictive measures to prevent falls. An observation of Resident 1 ' s room on 11/15/24 at 9:55 am, displayed Resident 1 lying in bed with his wife ' s bed pushed up against the right side of Resident 1 ' s bed. The left side of Resident 1 ' s bed was observed as the only exit side of the bed for Resident 1. Two pillows were observed stuffed under the left side of the mattress (between the mattress and supporting frame) which created a tilt of the mattress forcing Resident 1 to roll toward the center of the bed and away from the exit (left) side of the bed. During a concurrent observation and interview with Certified Nursing Assistant (CNA) B on 11/15/24 at 10:00 am, Resident 1 ' s room and bed were observed. CNA B confirmed that there were pillows stuffed under his mattress and that Resident 1 was not able to remove them by himself. CNA B indicated she did not know why they were there, and they should be removed. Resident 1 was asked if he knew why there were pillows stuffed under his mattress and Resident 1 stated The night nurse put them there so I would not fall out of bed. They thought I was tending to roll out of bed. CNA B confirmed that this restricted his ability to get out of bed on his own and move freely in bed. During an interview with the Director of Nursing (DON) on 11/15/24 at 10:12 am, the DON indicated that the pillows were not supposed to be there and will be removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received assistance devices to prevent accidents for two of four sampled residents (Resident 1 and Resident 2) when: 1. Staff did not ensure that Resident 1 had his call light (a bedside button that directly signals the nursing staff when a resident required assistance) and a urinal (a plastic container that a resident can urinate in while in bed or next to the bed) within reach per his fall prevention care plan. 2. Staff did not ensure that Resident 2 had anti-rollback brakes (a device that attaches to a wheelchair and locks the wheels when a resident stands up, preventing the chair from rolling away from the resident) on her wheelchair per her fall prevention care plan. These failures had the potential to place Resident 1 and Resident 2 at risk for falls and possible injuries. Findings: A review of the facility ' s policy titled Falls/Accidents dated 11/2023, indicated The resident will remain as free from falls/accidents as is possible. The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. 1. Identification of Hazards and Risks, and 2. Evaluation and Analysis; and 3. Implementation of Interventions. 1. A review of Resident 1 ' s admission Record (undated), indicated Resident 1 was admitted on [DATE] with diagnoses that included Parkinson ' s disease (a movement disorder that may cause stiffness, slowing of movement and trouble with balance that raises the risk of falls), diabetes (high blood sugar levels), Chronic Obstructive Pulmonary Disease (lung disease), history of falling, difficulty in walking, and cognitive communication deficit. A review of Resident 1 ' s Quarterly Minimum Data Set (a complete clinical assessment) dated 10/2/24, indicated Resident 1 required supervision by staff when transferring in and out of the bed and the chair. Resident 1 was able to walk with supervision. Resident 1 ' s Brief Interview of Mental Status (BIMS, an evaluation of cognition [thinking, recalling, and making decisions]) indicated his cognition was moderately impaired. Section H indicated Resident 1 was frequently incontinent of urine. A review of Resident 1 ' s Fall Risk Evaluation dated 10/11/23, indicated Resident 1 was at high risk for falls. A review of Resident 1 ' s Progress Notes indicated Resident 1 had four falls since his 12/28/23 admission which were as follows: a. On 2/25/24 Resident 1 ' s nurses notes indicated Resident was found on the floor sitting and leaning against bed. Wife was standing next to him stating I was just trying to help him go to the bathroom. b. On 3/21/24 Resident 1 ' s alert charting indicated Around 10:40 am, this nurse heard yelling help help down the hallway, went to see who was calling out and found resident lying on the floor with protectors (large cushion boots, only to be worn in the bed, to protect feet from pressure injuries) on feet . Resident stated 'I was trying to walk to the closet to get a pair of pants, call light was not on.' c. On 8/21/24, Resident 1 ' s Interdisciplinary Team (IDT - group of health care disciplines that discuss resident care needs) note indicated that on 8/15/24 at 3:25 pm, CNA went to room for call light response and noted resident on the floor. He was wearing slippers. He said, ' I got up and went to the bathroom and came back and was just trying to tidy up some of the trash we had lying around and then I fell over. ' d. On 10/11/24, Resident 1 ' s nurses notes indicated He went to the bathroom by self and slipped on a wet floor that had water and urine on it. A review of Resident 1 ' s fall prevention care plan revised 10/31/24, indicated Resident 1 was at risk for falls due to having poor balance, unsteady gait and requiring assistive device for ambulation. Interventions included, but was not limited to, encourage resident to use call light for assistance, offer toileting to bathroom after meals and as needed, urinal within reach at all times. During an observation on 11/15/24 at 9:45 am, Resident 1 was observed in his room and lying in bed. Resident 1 ' s call light and walking cane were under his bed and out of his reach. There was no visible urinal next to his bed. During a concurrent observation and interview with Licensed Vocational Nurse A (LVN A) on 11/15/24 at 9:55 am, Resident 1 ' s room was observed. LVN A picked up the call light and walker from under the bed and placed them within Resident 1 ' s reach and stated, He throws things under the bed. LVN A was observed attempting to pin the call light onto Resident 1 ' s sheets but was unable to. LVN A indicated that the call light clip (a metal clip attached to the call light cord to allow call lights to be clipped onto the bedsheets and keep them within a resident ' s reach) was broken, and she would notify maintenance to get it fixed. LVN A indicated that the call light and his walking cane should be within reach and not be on the floor. During a concurrent observation and interview with Certified Nursing Assistant B (CNA B) on 11/15/24 at 2:33 pm, Resident 1 ' s room was observed. CNA B indicated that Resident 1 did not have a urinal and she had not remembered him using one. Resident 1 ' s call light was located under his covers and behind his back. CNA B attempted to clip the call light cord to the top of his bed covers but was unable to so she just laid the call light on top of the bedsheets. CNA B indicated the clip was broken. During a concurrent record review of Resident 1 ' s fall prevention care plans and interview with the Director of Nursing (DON) and Administrator on 11/15/24 at 2:59 pm, the DON confirmed that Resident 1 had not had a urinal at bedside but should have because it was on his care plan to have one within reach at all times. The DON confirmed that Resident 1 ' s call light clip was broken and needed to be fixed to keep the call light within his reach. 2. A review of Resident 2 ' s admission Record (undated), indicated Resident 2 was admitted on [DATE] then re-admitted on [DATE] after a short hospital stay from a fracture of the left leg due to a fall sustained in the facility. Resident 2 ' s diagnoses included, fracture of left femur (upper leg), need for assistance with personal cares, respiratory failure, depression, history of falling, dementia, and high blood pressure. A review of Resident 2 ' s admission MDS dated [DATE], indicated Resident 2 ' s BIMS score was 5 indicating she was severely cognitively impaired. Section GG indicated she required maximum assistance from staff with lying to sitting and sitting to standing. A review of Resident 2 ' s Fall Risk Evaluation dated 10/21/24, indicated Resident 2 was at high risk for falls. A review of Resident 2 ' s nurses progress notes dated 10/14/24, indicated Resident 2 attempted to stand unassisted from her wheelchair while wheelchair was unlocked. The wheelchair rolled backwards, and Resident 2 fell to ground. A review of Resident 2 ' s fall prevention care plan revised 10/23/24, indicated fall interventions included, but were not limited to, apply anti-roll back brakes to wheelchair. During an observation on 11/15/24 at 1:24 pm in Resident 2 ' s room, Resident 2 was sleeping in bed and there was a wheelchair next to her bed. The wheelchair did not have anti-roll back brakes on it. During a concurrent observation and interview with LVN A on 11/15/24 at 1:35 pm, Resident 2 ' s wheelchair was observed. LVN A confirmed Resident 2 ' s wheelchair did not have anti-roll back brakes attached to the wheelchair and they should be.

Based on observation and interview the facility failed to ensure one of three residents (Resident 1) was free from abuse when another resident (Resident 2) pushed him down. This failure resulted in a rib fracture of Resident 1. Findings: During a review of the facility ' s policy and procedure, Resident-To-Resident Altercations, revised 11/16, indicated that the facility acts promptly and conscientiously to prevent and address altercations between residents. The purpose of this policy is to protect the health and safety of residents by ensuring that altercations between residents are promptly reported, investigated, and addressed by the facility. During a review of the facility ' s policy, Resident [NAME] of Rights, California Code of Regulations Title 22, Section 72527, Skilled Nursing Facilities, no date noted, indicated that patients have the rights detailed in these sections and the facility will safeguard that these rights are not violated. Paragraph (10) states, patients shall have the right to be free from mental and physical abuse. A review of a facility reported incident to the California Department of Public Health, dated 06/03/24 at 8:09 am, indicated Resident 2 pushed Resident 1 when Resident 1 entered Resident 2 ' s room and began to flip the light switch on and off. The actions of Resident 2 resulted in Resident 1 acquiring a broken rib. During a review of Resident 1 ' s records, initial admit date was 10/26/2023, with diagnoses of Alzheimer ' s Disease, dementia- moderate with other behavioral disturbances, and insomnia. During a review of Minimum Data Sets (MDS- a standardized assessment and care screening tool for residents), on 06/19/24, at 1:09 pm, indicated that the Brief Interview for Mental Status (BIMS- test of mental capacity) score of Resident 1 on 05/02/24, was scored a 3, which is severe cognitive impairment. During a review of Resident 2 ' s records, his initial admit date was 12/02/2023, with diagnoses of dementia- unspecified severity with other behavioral disturbances, paranoid schizophrenia, and anxiety disorder. During a review of MDS on 06/19/24, at 1:09 pm, indicated the BIMS for Resident 2 on 03/07/24, was scored at a 7, which is severe cognitive impairment, and on 06/10/24, his BIMS was scored at a 12, which is moderate cognitive impairment. During a review of Resident 2 ' s Care Plan (CP) about Mood and Behavior, initiated on 12/07/23, indicated that Resident 2 had a history of kicking in doors and a history of resident-to-resident abuse. Resident to Resident Altercation #1: During a review of Interdisciplinary Team Note (IDT- a meeting that includes several departments to discuss care of residents), dated 12/26/23, at 12:1 pm, indicated on 12/25/23, around 4:00 pm, a loud noise was heard in the hallway. A Licensed Vocational Nurse (LVN) found a resident (Resident 4) on the floor, on his right side. Resident 4 stated that Resident 2 hit him. Resident 2 opened his door and stated Resident 4 hit him first on the lip. Resident 2 stated that Resident 4 had gained access to his room by way of a shared bathroom. When Resident 2 found Resident 4 in his room, he told him that that he was in the wrong room. Then resident 4 proceeded to hit Resident 2, and then Resident 2 pushed resident 4 out of his room, with Resident 4 being found on the floor. Resident to Resident Altercation #2: During a review of IDT Note, dated 01/03/24, at 11:37 am, indicated on 01/02/24, around 11:15 am, a Certified Nursing Assistant (CNA) heard a housekeeper say, No!. The CNA noticed that another resident (Resident 3) was backing out of Resident 2 ' s room, and both residents were throwing punches at each other. When asked about what had occurred, Resident 2 stated that Resident 3 was grabbing his belongings. Resident 2 stated he proceeded to grab Resident 3 by the back of the head and slammed his face into the door. Resident to Resident Altercation #3: During a review of IDT Note, dated 02/26/24, at 11:23 am, indicated on 02/24/24, around 5:00 am, Resident 2 came out of his room and stated his roommate was in his bed. Resident 2 stated that if they did not go in and take care of it, he was going to beat him the F up. The roommate was assisted out of the bed, and he went out to the nurses ' station. Resident 2 came out of his room a couple more times stating this was all BS. Just before 6:00AM, Resident 2 came out of his room, with his backpack on, and stated something about the FBI. Resident 2 proceeded down the hallway, with a CNA following him. Staff heard two loud bangs and Resident 2 had kicked the side door open. Resident to Resident Altercation #4: During an interview with Resident 2 on 06/19/24, at 11:28 am, he indicated that Resident 1 was in his closet. I was in bed and Resident 1 was turning my light on and off and was rummaging through my closet. I grabbed him by the t-shirt and pushed him through the door and he tripped over his feet. That didn ' t seem to do much to him at all. They claim he may have cracked a rib. I am up to my ears with this situation. I don ' t want people in my room; it upsets me. During an interview with Certified Nursing Assistant (CNA 1) on 06/19/24, at 11:22 am, who was doing 1:1 (provides direct supervision of resident) with Resident 1 and stated that he was curious about everything. CNA 1 stated Resident 1 will wander around the halls, confused, and tends to go into rooms; he was a busy man. During an interview with the Administrator (Admin) on 06/19/24, at 12:13 pm, Admin stated that Resident 1 was sent to the hospital after Resident 2 pushed him, which resulted in a fall. The facility was given a verbal report that Resident 1 had two broken ribs. The discharge papers from the hospital did not contain a record of rib x-rays, so the facility ordered in-house (performed in the facility) x-rays. These showed a new fracture at a rib and an old fracture at a rib. A review of the in-house x-ray findings report, dated 06/10/24, indicated a fracture of the sixth rib and an old fracture of the right ninth rib of Resident 1. During an interview with the Admin on 06/19/24, at 1:28 pm, she indicated that Resident 1 goes where he goes, and it can be into rooms. During an interview with Licensed Vocational Nurse (LVN A) on 06/19/24, at 1:40 pm, she indicated that Resident 1 wanders into rooms. During an interview with the Infection Preventionist (IP) on 06/19/24, at 1:43 pm, she indicated that Resident 1 tries to get into rooms, but we re-direct him. During an interview with the Director of Nursing (DON) on 06/19/24, at 1:50 pm, she indicated that Resident 1 wanders everywhere, including into rooms and he will open doors. During an interview on 06/19/24, at 2:00 pm, with CNA 2, stated she observed Resident 1 at Resident 2 ' s door and Resident 1 was closing the door. Resident 2 came to his door as Resident 1 was closing it and started yelling at Resident 1. Then Resident 2 pushed Resident 1 into the corner and Resident 1 fell. Resident 1 sustained a right broken rib. CNA 2 stated that Resident 2 gets upset easily. CNA 2 also stated that Resident 1 wanders up and down the hallways, and he loved to open doors and sometimes will go in the room once he opens the door. During an interview with CNA 3 on 06/19/24, at 2:25 pm, via a phone call, she stated that CNA 2 was keeping an eye on Resident 1. CNA 3 stated she only saw Resident 1 hit the wall and fall after Resident 2 pushed him; she heard Resident 2 cussing at Resident 1. CNA 3 stated that Resident 2 was an angry person. CNA 3 also stated the Resident 1 wanders the halls. He will go into peoples ' rooms, and that is the main thing he likes to do. During an interview on 06/26/24, at 4:43 pm, with Licensed Vocation Nurse (LVN B) stated that Resident 2 was territorial of his room. She states you never know when he is going to go off. CNA 3 stated that Resident 2 doesn ' t like loud noises. During an interview with LVN C on 06/26/24, at 4:54 pm, she stated that Resident 2 does not like anyone going into his room. She stated that Resident 2 knows how to follow the rules and he gets upset when other don ' t follow the rules; he will yell. During an interview with the Assistant Director of Nursing (ADON) on 06/26/24, at 5:03 pm, she stated that Resident 2 fights the demons in his head and doesn ' t always win and that he can be an angry person. During an observation on 06/26/24, at 5:15 pm, Resident 1 entered the room twice, where the ADON was being interviewed, and both the CNA and ADON redirected him each time. During an interview with CNA 4 on 06/26/24, at 5:29 pm, she stated that Resident 2 gets irritated with other residents and that he is territorial, and he yells a lot. During an observation on 06/26/24, at 5:45 pm, Resident 1 attempted to get into Resident 2 ' s room three times within 45 seconds, with two CNAs and the ADON attempting to redirect each time. Resident 1 was determined, grabbing the handle firmly, with one and then two hands, and trying to turn the handle to open the door each time. Resident 2 ' s door was shut, and a stop sign across the threshold. Resident 2 remained in his room. Resident 1 was on a 1:1 at the time. During a phone call on 07/09/24, at 12:20 pm, a family member of Resident 2 stated that Resident 2 is living 20 to 25 years ago, when his parents passed. When the family member was asked what Resident 2 ' s disposition was like prior to his mental decline, the family member stated that Resident 2 was, always confrontational and combative, always. He gave the example of their neighbor ' s dogs that would bark. Resident 2 would get into physical and verbal fights with the neighbors over their dogs barking and would threaten the neighbors. The family member also stated that Resident 2 got into no more than the normal amount of fights during high school.

Based on observation, interview, and record review, the facility failed to develop and implement a care plan for one of three residents (Resident 2) that would prevent altercations with other residents, thus hindering the delivery of individualized dementia care needs. These failures have resulted in multiple resident to resident altercations with injuries and places this resident at high risk of further harm to others and self. Findings: During a review of the facility ' s policy, Care Plans, Comprehensive Person-Centered, revised 03/2022, indicated that the IDT team develops and implements a comprehensive, person-centered care plan, and the interventions come from thorough analysis of information gathered as part of the comprehensive assessment of the resident. These interventions are chosen with consideration of the relationship between the resident ' s problem areas and the causes, in alignment with clinical decision making. During a review of the facility ' s policy, Resident [NAME] of Rights, Title 22, Chapter IV, Part 483- Requirements For States And Long Term Care Facilities, Subpart B-Requirements for Long Term Care Facilities, Section 483.10- Resident Rights, paragraph (e) Privacy and Confidentiality, no date noted, Paragraph (1) indicated that personal privacy includes accommodations. During a review of Resident 2 ' s records, his initial admit date was 12/02/2023, with diagnoses of dementia- unspecified severity with other behavioral disturbances, paranoid schizophrenia, and anxiety disorder. During a review of the Minimum Data Sets (MDS- a standardized assessment and care screening tool for residents), it indicated the BIMS for Resident 2 on 03/07/24, was scored at a 7, which is severe cognitive impairment, and on 06/10/24, his BIMS was scored at a 12, which is moderate cognitive impairment. During a review of Resident 2 ' s Care Plan (CP) about Mood and Behavior, initiated on 12/07/23, indicated that Resident 2 had a history of kicking in doors and a history of resident-to-resident abuse. Resident to Resident Altercation #1: During a review of Interdisciplinary Team Note (IDT- a meeting that includes several departments to discuss care of residents), dated 12/26/23, at 12:1 pm, indicated on 12/25/23, around 4:00 pm, a loud noise was heard in the hallway. A Licensed Vocational Nurse (LVN) found a resident (Resident 4) on the floor, on his right side. Resident 4 stated that Resident 2 hit him. Resident 2 opened his door and stated Resident 4 hit him first on the lip. Resident 2 stated that Resident 4 had gained access to his room by way of a shared bathroom. When Resident 2 found Resident 4 in his room, he told him that that he was in the wrong room. Then resident 4 proceeded to hit Resident 2, and then Resident 2 pushed resident 4 out of his room, with Resident 4 being found on the floor. During review of Interdisciplinary Team Notes (IDT, team of various staff to evaluate and develop resident plan of care) Notes, dated 12/26/23 at 12:13 pm, indicated Resident 2 was to be moved into a new room, nursing was to do alert charting (charting during all shifts that keeps track- mentally, physically, emotionally- of a resident after an incident), and a follow up with a psychologist for medication management. Nurses Note dated 12/26/23 at 1:30 pm, indicated that Resident 2 was on alert charting for the incident and was adjusting well to his new room, and a Nurses Note dated 12/28/23 at 9:22 am, indicated that the Medical Doctor (MD) reviewed the psychiatrist notes and no new orders given. Resident to Resident Altercation #2: During a review of IDT Note, dated 01/03/24, at 11:37 am, indicated on 01/02/24, around 11:15 am, a Certified Nursing Assistant (CNA) heard a housekeeper say, No!. The CNA noticed that another resident (Resident 3) was backing out of Resident 2 ' s room, and both residents were throwing punches at each other. When asked about what had occurred, Resident 2 stated that Resident 3 was grabbing his belongings. Resident 2 stated he proceeded to grab Resident 3 by the back of the head and slammed his face into the door. During review of IDT Notes, dated 01/03/24 at 11:37 am, indicated that staff was to attempt to keep these residents apart while in the common area, STOP sign on the door of Resident 2 to attempt to keep other resident out of his room, and a follow up with a psychologist. Nurses Note, dated 01/01/24 at 1:15, indicated the nursing staff received orders to increase a behavior modification medication for Resident 2. On 01/02/24 at 4:01 pm, a Nurses Note indicated that Resident 2 was given orders for as needed anxiety medication. Resident to Resident Altercation #3: During a review of IDT Note, dated 02/26/24, at 11:23 am, indicated on 02/24/24, around 5:00 am, Resident 2 came out of his room and stated his roommate was in his bed. Resident 2 stated that if they did not go in and take care of it, he was going to beat him the F up. The roommate was assisted out of the bed, and he went out to the nurses ' station. Resident 2 came out of his room a couple more times stating this was all BS. Just before 6:00AM, Resident 2 came out of his room, with his backpack on, and stated something about the FBI. Resident 2 proceeded down the hallway, with a CNA following him. Staff heard two loud bangs and Resident 2 had kicked the side door open. During review of IDT Notes, dated 02/26/24 at 11:23 am, indicated Resident 2 was moved into a new room with a new roommate, was referred to a psychologist, Responsible Party (RP) inquired about an inpatient behavioral health program, use of distraction (model airplane, model car, sketchpad, pencils, paper), attempt to redirect, and attempt to prevent triggers via room change and evaluation from psychologist. Nurses Note, dated 02/27/24 at 12:56, indicated resident was moved into a new private room and at 5:46 pm, nursing staff received orders to increase the behavior modification medication, with a blood draw and an analysis of urine. Nurses Note, dated 03/07/24 at 7:30, indicated that Resident 2 left for an inpatient stay at a behavioral health program. Resident to Resident Altercation #4: During an interview with Resident 2 on 06/19/24, at 11:28 am, he indicated that Resident 1 was in his closet. I was in bed and Resident 1 was turning my light on and off and was rummaging through my closet. I grabbed him by the t-shirt and pushed him through the door and he tripped over his feet. That didn ' t seem to do much to him at all. They claim he may have cracked a rib. I am up to my ears with this situation. I don ' t want people in my room; it upsets me. During a review of Resident 2 ' s Care Plan regarding mood and behavior problems, indicated that most interventions, except for one, were not recently updated: Administer medications as ordered. Initiated 12/07/23. Hall monitor to deter other resident from entering room. Revised 02/07/24. If/when having aggressive outbursts: provide redirection, monitor pain, toilet, offer snack/drink, Outdoor patio, tv. Resident enjoys doing projects in his room. Offer drawing supplies, model airplanes to put together, puzzles, etc. Revised 02/14/24. If/when having anxious statements of feeling trapped: offer outdoor patio, offer a snack, offer music. Revised 04/04/24. If/when having auditory hallucinations: approach in a calm, reassuring manner, provide orientation to reality, offer distraction techniques, diversional activities for distraction. Date initiated 01/17/24. If/when resident removes stop sign from door educate resident on the reasoning for the need of the stop sign and encourage to leave it on the door. Initiated 06/19/24. Keep resident comfortable and pain management controlled. Initiated 03/08/24.There was no documentation found in the IDT notes or care plans that address the issues Resident 1 and direct care staff have communicated that he does not like others in his room. During an interview on 06/19/24, at 2:00 pm, with CNA 2, stated she observed Resident 1 at Resident 2 ' s door and Resident 1 was closing the door. Resident 2 came to his door as Resident 1 was closing it and started yelling at Resident 1. Then Resident 2 pushed Resident 1 into the corner and Resident 1 fell. Resident 1 sustained a right broken rib. CNA 2 stated that Resident 2 gets upset easily. CNA 2 also stated that Resident 1 wanders up and down the hallways, and he loved to open doors and sometimes will go in the room once he opens the door. During an interview with CNA 3 on 06/19/24, at 2:25 pm, via a phone call, she stated that CNA 2 was keeping an eye on Resident 1. CNA 3 stated she only saw Resident 1 hit the wall and fall after Resident 2 pushed him; she heard Resident 2 cussing at Resident 1. CNA 3 stated that Resident 2 was an angry person. CNA 3 also stated the Resident 1 wanders the halls. He will go into peoples ' rooms, and that is the main thing he likes to do. During an interview on 06/26/24, at 4:43 pm, with Licensed Vocation Nurse (LVN B) stated that Resident 2 was territorial of his room. She states you never know when he is going to go off. CNA 3 stated that Resident 2 doesn ' t like loud noises. During an interview with LVN C on 06/26/24, at 4:54 pm, she stated that Resident 2 does not like anyone going into his room. She stated that Resident 2 knows how to follow the rules and he gets upset when other don ' t follow the rules; he will yell. During an interview with the Assistant Director of Nursing (ADON) on 06/26/24, at 5:03 pm, she stated that Resident 2 fights the demons in his head and doesn ' t always win and that he can be an angry person. During an observation on 06/26/24, at 5:15 pm, Resident 1 entered the room twice, where the ADON was being interviewed, and both the CNA and ADON redirected him each time. During an interview with CNA 4 on 06/26/24, at 5:29 pm, she stated that Resident 2 gets irritated with other residents and that he is territorial, and he yells a lot. During an observation on 06/26/24, at 5:45 pm, Resident 1 attempted to get into Resident 2 ' s room three times within 45 seconds, with two CNAs and the ADON attempting to redirect each time. Resident 1 was determined, grabbing the handle firmly, with one and then two hands, and trying to turn the handle to open the door each time. Resident 2 ' s door was shut, and a stop sign across the threshold. Resident 2 remained in his room. Resident 1 was on a 1:1 at the time. During a phone call on 07/09/24, at 12:20 pm, a family member of Resident 2 stated that Resident 2 is living 20 to 25 years ago, when his parents passed. When the family member was asked what Resident 2 ' s disposition was like prior to his mental decline, the family member stated that Resident 2 was, always confrontational and combative, always. He gave the example of their neighbor ' s dogs that would bark. Resident 2 would get into physical and verbal fights with the neighbors over their dogs barking and would threaten the neighbors. The family member also stated that Resident 2 got into no more than the normal amount of fights during high school. During an interview with the Admin on 07/26/24, at 11:47 am, stated that before the inpatient stay at a behavioral health facility, resident was involved in several altercations, but since the inpatient program he has had fewer altercations. A new intervention is implemented each time an incident happens. We have considered moving the resident off the unit, but we are concerned about him going out of the facility and not being able to get him back in. During an interview with the DON on 07/26/24, at 12:10 pm, stated, like the Admin stated, before the inpatient stay, the resident had lots of issues but since the stay he has had one incident. The care plans seem to be doing well, and we have had to add interventions as needed.

Based on interviews, record reviews, and facility policy review, the facility failed to refer 2 (Resident #40 and Resident #55) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR) when the resident received a new mental illness diagnosis. Findings included: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, implemented on 07/23/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder [MD], intellectual disability [ID], or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASARR evaluation and determination. Review of Resident #40's admission Record revealed the facility admitted the resident on 02/02/2022. Per the admission Record, on 02/17/2022, the resident received a diagnosis of post-traumatic stress disorder, on 03/18/2022, a diagnosis of anxiety disorder, and on 09/26/2023, a diagnosis of depression. Review of Resident #40's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had active diagnoses to include anxiety disorder and post-traumatic stress disorder. Review of Resident #55's admission Record revealed the facility admitted the resident on 06/24/2019. Pe the admission Record, the resident received a diagnosis of generalized anxiety disorder on 04/07/2022. Review of Resident #55's quarterly MDS, with an ARD of 06/17/2022, revealed Resident #55 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had active diagnoses to include anxiety disorder, depression, and psychotic disorder. During an interview on 01/23/2024 at 9:50 AM, the MDS Director, stated a new PASARR screen was not completed for Resident #40 or Resident #55 when the residents received new mental health diagnoses. The MDS Director stated she thought a new PASSAR was only required if the resident had behaviors or symptoms after receiving a new mental health diagnosis. During an interview on 01/23/2024 at 10:59 AM, the Administrator stated she did not think that a new mental illness diagnosis would require a new PASSAR to be completed. During an interview on 01/23/2024 at 11:17 AM, the Director of Nursing stated she did not do PASSARs, but she expected the policy to be followed.

Based on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the preadmission screening and resident review (PASARR) level I screening for 1 (Resident #77) of 4 sampled residents reviewed for PASARR. Findings included: Review of the facility policy titled, Resident Assessment-Coordination with PASARR Program, implemented on 07/23/2023, revealed, This facility coordinates assessments with the preadmission screening and resident review program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. A review of Resident #77's admission Record revealed the facility admitted the resident on 12/09/2023, with diagnoses that included bipolar disorder, major depressive disorder, and anxiety disorder. A review of Resident #77's Preadmission Screening and Resident Review Level I Screening, dated12/08/2023, revealed the resident did not have a serious diagnosed mental disorder such as depression disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, ad/or mood disturbance. A review of Resident #77's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/13/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS revealed the resident had active diagnoses to include anxiety disorder, depression, and bipolar disorder. A review of Resident #77's Order Summary Report, with active orders as of 01/23/2024, revealed an order dated 12/30/2023, for olanzapine (an antipsychotic medication) oral tablet 10 milligram (mg), give one tablet by mouth at bedtime for bipolar disorder and nortriptyline oral capsule 25 mg, give one capsule by mouth at bedtime for depression. During an interview on 01/23/2024 at 9:50 AM, the MDS Director indicated she was responsible for completing the PASARRs. When she would get the initial packet from the hospital, she would look through it and see if there were any mental diagnoses for the resident and add them to the Level I. Sometimes The MDS Director confirmed Resident #77's PASARR level I screening was inaccurate. Per the MDS Director, a level II examination should have been done for Resident #77. During an interview on 01/23/2024 at 11:00 AM, the Administrator stated Resident #77's mental illness diagnoses should have been included on the resident's PASARR level I screening. During an interview on 01/23/2024 at 11:17 AM, the Director of Nursing (DON) stated she did not do anything specific with the PASARRs, but indicated the PASARR was important to see what other services may be available for the resident. The DON stated her expectation was during the admission process, staff would make sure the documentation was correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan was developed and implemented, for one of 21 residents (Resident 139), when the nutrition care plan was not updated to include a nutritional supplement, and adequate monitoring of that supplement. This failure had the potential to result in a decline in Resident 139's condition, including unintended weight loss, which could lead to negative clinical outcomes. Findings: Resident 139's medical record was reviewed. Resident 139 was admitted on [DATE], with diagnoses that included protein calorie malnutrition and dementia (degenerative disorder of the brain). Resident 139's admission weight was 95-pounds. The Diet Requisition, dated 7/10/21, included healthshakes with meals, three times per day. The care plan included, Diet as ordered, and Monitor meal consumption, but had not been updated to reflect the healthshake, and monitoring of the amount of healthshake consumed. During an observation, on 7/12/21 at 2:55 pm, Resident 139 had a healthshake (nutritional supplement) on her bedside table that had not been touched by the resident. Resident 139 reported that she didn't like the healthshake, but would be willing to try a different flavor. On 7/13/21 at 9:51 am, Resident 139 had a healthshake sitting on her bedside table and none of it had been consumed. Resident 139 again reported that she did not like it, but would be willing to try a different flavor. At 10:20 am, the healthshake was still untouched on her bedside table. At 12 pm, Resident 139 had received her lunch and another healthshake was on her lunch tray. Resident 139's lunch tray was taken away at 1:04 pm, along with the untouched healthshake. During an interview, on 7/14/21 at 8:55 am, the Registered Dietitian (RD) reported, that as of this time, the percentage of supplements consumed by the residents was not being documented when the supplements were given with the meal trays. She said she had first contacted corporate, in March, to see how it could be done, but they had not come back with a response. She said she requested more information in June. The RD said if it was documented, then she could tell if the resident was drinking it, or not, and if it needed to be changed to another supplement. During a concurrent interview, and record review, on 7/14/21 at 9:43 am, the Director of Staff Development (DSD) and Director of Nursing, reviewed Resident 139's medical record, and reviewed the percentage of meal intake for today and yesterday. She said the supplement consumption was included with the meal intake. The DSD could not say how much of the supplement had been consumed, if any, since it was included with the meal and not separated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure that outdated medication were removed from the medication cart, and disposed of per manufacturer's guidelines for one of eight sampled residents (Resident 11). This failure caused this resident to receive outdated medication for seven days, which had the potential to cause infection, or for the medication to longer be effective. Findings: The facility's policy and procedure titled, Medication Storage in the Facility, dated [DATE], was reviewed, and indicated that no expired medication are to be administered to a resident. Resident 11's medical record was reviewed. Resident 11 was admitted to this facility on [DATE], with diagnosis that included dementia (a degenerative brain disorder), and glaucoma (increased pressure in eyes). During a concurrent observation, interview, and record review, on [DATE] at 9 am, with Licensed Nurse (LN) 3, Latanoprost solution 0.005% eye drops (medication to control pressure in the eyes) was observed open in the medication cart for dispensation for Resident 11, with an expiration date of [DATE]. Resident 11's Medication Administration Record (MAR), dated July, 2021 was reviewed. The MAR indicated, that at 8 PM on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], that Resident 11 had received the expired eye drops administered into both eyes. LN 3 confirmed the expiration date on the Latanoprost eye drops, and that there were no other eyes drops available in the cart.

Based on observation, interview, and record review, the facility failed to ensure one of 21 residents (Resident 20) was provided the specialized cup for meals, as ordered by his physician. This failure had the potential to result in swallowing difficulties which could cause aspiration (when liquids enter the airway), which could lead to negative clinical outcomes. Findings: Resident 20's medical record was reviewed. Resident 20 was readmitted to this facility on 6/17/21, with diagnoses that included obstructive uropathy (condition in which the flow of urine is blocked), heart disease, and dysphagia (difficulty swallowing). Resident 20's record contained a recommendation from the Speech Therapist (ST) on 6/21/21, to place Resident 20's food in bowls with a small spoon, and nectar thick liquids in a nosey cup (an adaptive drinking cup with a U-shaped cut-out on one side which provides space for the nose, allowing the user to tilt the cup for drinking without bending the neck or tilting the head) for all meals. This recommendation was signed by the physician as an order. Resident 20's care plan for nutrition included the nosey cup. On 7/13/21 at 7:34 am, a Certified Nursing Assistant (CNA) was observed with Resident 20 and was supervising him as he fed himself. The breakfast tray was on his bedside table, and included a small spoon but no nosey cup. All liquids were in regular glasses. The tray card (specified the type and texture of diet and any specialized equipment) which included the nosey cup. On 7/13/21 a CNA was observed entering Resident 20's room at 1:10 pm, and helped Resident 20 with his lunch. At 1:13 pm the Registered Dietitian (RD) was asked if Resident 20 had a nosey cup as ordered. RD said, no those are not nosey cups, I'll go get one and left to go to kitchen and returned with a couple of nosey cups. During an interview, on 7/14/21 at 11 am, The ST said the small spoon and nosey cup was to help Resident 20 slow down his eating and prevent swallowing problems. He said, with the nosey cup the resident doesn't have to tilt his head back all the way when he drinks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview, the facility failed to ensure that the resident environment remained free of accident hazards when the bathroom hot water temperature for numerous residents exceeded 120° degrees Fahrenheit (°F). This failure had the potential to result in burns for residents who had access to this hot water source, which could lead to pain, and negative clinical outcomes. Findings: The interpretive guidelines provided by the Centers for Medicare and Medicaid Services (CMS) indicated: Water may reach hazardous temperatures in hand sinks, showers, tubs, and any other source or location where hot water is accessible to a resident. Burns related to hot water/liquids may also be due to spills and/or immersion. Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. The degree of injury depends on factors including the water temperature, the amount of skin exposed, and the duration of exposure. A third degree thermal burn may occur after: 1 minute of exposure to 127°F water, 3 minutes of exposure to 124°F water, and 5 minutes of exposure to 120°F water. During observations, on 7/14/21 at 10:37 am, the hot water temperature was 125.5°F in the bathroom shared by residents in room [ROOM NUMBER], and 205. The residents in room [ROOM NUMBER] were mobile in their wheelchairs, and used their bathroom. Additional random hot water temperatures on this hall were checked and were noted to be: 126.2°F at 10:40 am in the bathroom shared by the residents in rooms [ROOM NUMBERS]; 124.6°F in room [ROOM NUMBER] at 10:45 am; 126°F in room [ROOM NUMBER] at 10:51 am; 126°F in room [ROOM NUMBER] at 11:09 am; 126°F in room [ROOM NUMBER] and 123°F in room [ROOM NUMBER] at 11:15 am. Random hot water temperatures in resident bathrooms, in the locked Alzheimer's unit, were checked at 11 am and were: room [ROOM NUMBER] was 129.6°F, room [ROOM NUMBER] was 123.8°F; room [ROOM NUMBER] was 123°F, room [ROOM NUMBER] was 124°F, and room [ROOM NUMBER] was 129°F. During an interview, on 7/12/21 at 11:02 am, Certified Nursing Assistant (CNA) 2 confirmed, that the residents in room [ROOM NUMBER] do use the bathroom, and would use the sink to wash their hands. During an interview, on 7/12/21 at 11:09 am, Resident 3 in room [ROOM NUMBER]A, reported that she uses the bathroom and washes her hands in the sink. During an interview, on 7/12/21 at 11:15 am, Resident 30 in room [ROOM NUMBER], reported that she uses the bathroom and washes her hands in the sink. During a concurrent observation, and interview, on 7/12/21 at 11:42 am, the Plant Maintenance Director (PM) checked the bathroom water temperature for the bathroom shared by the residents in rooms [ROOM NUMBERS], with his thermometer, and it showed 124°F. The surveyor's thermometer indicated the temperature was 124.7°F. The PM reported that he tries to keep the temperature between 104°F and 116°F. He checked the nursing station water temp and it was 122°F. He said he will turn down the water temperature, and will recheck the water temperatures. The PM said he usually takes random water temperatures on Tuesdays. During an interview, on 7/12/21 at 11:55 am, the Administrator in training (AIT) stated they had no policy on water temperatures monitoring, but they do comply with all state and federal regulations. The AIT said they have told the CNAs to make sure the water is not too hot, and the PM was currently fixing the problem. During a subsequent interview, on 7/12/21 at 4:30 pm, the PM said the hot water heater had been set at a temperature of 125°F. He said he turned it down, and rechecked temperatures in rooms around the facility and they were all at 116°F and below, this was verified by the survey team as well.

Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff were properly trained, and educated on hand hygiene during medication administration for four of eight sampled residents (Residents 68, 27, 33, and 26). This failure had the potential for residents to be at risk for cross contamination from dirty contaminated hands during medication pass, which could lead to negative clinical outcomes. Findings: The facility's policy and procedure titled, Specific Medication Administration Procedures, dated 3/4/14, was reviewed, and indicated that staff are to cleanse their hands using an antimicrobial soap and water, or facility approved hand sanitizer before having any contact with the residents. The facility's policy titled, Handwashing/Hand Hygiene, dated 2/28/17, was reviewed, and indicated that staff are to cleanse their hands using an antimicrobial soap and water, or facility approved hand sanitizer before and after direct resident care contact. Resident 68's medical record was reviewed. Resident 68 was admitted to this facility on 9/4/20, with diagnosis that included dementia (degenerative disorder of the brain), muscle weakness, and high blood pressure. Resident 27's medical record was reviewed. Resident 27 was admitted to this facility on 10/19/16, with diagnosis that included diabetes, dementia, and difficulty walking. Resident 33's medical record was reviewed. Resident 33 was admitted to this facility on 8/23/19, with diagnosis that included high blood pressure, diabetes, and muscle weakness. Resident 26's medical record was reviewed. Resident 26 was admitted to this facility on 10/16/19, with diagnosis that included dementia (memory loss), muscle weakness, and failure to thrive. During a concurrent observation, and interview, on 7/13/21 at 8 am, with Licensed Nurse (LN) 1, medication administration was observed for Residents 33 and 27. LN 1 did not perform hand hygiene prior to administering medication. LN 1 stated, I forgot to wash my hands prior to giving the medications. During a concurrent observation, and interview, on 7/13/21 at 8:20 am, with LN 3, medication administration was observed for Residents 68 and 26. LN 3 did not perform hand hygiene prior to administering medication. LN 3 stated, I did not realize that I was supposed to wash my hands before I administer the medication to the residents. During a concurrent interview, and record review, on 7/13/21 at 10:30 am, with the Director of Nursing, the facility policy titled, Specific Medication Administration Procedures, dated 3/4/14, and Handwashing/Hand Hygiene, dated 2/28/17 were reviewed. The DON confirmed that hand hygiene is expected to be performed prior to preparation of medications, and again prior to administration, and once again following the administration.

Based on observation, interview, and document review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food services when several resident trays and plate covers were not allowed to dry fully before being stacked. This failure had the potential to result in bacteria growth and cause foodborne illness to residents who received food from these items. Findings: According to the Federal Food Code 2017, Section 4.901.11, after cleaning and sanitizing, equipment and utensils shall be air dried. During an observation, in the kitchen with the Registered Dietitian (RD), on 7/14/21 at 8:15 am, the Dietary Aide (DA) took several trays off the drying rack, and stacked them on a cart while they were still wet. She then took several plate covers off the drying rack and stacked them on a cart while they were still wet. The RD left and spoke with the Dietary Supervisor for a brief moment then returned. The RD confirmed that the items should have been completely dry before being stacked, and said all those items would be rewashed. On 7/15/21 at 9:48 am, the RD was asked to provide the training that had been given to DA regarding drying of dishes. The RD provided an inservice which had been provided to dietary staff including DA. The RD pointed out the following on the second page of the inservice: Allow all dishes to air-dry in racks before stacking and storing.