Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 3 errors out of 43 opportunities, which resulted in a medication error rate of 6.98 % for 2 (Resident #2 and Resident #4) of 5 residents observed during medication administration. Findings included: A facility policy titled, Administration Procedures For All Medications, dated 05/2022, indicated, C. Review 5 Rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR [medication administration record/treatment administration record] for order. b. Note any allergies or contraindications the resident may have prior to drug administration. c. If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. d. Check for vital signs, other tests to be done during/prior to medication administration. e. Prepare resident for medication administration. 2) Prior to removing the medication from the container a. Check the label against the order on the MAR. b. Note any supplemental labeling that applies (fractional tablet, multiple tablets, volume of liquid, shake well, give with another medication, etc. [et cetera, and other similar things]). 1. An admission Record indicated the facility admitted Resident #2 on 10/10/2008. According to the admission Record, the resident had a medical history that included diagnoses of heart failure, atherosclerotic heart disease, and constipation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #2's Order Summary Report, reflecting active orders as of 04/09/2025, contained an order dated 10/30/2015 for aspirin 81 milligram (mg), give two tablets by mouth one time a day for coronary atherosclerosis. The Order Summary report also contained an order dated 05/04/2023 for sennosides-docusate sodium 8.6-50 mg, give two tablets by mouth one time a day for bowel care, with instructions to hold for loose stools. Resident #2's 04/2025 MAR revealed the resident's aspirin and sennosides-docusate sodium were scheduled for administration at 8:00 AM each day. An observation of medication administration on 04/09/2025 at 7:05 AM, revealed Registered Nurse (RN) #3 administered one aspirin 81 mg tablet and one sennosides-docusate sodium 8.6-50 mg tablet to Resident #2, instead of two of each tablet as ordered. During an interview on 04/10/2025 at 2:28 PM, RN #3 stated he had been trained and was expected to follow physician orders. During an interview on 04/10/2025 at 4:18 PM, the Director of Nursing (DON) stated staff were trained to verify the dose and the order for the number of tablets to be administered. The DON stated staff were expected to administer medications by using the seven rights of medication administration (right patient, right medication, right dose, right route, right time, right documentation, and right response). During an interview on 04/10/2025 at 4:49 PM, the Administrator stated staff were trained and expected to administer the right medications and doses using the seven rights of medication administration. 2. An admission Record indicated the facility admitted Resident #4 on 07/31/2023. According to the admission Record, the resident had a medical history that included diagnoses of aftercare following joint replacement surgery and unilateral primary osteoarthritis, left hip. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #4's Order Summary Report, reflecting active orders as of 04/09/2025, contained an order dated 03/21/2025 for Bengay greaseless cream 10-15%, apply topically four times a day for arthritis pain management to bilateral knees and bilateral hands. An observation of medication administration on 04/09/2025 at 7:34 AM, revealed Registered Nurse (RN) #4 applied Resident #4's Bengay greaseless cream to the resident's bilateral knees but not their bilateral hands. During an interview on 04/09/2025 at 1:23 PM, RN #4 stated she should have applied the Bengay cream to the resident's hands as well, but it was an oversight. She stated she was expected to administer medications as ordered. During an interview on 04/10/2025 at 4:18 PM, the Director of Nursing (DON) stated staff were expected to administer medications by using the seven rights of medication administration (right patient, right medication, right dose, right route, right time, right documentation, and right response). During an interview on 04/10/2025 at 4:49 PM, the Administrator stated staff were trained and expected to administer the right medications and doses using the seven rights of medication administration.

Based on interview, record review, and facility document and policy review, the facility failed to ensure medication administration records accurately reflected the medications administered for 1 (Resident #27) of 5 residents reviewed for unnecessary medications. In addition, the facility failed to ensure medication orders were correctly transcribed into the electronic health record (EHR) for 1 (Resident #2) of 5 residents observed during medication administration. Findings included: 1. A facility policy titled, Administration Procedures for All Medications dated 05/2022, revealed, J. After administration, return to the cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR [Medication Administration Record] or TAR [Treatment Administration Record]. An admission Record revealed the facility admitted Resident #27 on 01/17/2025. According to the admission Record, the resident had a medical history that included diagnoses of gout and chronic kidney disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2025, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #27's Order Summary Report, reflecting active orders as of 04/10/2025, contained the following orders: - an order dated 03/30/2025 for ascorbic acid 1000 milligrams (mg) by mouth twice a day for supplement; - an order dated 03/30/2025 for Eliquis 5 mg by mouth two times a day for anticoagulant; - an order dated 03/30/2025 for potassium chloride extended release 20 milliequivalents (mEq) two times a day for hypokalemia (low potassium levels); - an order dated 03/30/2025 for Senna, two tablets by mouth two times a day for routine bowel care; - an order dated 03/24/2025 for ciclopirox external gel 0.77 percent (%), apply to bilateral toenails topically at bedtime for yellow, brittle, thickened, fungal toenails; and - an order dated 03/09/2025 for nystatin cream 100000 units per gram, apply to groin/ pannus topically every shift for redness. Resident #27's 04/2025 TAR revealed no documentation of the administration of the resident's ciclopirox external gel on 04/02/2025 and 04/03/2025 at 8:00 PM or the resident's nystatin cream on 04/02/2025 or 04/03/2025 for the NOC 1 (evening) doses. Resident #27's 04/2025 MAR revealed no documentation of the administration of the resident's ascorbic acid, Eliquis, potassium chloride extended release, or Senna tablets on 04/05/2025 at 4:00 PM. During an interview on 04/09/2025 at 1:41 PM, Resident #27 stated they had not missed any doses of their medications while at the facility. Resident #27 stated that on 04/02/2025 and 04/03/2025, they received their medications and treatments as ordered. Resident #27 further stated that on 04/05/2025, they left the facility for a memorial service but received their medication after returning to the nursing facility the same day. During an on 04/10/2025 at 12:46 PM, the Director of Nursing (DON) stated Licensed Vocational Nurse (LVN) #1 was the nurse assigned to Resident #27 on 04/02/2025 and 04/03/2025. The DON stated she expected nurses to document the administration of medications or treatments on the MAR or TAR. During an interview on 04/10/2025 at 3:44 PM, LVN #1 stated he struggled to sign off on the MAR because he would get busy and forget to sign off that the medication was administered. He stated Resident #27 had received all their medications, but he had not documented it on the MAR. During an interview on 04/10/2025 at 2:32 PM, LVN #2 stated he was the nurse assigned to Resident #27 on 04/05/2025. LVN #2 stated the resident went to a memorial service and returned to the facility the same day. LVN #2 stated he administered the resident's medications when they returned to the facility but did not document the administration on the resident's MAR. During an interview on 04/10/2025 at 2:19 PM, the Administrator stated nurses should document on the MAR when medications were administered. 2. An admission Record revealed the facility admitted Resident #2 on 10/10/2008. According to the admission Record, the resident had a medical history that included a diagnosis of heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A handwritten physician's order for Resident #2, dated 03/23/2025, specified an order for Bumex (a diuretic medication) 0.5 milligrams (mg) in the morning and 0.25 mg at 1:00 PM, with instructions to hold the Bumex for a systolic blood pressure reading less than (<) 110 millimeters of mercury (mmHg). Resident #2's Order Summary Report, reflecting active orders as of 04/09/2025, revealed the order for Bumex was transcribed into the EHR as two separate orders. The orders, dated 03/24/2025, specified Bumex 0.25 mg was to be given once a day and held for a systolic blood pressure < 110 mmHg; however, the order for Bumex 0.5 mg once a day was transcribed with instructions to hold for a systolic blood pressure greater than (>) 110 mmHg. An Orders note, effective 03/24/2025, revealed Licensed Vocational Nurse (LVN) #2 transcribed Resident #2's Bumex orders into the resident's EHR. During an interview on 04/10/2025 at 2:33 PM, LVN #2 stated that when he received a new order, he read it and entered it into the EHR. LVN #2 stated that Resident #2's order with parameters to hold the medication for a systolic blood pressure > 110 mmHg was a mistake. LVN #2 stated he had received education regarding transcribing physician's orders, and he was expected to transcribe physician's orders correctly. During an interview on 04/09/2025 at 4:36 PM, the Medical Director stated the staff were to hold Resident #2's Bumex if the resident's systolic blood pressure was < 110 mmHg. The Medical Director stated she thought the order was a typo, and the nursing staff should know not to hold the Bumex for a systolic blood pressure > 110 mmHg, as that would never be appropriate. During an interview on 04/10/2025 at 2:19 PM, the Administrator stated staff were trained and expected to transcribe physician's orders correctly.

Based on interview and record review, the facility failed to ensure its policy and procedure on abuse prevention indicated required time frames for reporting allegations of abuse, neglect, misappropriation of resident property, or exploitation to the Department, as well as the need to submit the facility's investigative report of such allegations to the Department, and the required time frame to do so. These failures had the potential for untimely reporting of abuse, neglect, misappropriation of resident property, or exploitation to the Department and failure to submit the respective investigative reports to the Department, thereby hindering the Department's investigation of the allegations. Findings: A review of facility policy and procedure titled Abuse: Prevention of and Prohibition Against, revised 01/2021, under section titled REPORTING/RESPONSE, indicated: Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported . to the appropriate State and Federal agencies in the applicable timeframes . and A summary of investigative findings will be reported to the Quality Assessment and Assurance (QAA) Committee for coordination with Quality Assurance and Performance Improvement (QAPI) program. The policy did not indicate that allegations of abuse should be reported to the Department within 2 hours and a summary of the investigative findings should be submitted the Department, and done so within 5 days of the allegation. During an interview on 3/23/23, at 10:49 a.m., the facility's Abuse Prevention Coordinator (APC) confirmed the policy titled Abuse: Prevention of and Prohibition Against, revised 01/2021, was the facility's policy on abuse prevention and that it lacked the time frames for reporting abuse allegations and submission of the facility's investigative report to the Department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to hold quarterly care conferences for one of three residents (Resident 16). This failure prevented Resident 16's Responsible Party to be involved in Resident 16's care plans. Findings: A review of Resident 16's facesheet indicated he was admitted to the facility on [DATE] and had a Responsible Party (RP) (a person responsible for making healthcare decisions on behalf of the resident). During an interview on 3/21/23, at 10:50 a.m., Resident 16's RP stated she had not been invited to attend care conferences for Resident 16. Resident 16's RP stated she would like to participate in Resident 16 care conferences. During an interview on 3/24/23, at 9:35 a.m., the Director of Nursing (DON) stated the facility's policy was to have resident care conferences upon admission and quarterly thereafter or upon a change in condition. The DON stated the resident, or their responsible party, were invited to participate in the care conferences. During a concurrent record review, the DON reviewed Resident 16's record and stated the last care conference for Resident 16 was held on 8/23/22. The DON confirmed Resident 16 had not had a care conference in seven months and should have had one during the interim. A review of facility policy and procedure titled Care Plans, Comprehensive Person-Centered, Revised December 2016, indicated care planning conferences are held at least quarterly and the residents or their responsible parties are invited to attend.

**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 12) who signed arbitration agreements understood the agreement when Resident 12 was cognitively impaired when he signed the agreement. This failure resulted in Resident 12 agreeing to something he did not understand. Findings: During an interview and record review on 3/22/23, at 10:05 a.m., the Business Office Manager (BOM) stated she was responsible for offering and explaining the facility's arbitration agreement to residents. The BOM stated residents were offered arbitration agreements during the admission process. The BOM stated Resident 12 had signed an arbitration agreement upon admission and provided the agreement. A review of the agreement indicated it was signed by Resident 12 himself on 10/27/22, which was confirmed by the BOM. During an observation and interview on 3/22/23, at 10:18 a.m., Resident 12 was in his room and was asked if he knew what an arbitration agreement was and if he remembered signing one at the facility. Resident 12 stated no to both questions. During an interview and record review on 3/22/23, at 10:25 a.m., the Director of Nursing (DON) reviewed Resident 12's clinical record. The DON stated Resident 12 was admitted to the facility on [DATE] from the General Acute Care Hospital for care following a stroke. The DON stated Resident 12 was his own Responsible Party. The DON stated on 10/31/22 a Minimum Data Set (MDS) assessment was completed which indicated Resident 12 had a Brief Interview for Mental Status (BIMs) (the MDS tool that measures resident cognition) score of 7 (BIMs scores range from 0-15 and are interpreted as follows: 0-7 = indicate severe cognitive impairment; 8-12 indicate moderate cognitive impairment and 13-15 = indicate intact cognition). A second and subsequent MDS assessment was completed on 1/31/23 which indicated Resident 12 had a BIMs score of 6. A further review of Resident 12's clinical record indicated Resident 12's Discharge Summary from the General Acute Care Hospital dated 10/24/22. The Discharge Summary indicated Resident 12 had diagnoses including Stroke due to intracerebral hemorrhage (bleeding in the brain) and Wernicke-Korsakoff syndrome (an amnestic disorder). Resident 12's Discharge Summary further indicated Resident 12 suffered from dementia and was profoundly impaired.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for two out of three residents (Resident 8 and Resident 26) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications. Findings: The controlled medication CDR for three random residents receiving as needed controlled medications were requested for review during the survey. During an interview on 3/21/23, at 9:44 a.m., with Licensed Nurse 2 (LN 2), LN 2 stated whenever a controlled medication was administered to a resident, the dose was to be documented in both the CDR and the MAR. He stated it was important for documentation to be in both places to know when a dose was last administered. During an interview on 3/21/23, at 10:22 a.m., with Director of Nursing (DON), DON stated the expectation of nursing staff was whenever a controlled medication was administered to a resident, they were to validate the tablet count, then document the given dose on the CDR and the MAR. 1a. Resident 26 had a physician's order for hydrocodone/APAP (a medication used to treat pain) 5/325 milligram/milligram (mg, a unit of measurement), dated 2/28/23. During a concurrent interview and record review on 3/21/23, at 10:25 a.m., with DON, a review of Resident 26's 3/2023 MAR indicated nursing staff removed 1 tablet on 3/13/23 from the medication cart and documented on the CDR without documenting the respective administration on the MAR. DON verified the finding. 1b. Resident 8 had a physician's order for lorazepam (a medication used to treat anxiety) 0.5 mg, 1 tablet every 4 hours as needed for anxiety, dated 2/11/23. During a concurrent interview and record review on 3/21/23, at 10:27 a.m., with DON, a review of Resident 8's CDR for lorazepam and 2/2023 through 3/2023 MARs indicated nursing staff removed the following from the medication cart and documented on the CDR without documenting the respective administration on the MAR: 1 tablet on 2/23/23, 1 tablet on 3/6/23, and 1 tablet on 3/19/23. DON confirmed the findings and stated, I don't see anything charted. During a review of the facility's policy and procedure titled, Preparation and General Guidelines, dated 10/2019, indicated, When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and/or the medication administration record (MAR): 1. Date and time of administration. (MAR, Accountability Record) 2. Amount administered. (Accountability Record) 3. Remaining quantity (Accountability Record) 4. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from supply 5. Initials of the nurse administering the dose, completed after the medication is actually administered (MAR).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on food production observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1) holding time for Penne pasta, green beans, and turkey and gravy was over 1 hour prior to the beginning of meal service, 2) frozen spinach was cooked on the stovetop for over two hours prior to placing on the steam table, 3) recipes were not followed, 4) two out of 12 Sampled Residents (Resident 2 and Resident 33) and three Unsampled Residents (Resident 1, Resident 4, and Resident 86) did not like the food and/or had issues with the temperature of the food, the texture of food items, quality of the food or taste of the food, and 5) test tray evaluation of noon meal tray on 3/22/23 at 1 p.m. found to have meat that was dry, lacked flavor and greasy tasting, spinach needed seasoning/lacked flavor, mashed potatoes were bland, and pureed meat and spinach were cold. Failure to ensure food distribution and food production systems that ensured food palpability and nutritional content may result in decreased dietary intake, which may result in weight loss and further compromise resident medical status. Findings: 1) During the initial tour of the kitchen on 3/20/23 at 11:20 a.m., lunch foods (turkey with [NAME] sauce, Penne pasta, and green beans) were on the steam table. During an interview on 3/20/23 at 11:45 a.m., [NAME] B was asked when the lunch foods were placed on the steam table. [NAME] B stated the Penne pasta and green beans were placed on the steam table at 10:30 a.m. & the turkey and gravy were placed on steam table at 10:45 a.m. During an observation on 3/20/23 at 11:47 a.m., [NAME] B started plating the lunch. The lunch foods had been warming on the steam table for over one hour. During concurrent interview and observation on 3/20/23 at 12:54 p.m., Resident 4 stated the pasta was Horrible, no taste. Resident 4 stated there was nothing she liked on her plate, and the pasta was cold. Resident 4 could not eat her pasta. Resident 4 stated she ate the turkey because she was hungry but if she was blindfolded, she would not know what she was eating. Resident 4 had been served one slice of turkey with a little gravy. Resident 4 stated she finished the slice of turkey in four and a half bites. 2) During an observation on 3/22/23 at 9:05 a.m. [NAME] B placed two frozen bags of spinach in a pot of water and started cooking the frozen spinach on the stovetop. During an observation on 3/22/23 at 9:15 a.m., the two bags of spinach were submerged in boiling water. During an observation on 3/22/23 at 10:10 a.m., the spinach was still cooking on the stovetop. During a concurrent observation and interview on 3/22/23 at 11:20 a.m. the spinach with added margarine and Swiss cheese was on the steam table. When [NAME] B was asked if he had baked the Spinach after adding the margarine and Swiss cheese per the Spinach Au Gratin recipe, [NAME] B stated, No, he first drained the spinach, added the spinach to the pan, placed the pan on the steam table and then added the margarine and Swiss cheese while in the pan on the steam table. The spinach had been cooking in boiling water for over two hours prior to placing the spinach on the steamtable. During an observation of tray line on 3/22/23 at 12:20 p.m., [NAME] B was using a slotted serving spoon (spoon with holes) to plate the Spinach Au Gratin, which was very watery. [NAME] B tapped the spoon on the side of the serving pan five times to drain off the excess water before plating the spinach. A review of the recipe titled, Spinach Au Gratin, indicated: 1. [NAME] spinach in enough water to cover. Drain well. Place in baking pan, 2. Add margarine and cheese and mix well, 3. Bake at 325 degrees Fahrenheit for 10-15 minutes, until cheese is melted . The facility Policy/Procedure titled, Food Preparation, dated 2018, indicated: Policy: Food shall be prepared by methods that conserve nutritive value, flavor. And appearance. Procedure: . 11 Do not use steamtable to cook food. 3) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 9:45 a.m., [NAME] B chopped carrots, onions and celery, but did not chop he mixed colored bell peppers, one of the ingredients needed. [NAME] B placed the carrots, celery and onions in the Robot Coupe (food processor used to dice, mince, grind, puree, slice, shred, etc.), blended the vegetables, and drained the excess water. When [NAME] B was asked why he blended the vegetables, [NAME] B stated it made it easier to mix all the ingredients together. The recipe indicated: Heat margarine or oil in skillet and sauté vegetables and Italian seasonings until vegetables are tender, approximately 3 to 5 minutes. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. [NAME] B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When the Dietary Supervisor was asked how [NAME] B was going to meet the portion size for 30 residents with six pounds of hamburger, the Dietary Supervisor stated he went to the store to buy the hamburger and did not buy enough. The Dietary Supervisor stated cook B would add the one pound of ground turkey, which was going to be used to make a meatloaf for the residents who did not like beef. [NAME] B then added the pound of ground turkey to the hamburger mix. This occurred after surveyor had to cue the Dietary Supervisor about there not being enough hamburger. The Dietary Supervisor was overseeing [NAME] B. [NAME] B had prepared the meatloaf following the recipe for 24 servings. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:15 a.m., [NAME] B added the one pound of ground turkey to the already mixed meatloaf. [NAME] B added chopped carrots, celery and onion. When [NAME] B was asked why he did not put the additional raw chopped vegetables in the food processor, [NAME] B stated to give the meatloaf a variation of cut vegetables. When [NAME] B was asked what he added to the bowl (meatloaf mix, ground turkey, and raw vegetables), he stated he added a 1/4 cup of Italian seasoning. When asked if the recipe asked for a ¼ cup of Italian seasoning, [NAME] B said, Yes. Surveyor asked [NAME] B to look at the recipe. [NAME] B stated he read the Garden Fresh Meatloaf recipe wrong. [NAME] B stated he was supposed to add 1/4 teaspoon (tsp) to the one pound of additional ground turkey. [NAME] B was observed taking a handful of the Italian Seasoning off the top of the ground turkey with his gloved hand. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:25 a.m. and 10:30 a.m., [NAME] B stated he had made two hamburger patties because one resident was allergic to onions and one resident could not have gluten (protein found in the wheat plant and some other grains). There were four loaves of meatloaf in a baking pan placed on the bottom oven rack, and the two hamburger patties were each in a baking dish placed on the top oven rack, baking at 400 degrees Fahrenheit. When [NAME] B was asked why he was cooking the meat at 400 degrees instead of following the recipe, which indicated: Bake at one and a half hours to two hours at 325 degrees, [NAME] B stated to speed up the process. During concurrent observation and interview on 3/22/23 at 11:25 a.m., [NAME] B pulled the meat out of the oven to temp. The meatloaf temperature was at 135.4 degrees. [NAME] B placed the meatloaf back in the oven to continue cooking. During a concurrent observation and interview on 3/22/23 at 11:30 a.m., when [NAME] B was asked what the other pan on the top rack in the oven was, [NAME] B stated a veggie patty. The two 4-ounce hamburger patties had been cooking on the top oven rack for one hour. The facility Policy/Procedure (P/P) tilted, Food Preparation, dated 2018, indicated: Policy: Food shall be prepared by methods that conserve nutritive valve, flavor and appearance. Procedure: . 2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. 3. Prepared food will be sampled . 4. Poorly prepared food will not be sampled. 5. Prepare foods as close as possible to serving time in order to preserve nutrition, freshness and to prevent overcooking . 7. Holding foods prior to service for as short a time as practical. A maximum 1 hour holding time is recommended . The facility P/P titled, Menu Planning, dated 2020, indicated: . Procedures: . 4. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. 4) During an interview on 3/20/23, at 11:55 a.m., Resident 1 stated, The food is lousy, the vegetables are undercooked, pasta is served all the time, the bread is stale, they serve powdered eggs, the food served is very low quality, the food is really terrible. During an interview on 3/20/23, at 12:20 p.m., Resident 2 stated, The food is really bad, the food all tastes the same, the food is very poor quality. During an observation and concurrent interviews on 3/20/2023 at 12:41 p.m., Resident 86 and Resident 33 were in their room eating lunch. When asked about their meals, Resident 86 stated it was, awful and stated the food was not warm. Resident 33 stated, it's all crap. When asked what she did not like about her food, Resident 33 stated she did not like, all of it. She stated there was no salt or pepper and the food was only, medium warm. During concurrent interview and observation on 3/20/23 at 12:54 p.m., Resident 4 stated all the food served was processed. Resident 4 stated when the kitchen served pizza the residents were only allowed one piece. Resident 4 stated she was told the kitchen was cutting back because food was being wasted. Resident 4 complained about small meat portions. Resident 4 had been served one slice of turkey with a little gravy. Resident 4 stated she finished the slice of turkey in four and a half bites. During a concurrent interview and dietary record review on 3/22/23 at 8:40 a.m., the Dietary Supervisor was asked to show where the carton of liquid eggs was kept. The Dietary Supervisor stated there was no liquid eggs used to cook omelets and scrambled eggs. The Dietary Supervisor stated he did the ordering for the kitchen but had missed ordering the cartons of liquid eggs. The Good For Your Health Menus, dated 3/20/23-3/26/26, indicated scrambled eggs were going to be served for breakfast on Friday (3/24/23). When the Dietary Supervisor was asked how the scrambled eggs would be made, the Dietary Supervisor stated he would normally go to the grocery store and buy a cartoon of liquid eggs. During a concurrent interview and record on 3/23/23 at 8:50 a.m., the Dietary Supervisor stated he went to the grocery store last night to get the liquid eggs needed to make omelets this morning. The dietary menu titled, Good For Your Health Menus, dated 3/20/23-3/26/23, indicated a Denver Omelet was on the 3/23/23 breakfast menu. The Dietary Supervisor stated he was overseeing the dietary budget and corporate wanted the facility to lower the budget. 5) On 3/22/23 at 1 p.m., a test tray was completed. The Dietary Supervisor tempted the pureed meatloaf at 85 degrees Fahrenheit and the spinach at 95 degrees Fahrenheit. The Dietary Supervisor agreed the hot pureed foods were cold. The pharmacy consultant stated the meatloaf tasted dry and bland. The Dietary Supervisor stated the meatloaf needed salt. The surveyor stated the meatloaf had very little flavor and she could taste the grease. No gravy had been poured over the meatloaf. All tasters agreed the mash potatoes were bland/no flavor. The pharmacy consultant and surveyor stated the spinach was bland, needed seasoning and there was no cheese noted. The survey said the pureed meatloaf and spinach tasted cold and spinach had no flavor/needed to be seasoned. During an interview on 3/22/23 at 1:15 p.m., Resident 4 stated the meatloaf was gross, had no gravy and no flavor. Resident 4 stated the mash potatoes had no flavor and no gravy. Resident 4 stated she would have liked to have had gravy on her meatloaf and mashed potatoes. Resident 4 stated she could not eat the garlic bread; it was soaked in butter and disgusting. A review of Resident 4's Lunch Meal Card for 3/22/23, indicated Resident 4 was on a Regular CCHO (Controlled Carbohydrate (include sugars, fibers and starches) diet. A review of the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the Garden Fresh Meatloaf for Regular, Mechanical Soft (includes foods that are soft and do not take a lot of effort to chew or swallow), Pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) and CCHO diets were supposed to have gravy on the meatloaf, not just the fortified diets. The facility P/P titled, Meal Service, dated 2018, indicated: Policy: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner, and served at the appropriate temperatures. Procedure: . 7. Temperatures of the food when the resident receives it based on palatability. The goal is to serve cold food cold and hot food hot. Hot entrée should be 120 [NAME] Fahrenheit or hotter . The facility P/P titled, Section 1: Purpose, dared 2018, indicated: Food and Nutrition Service means a service organized, staffed and equipped to assure that the food service to residents is safe, appetizing and provides for their nutritional needs. Policy: It is the policy of this facility to serve nourishing attractive meals to all our residents, to meet the nutritional needs of each individual resident, to totally integrate food and nutrition service polices and procedures with all other resident care policies and procedures, to comply with all federal, state, and local regulations pertaining to food and nutrition services, and to employ an adequate, competent staff, including a registered dietician or dietary consultant, to ensure high quality meals, excellent service and maximum safety of food and nutrition services department. Procedures . Resident's meals shall be prepared from quality food purchases with the food budget. The facility job description titled, Cook, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to prepare meals in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with established policies and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided at all times. Essential Functions and Responsibilities: . Ensure that all dietary procedures are followed in accordance with established policies . Review menus prior to preparation of food . Prepare and serve meals that are palatable and appetizing in appearance . Ensure that food and supplies for the next meal are readily available . The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . The facility job description titled, Personnel Management, dated 2018, indicated: Policy: A qualified FNS (Food and Nutrition Service) Director, chosen by the Administrator, is responsible for the total operation of the Food and Nutrition Services Department. All Food and Nutrition service is performed under their direction. (Note the Dietary Supervisor was not Certified Dietary Manger/had not completed the Dietary Management Program). Procedure: If a person is not a RD, he must meet the Federal and State laws and receive regular consultation from the RD or have met equivalent requirements. Responsibilities of FNS Director: . Food and Nutrition service orientation, staffing, supervision, staff training and in-servicing . Maintaining Acceptable standards of Sanitation and food safety. Responsibilities of the Consultant Dietician: . The Dietician will provide staff development programs, (in-servicing) for FNS . that assure the professional food and nutrition service needs of the facility are met. This will include, but is not limited to . meal service accuracy and enforcement/education of State, County and Federal regulations . The facility job description titled, Registered Dietitian, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Monitor dietary services to assure that all residents' dietary needs are being met . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the Registered Dietician would monitor General Sanitation and Safety: . 17. Competency of the staff is routinely done and documented . Food Preparation: 1. Recipes and instructions for food preparation are being followed. 2. Spreadsheets are used for service of the correct food and portion. 7. Temperature retention methods keep hot foods hot and cold foods cold during time of service . 9. Food is placed on steam table less the 30 minutes prior to meal service .

Based on interview and record review, the facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program addressed the full range of care and services provided by the facility when a dietary department representative participated in only three of the previous 12 QAPI meetings. This failure had the potential for the facility to neglect dietary quality deficits. Findings: During an interview and record review on 3/24/23, at 1:26 p.m., the Administrator stated the facility's Quality Assurance and Performance Improvement (QAPI) committee met monthly to review and address quality issues in the facility. The Administrator stated all department heads attended the QAPI committee meetings. The Administrator provided the attendance sheets of the past 12 QAPI committee meetings, held on 2/28/23, 1/25/23, 12/22/22, 11/30/22, 10/27/22, 9/28/22, 8/30/22, 7/28/22, 6/22/22, 5/26/22, 4/28/22 and 3/23/22. A review of the attendance sheets of the above 12 meetings indicated a representative from the dietary department only attended three of the meetings: on 2/28/23, 1/25/23 and 5/26/22, which was confirmed by the Administrator. A review of facility policy and procedure titled: 2023 Quality Assurance and Performance Improvement (QAPI) Plan indicated: The scope of the QAPI program encompasses all segments of care and services provided by our facility that impact clinical care, quality of life, resident choice, and care transitions with participation from all departments.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when a glucometer was not disinfected in accordance with facility policy and procedure (P&P) and manufacturer's specifications after resident use. This failure had the potential to result in the development of infection and transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C). Findings: During an observation on 3/20/23, at 12 p.m., with Licensed Nurse 2 (LN 2), LN 2 was observed testing Resident 4's blood sugar using an Assure Platinum glucometer. He inserted the test strip into the glucometer, poked the resident's finger with a lancet, placed a drop of Resident 4's blood on the test strip, and allowed the glucometer to measure the blood sugar level. Once the reading was complete, LN 2 disposed of the test strip and returned to the medication cart with the glucometer. LN 2 then used an alcohol prep pad to wipe down the glucometer. During an interview on 3/20/23, at 12:08 p.m., with LN 1, LN 1 stated the proper way to disinfect the glucometer after use was to wipe it down with a Super Sani-Cloth germicidal wipe, then use a second wipe to wrap around the meter for two minutes. During an interview on 3/20/23, at 12:11 p.m., with LN 2, LN 2 stated the process he followed for disinfecting the glucometer was to, Wipe it down with alcohol wipes, let it dry off then take it to the next [resident]. LN 2 stated he was trained to use the Super Sani-Cloth wipes and when asked if the alcohol prep pads were just as effective he stated, No. During an interview on 3/21/23, at 10:35 a.m., with the Director of Nursing (DON), DON stated the guideline for cleaning and disinfecting the glucometer after use was to wipe it with alcohol and then disinfect with a Super Sani-Cloth wipe, leaving the surface wet for a minimum of two minutes. During a review of the facility's P&P titled, Maintenance: Cleaning and Disinfecting Guidelines, undated, indicated, Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. During a review of the facility's P&P titled, Obtaining a Fingerstick Glucose Level, revised 10/2011, indicated, Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.

Based on observation, interview, and record review, the facility failed to ensure discontinued medications were removed from stock according to facility policy and procedure (P&P), medications were appropriately labeled with a pharmacy label identifying which resident they were for, and expired medications were not available for resident use. The deficient practices had the potential to result in medications being administered not in accordance with physician's order and residents receiving medications with unsafe or reduced potency from being used past their discard date. Findings: On 3/20/23 at 11:14 a.m., an inspection of the Medication Storage Room alongside Licensed Nurse 1 (LN 1) identified two Mounjaro (an injectable medication used to treat diabetes) 2.5 milligram/0.5 milliliter (mg/ml, a unit of measurement) pens. One pen was inside a clear bag with a pharmacy label on the outside for Resident 4. The second pen was unlabeled with a pharmacy label and was not in any other packaging identifying which resident it was for. LN 1 stated all medications should have a pharmacy label affixed to the medication or packaged inside a bag with a label on the outside to identify which resident it was for. She stated Resident 4's order for Mounjaro had been discontinued and the pen should have been discarded in the discontinued medications bucket (DC bucket, a container designated for discontinued or expired medications). Further inspection identified two amber prescription vials sitting on top of the counter for Resident 27. One vial contained omeprazole (a medication used to treat acid reflux) 20 mg capsules and the second contained nitrofurantoin (an antibiotic used to treat infection) 100 mg capsules. LN 1 stated both vials should have been placed in the DC bucket because the resident was no longer taking those medications. During the same inspection, one Eliquis (a medication used to prevent blood clots) 2.5 mg tablet inside plastic strip packaging expired 9/19/22, was identified inside a cabinet. LN 1 stated the tablet was expired and should have been discarded in the DC bucket. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 8/2019, indicated, All medications dispensed by the pharmacy are stored in the box, bag or other container with the pharmacy label . During a review of the facility's P&P titled, Disposal of Medications and Medication-Related Supplies, dated 8/2014, indicated, If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose . An inspection of Medication Storage Cart 1, on 3/20/23 at 12:15 p.m., alongside LN 1 identified one calcitonin salmon (a medication used to prevent osteoporosis) 200 units/ml nasal spray, opened 2/5/23. LN 1 reviewed the manufacturer's labeling on the product packaging and stated the nasal spray expired 35 days after opened. LN 1 confirmed the nasal spray had expired 7 days prior. During an interview on 3/21/23, at 10:36 a.m., with Director of Nursing (DON), DON stated the expectation of nursing staff was to remove expired medications from stock and replace with new supply. She stated discontinued medications were to go in the DC bucket and their disposal documented by signatures of two licensed nurses. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 8/2019, indicated, Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of accorder to procedures for medication, and reordered from the pharmacy, if a current order exists.

Based on food production observation, dietary staff interview, and dietary document review, the facility failed to ensure a Registered Dietician (RD) was overseeing the operations of the facility's Food Service Department and a qualified Dietary Supervisor or fulltime RD was overseeing the day-to-day operations of the kitchen, and evaulating dietary staff for competencies (cross reference F 812). These failures resulted in issues with safe and effective food storage, meal production (cross reference F 804) correct therapeutic diets being plated (cross reference F803) and infection control (cross reference F 812). Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness. Findings: During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. there was no Dietary Supervisor overseeing the kitchen. The Rehabilitation Manager stated she was overseeing the kitchen. The Rehabilitation Manager stated the Dietary Supervisor was on the way. A review of the facility job descriptions titled, Director of Rehabilitation, and Speech-Language Pathologist indicated the Rehabilitation Manager was hired as the Director of Rehabilitation on 12/20/2012. On 12/10/2010, the Rehabilitation Manager was hired in the position of Speech-Language Pathologist. During a concurrent interview and dietary record on 3/22/23 at 8:40 a.m., the Dietary Supervisor stated he had worked at the facility for a year, started as a cook and has been the Dietary Supervisor for the past six months. The Dietary Supervisor stated he was not yet qualified to be a Dietary Supervisor. He had his California Food Handlers Card, but was not a Certified Dietary Manager (CDM). The Dietary Supervisor stated he was still taking the Certified Dietary Manager course. During an interview on 3/22/23 at 3:45 p.m., the Dietary Supervisor stated he was trained by the Rehabilitation Manager, the Dietary Supervisor from the facility's sister facility located in another town, who was a Certified Dietary Manager, and the corporate Registered Dietician (RD) consultant, who came to the facility every few months. The Dietary Supervisor stated he could e-mail and call the corporate RD consultant as well. The Dietary Supervisor stated he trained [NAME] B. The Dietary Supervisor stated he had no training by the facility RD, who came every Thursday. The Dietary Supervisor stated the Dietary Supervisor oversaw the kitchen. The Dietary Supervisor stated he had never seen the RD oversee the kitchen and observe tray line. During an interview on 3/23/23 at 8:50 a.m., the Dietary Supervisor stated the Dietary Supervisor from their sister facility did one inspection of kitchen but technically it did not count because she was not the RD, not part of her job description. The Dietary Supervisor stated the Dietary Supervisor oversaw the cooks. The Dietary Supervisor stated when he was on vacation the Rehabilitation Manager would be checking on the dietary staff to make sure everything was flowing well. The Dietary Supervisor stated the Rehabilitation Manager hired him in the Dietary Supervisor position, and when he was first hired in the cook position. The Dietary Supervisor stated he worked as the Dietary Supervisor on Monday through Thursday, and as a cook on Fridays. During an interview on 3/23/23 at 11:05 a.m., the RD stated she started working at the at the end of August or September 2022. The RD stated she was at the facility once per week and was also available by e-mail and/or phone. The RD stated when she first started, she mainly was in orientation and in October 2022, she started overseeing the operations of the facility's Food Service Department, by doing her monthly inspection of kitchen, and tray line and dining observations. The RD stated she was supposed to do a kitchen inspection monthly, starting October 2022, but she did not know if she had done many kitchen inspections. The RD stated the Rehabilitation Manager was overseeing the kitchen while the RD was orientating. The RD stated she understood and agreed the Dietary Supervisor was not qualified yet to oversee the kitchen. The RD stated she had never met and oversaw [NAME] B and verified [NAME] B's competencies as a cook by demonstration. The RD stated she did not oversee the ordering of food supplies. During a concurrent interview and review of the RD's monthly inspections of the kitchen from 1/2022 through 3/23/23, on 3/23/23 at 11:45 a.m., the Administrator was able to show a kitchen inspection took place by a RD six times. The current RD inspected the kitchen on 11/3/22, 1/27/23, and 2/27/23, the facility's corporate RD consultant inspected the kitchen on 5/2-5/3/22 and another RD inspected the kitchen on 1/21/22 and 8/6/22. The Administrator stated the RD, who inspected the kitchen on 1/21/22 and 8/6/22, used to be the facility's RD for a while and when she left, she was still helping at times. The Administrator stated the current RD started on 8/23/22. The Administrator stated it has been difficult to find a qualified RD to oversee the operations of the facility's Food Service Department and qualified Dietary Supervisor or fulltime RD to oversee the day-to-day operations of the kitchen. During an interview on 3/23/23 at 1:45 p.m., the Administrator stated she hired the Dietary Supervisor in 10/2022 as the Director of Food Services in training. The Administrator stated the corporate RD consultant has been helping at the facility at times. The Administrator stated the RD started in August/September 2022 and was mainly learning the computer, resident assessments and physician dietary orders at first. During an interview on 3/23/23 at 2 p.m., the Rehabilitation Manager stated she was mainly a support for the kitchen. The Rehabilitation Manager stated she was the Director of the Rehabilitation Department. The Rehabilitation Manager stated in her scope of practice, she would be looking at the resident's diet orders, advising the dietary staff in changes to a resident's therapeutic diet, advising if the texture of the resident's pureed diet was not prepared correctly, amongst other things. During an interview on 3/24/23, at 1:26 p.m., the Administrator stated the facility had been without a certified dietary manager (CDM) since July 2021, when the CDM quit. Since then, the Administrator stated, the facility had not been able to hire a CDM. The Administrator stated around October 2022 the facility started training a cook (the Dietary Supervisor) to take on the role as CDM. A review of the RD's New Hire/Employment Record Transfer Form, indicated the RD's hire date was 8/23/22, she was part-time, and her scheduled weekly hours was 16 hours. The facility job description titled, Registered Dietitian, undated, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Plan, develop, organize, implement, evaluate, and direct the Dietary Department, its programs and activities . Make written and oral reports/recommendations to the Food Service Supervisor and/or administrator as necessary/required concerning the operations of the Dietary Department . Develop and participate in the planning, conducting, and scheduling of timely in-service training that ensure a well-educated competent dietary services department . Monitor dietary services to assure that all residents' dietary needs are being met . A review of the Dietary Supervisors New Hire/Employment Record Transfer Form, indicated the Dietary Supervisor was hired on 9/23/21 and his job title was cook. A review of the facility job description titled, Director of Food Services, indicated the Dietary Supervisor took the title as Director of Food Services on 10/1/22, and under Education, written next to qualifications, the Dietary Supervisor was In Training, dated and signed on 10/1/22. The facility job description titled, Director of Food Services, signed by the Dietary Supervisor on 10/1/22, indicated: Purpose of Your Job Position: The primary purpose of your job position is to assist the Dietician in planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations, governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: Assist in planning, developing, organizing, implementing, evaluating and directing the Dietary Department, its programs and activities . Personnel Functions: . Review and check competence of dietary personnel and make necessary adjustments/corrections as required or that may become necessary . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . Conduct departmental performance evaluations in accordance with the facility's policies and procedures . Equipment and Supply Functions: . Ensure that stock levels of staple/non-staple food, supplies, equipment, etc. are maintained at adequate levels at all times . Assist in the purchase of food services supplies, equipment, etc., as required . Education: . Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association . Handwritten next to qualification: In Training, signed and dated, 10/1/22 . Specific Requirements: Must be registered as Food Service Director in this state . Note there has not been a qualified certified dietary manager (CDM) since July 2021. The facility job description titled, Personnel Management, dated 2018, indicated: Policy: A qualified FNS (Food and Nutrition Service) Director, chosen by the Administrator, is responsible for the total operation of the Food and Nutrition Services Department. All Food and Nutrition service is performed under their direction. (Note the Dietary Supervisor was not a Certified Dietary Manger/had not completed the Dietary Management Program). Procedure: If a person is not a RD, he must meet the Federal and State laws and receive regular consultation from the RD or have met equivalent requirements. Responsibilities of FNS Director: . Food and Nutrition service orientation, staffing, supervision, staff training and in-servicing . Maintaining Acceptable standards of Sanitation and food safety. Responsibilities of the Consultant Dietician: . The Dietician will provide staff development programs, (in-servicing) for FNS . that assure the professional food and nutrition service needs of the facility are met. This will include, but is not limited to sanitation inspections . and enforcement/education of State, County and Federal regulations .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dietary observation, interview, and dietary record review, the facility failed to ensure staff possessed required competency as evidenced by dietary staff members were not: 1) following recipes for a.spinach and b. meatloaf 2) following therapeutic diets when a. portion sizes were not plated correctly, meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed properly, and b.mash potatoes were not fortified 3) qualified to oversee the day-to-day operations of the kitchen and 4) qualified to evaluate cooks for competences. Failure to ensure staff competency could result in decreased food distribution and food production systems to ensure food palpability and nutritional content, which could result in decreased dietary intake that did not meet individual resident nutritional requirement. This could result in weight loss and further compromise resident medical status. Findings: 1a) During an observation on 3/22/23 at 9:05 a.m. [NAME] B placed two frozen bags of spinach in a pot of water and started cooking the frozen spinach on the stovetop. During an observation on 3/22/23 at 9:15 a.m., the two bags of spinach were submerged in boiling water. During an observation on 3/22/23 at 10:10 a.m., the spinach was still cooking on the stovetop. During a concurrent observation and interview on 3/22/23 at 11:20 a.m. the spinach with added margarine and Swiss cheese was on the steam table. When [NAME] B was asked if he had baked the Spinach after adding the margarine and Swiss cheese per the Spinach Au Gratin recipe, [NAME] B stated, No, he first drained the spinach, added the spinach to the pan, placed the pan on the steam table and then added the margarine and Swiss cheese while in the pan on the steam table. The spinach had been cooking in boiling water for over two hours prior to placing the spinach on the steam table. During an observation during tray line on 3/22/23 at 12:20 p.m., [NAME] B was using a slotted serving spoon (spoon with holes) to plate the Spinach Au Gratin, which was very watery. [NAME] B tapped the spoon on the side of the serving pan five times to drain off the excess water before plating the spinach. A review of the recipe titled, Spinach Au Gratin, indicated: 1. [NAME] spinach in enough water to cover. Drain well. Place in baking pan, 2. Add margarine and cheese and mix well, 3. Bake at 325 degrees Fahrenheit for 10-15 minutes, until cheese is melted . 1b) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 9:45 a.m., [NAME] B chopped carrots, onions and celery, but did not chop the mixed colored bell peppers, one of the ingredients needed. [NAME] B placed the carrots, celery and onions in the Robot Coupe (food processor used to dice, mince, grind, puree, slice, shred, etc.), blended the vegetables, and drained the excess water. When [NAME] B was asked why he blended the vegetables, [NAME] B stated it made it easier to mix all the ingredients together. The recipe indicated: Heat margarine or oil in skillet and sauté vegetables and Italian seasonings until vegetables are tender, approximately 3 to 5 minutes. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. [NAME] B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When the Dietary Supervisor was asked how [NAME] B was going to meet the portion size for 30 residents with six pounds of hamburger, the Dietary Supervisor stated he went to the store to buy the hamburger and did not buy enough. The Dietary Supervisor stated [NAME] B would add the one pound of ground turkey, which was going to be used to make a meatloaf for the residents who did not like beef. [NAME] B then added the pound of ground turkey to the hamburger mix. This occurred after the surveyor had to cue the Dietary Supervisor about not having enough hamburger to serve 30 residents. The Dietary Supervisor was overseeing [NAME] B. [NAME] B had prepared the meatloaf following the recipe for 24 servings. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:15 a.m., [NAME] B added the one pound of ground turkey to the already mixed meatloaf. [NAME] B added chopped carrots, celery and onion. When [NAME] B was asked why he did not put the additional raw chopped vegetables in the food processor, [NAME] B stated to give the meatloaf a variation of cut vegetables. When [NAME] B was asked what additional ingredient he added to the bowl, which had the meatloaf mix, ground turkey, and raw vegetables, he stated he added a 1/4 cup of Italian seasoning. When asked if the recipe asked for a ¼ cup of Italian seasoning, [NAME] B said, Yes. Surveyor asked [NAME] B to look at the recipe. [NAME] B stated he read the Garden Fresh Meatloaf recipe wrong. [NAME] B stated he was supposed to add 1/4 teaspoon (tsp) to the one pound of additional ground turkey. [NAME] B was observed taking a handful of the Italian Seasoning off the top of the ground turkey with his gloved hand. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:25 a.m. and 10:30 a.m., [NAME] B stated he had made two hamburger patties because one resident was allergic to onions and one resident could not have gluten (protein found in the wheat plant and some other grains). There were four loaves of meatloaf in a baking pan placed on the bottom oven rack, and the two hamburger patties, each in a baking dish, placed on the top oven rack, baking at 400 degrees Fahrenheit. When [NAME] B was asked why he was cooking the meat at 400 degrees instead of following the recipe, which indicated: Bake at one and a half hours to two hours at 325 degrees, [NAME] B stated to speed up the process. During a concurrent observation and interview on 3/22/23 at 11:25 a.m., [NAME] B pulled the meat out of the oven to check the temperature. [NAME] B stated the meatloaf temperature was at 135.4 degrees. [NAME] B placed the meatloaf back in the oven to continue cooking. During a concurrent observation and interview on 3/22/23 at 11:30 a.m., when [NAME] B was asked what the other pan on the top oven rack was, [NAME] B stated a veggie patty. The two 4-ounce hamburger patties had been cooking on the top oven rack for one hour. The facility Policy/Procedure (P/P) titled, Food Preparation, dated 2018, indicted: Policy: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedure: . 2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. The facility P/P titled, Menu Planning, dated 2020, indicated: . Procedures: . 4. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. 2a) During an observation on 3/22/23 at 11:45 a.m., [NAME] B had placed a slice of meatloaf on a medal spatula and placed the spatula with the meat on the kitchen food scale. He was measuring the meat for the pureed diets. [NAME] B then pureed the meat using low sodium broth. During an observation during tray line on 3/22/23 at 12:20 p.m., one slice of meatloaf (regular portion size) was seen on the shelf above steamtable. During a concurrent observation and dietary record review on 3/22/23 at 12:30 p.m., the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated a small portion of meatloaf should weigh three oz and a regular or large portion of meatloaf should weigh 4 oz. Plating the residents lunch meal ended at 12:30 p.m. and there was one of four loaves of meatloaf left in the baking pan, which was full of grease. The grease had not been drained from the baking pan before plating the meatloaf. There was six pounds (96 oz) of hamburger and one pound (16 oz) of ground turkey, total of 112 oz of meat used to serve 30 residents. A review of the residents Lunch Meal Cards, indicated 118 oz of meat was needed to serve 30 residents, based on portion size. [NAME] B was short six oz of meat before he started plating the meatloaf and hamburger patties.There was a loaf of meatloaf left over after the last slice of meatloaf was plated. During an interview on 3/23/23 at 8:00 a.m., the Dietary Supervisor stated he did not see [NAME] B weigh the meatloaf periodically. The Dietary Supervisor stated [NAME] B did have a slice of meatloaf on the shelf above the steam table for an example of the portion size he needed to slice. The Dietary Supervisor stated [NAME] B was slicing the meatloaf as he was periodically eyeballing the example of meatloaf portion size. The Dietary Supervisor stated to accurately weigh meat [NAME] B should have used cellophane to cover the scale, placed the slice of meat on the scale, and then weigh the meat. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. When asked how the Dietary Supervisor measured out meat, the Dietary Supervisor stated he usually sliced and measured a few pieces of meat. The Dietary Supervisor stated he would then eyeball the slices of meat he sliced against the meat he had weighed for his portion size example to make sure he was plating the correct portion size. The Dietary Supervisor stated if he felt he had not sliced enough meat he would remeasure a slice of meat to make sure he was slicing the correct portion size. The Dietary Supervisor stated [NAME] B felt rushed because he had to place the meatloaf back in the oven, because it was not cooked. The Dietary Supervisor stated [NAME] B did not measure the meat out like he would normally. The facility P/P titled, Food Preparation: Portion Control, dated 2018, indicated: Policy: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food . 3. A diet scale should be used to weigh meats . It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy. The facility job description titled, Cook, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to prepare meals in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with established policies and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided. Essential Functions and Responsibilities: . Ensure that all dietary procedures are followed in accordance with established policies . Review menus prior to preparation of food . Serve meals in accordance with established portion control procedures . Ensure that food and supplies for the next meal are readily available . 2b) During an observation on 3/22/23 at 12:20 p.m., [NAME] B was fortifying the meatloaf with gravy and extra liquid butter on the spinach for residents on a Fortified diet. During an interview on 3/22/23 at 1:20 p.m., [NAME] B stated the gravy on the meatloaf was for the Fortified diets. [NAME] B stated per the Fortified instructions, he should have fortified both the meatloaf and the mashed potatoes with gravy and fortified the spinach with additional butter. [NAME] B stated he missed putting gravy on the mash potatoes. A review of the dietary document titled, Fortified Lunch dated Spring 2023 Week 3, indicated for Wednesday's lunch, the mashed potatoes needed 2 oz of gravy and the Spinach needed ½ oz melted margarine. A review of the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the Garden Fresh Meatloaf for Regular, Mechanical Soft (includes foods that are soft and do not take a lot of effort to chew or swallow), Pureed and CCHO (Controlled Carbohydrate include sugars, fibers and starches) diet were supposed to have gravy on the meatloaf, not just the fortified diets. The facility P/P titled, Fortified Diet, dated 2020, indicated: Description: The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional Breakdown: The goal is to increase the calorie density of the foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day . Sample Fortified Meal Plan: . Lunch: Extra sauce or gravy on meat, extra margarine on potatoes, rice or paste . The facility P/P titled, Section 1: Purpose, dated 2018, indicated: .Therapeutic diets shall be prepared and served in accordance with the physician diet order . The facility job description titled, Registered Dietitian, undated, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Monitor dietary services to assure that all residents' dietary needs are being met . 3) During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. there was no Dietary Supervisor overseeing the kitchen. The Rehabilitation Manager stated she was overseeing the kitchen. The Rehabilitation Manager stated the Dietary Supervisor was on the way. During a concurrent interview and dietary record on 3/22/23 at 8:40 a.m., the Dietary Supervisor stated he had worked at the facility for a year, started as a cook and has been the Dietary Supervisor for the past six months. The Dietary Supervisor stated he was not yet qualified to be a Dietary Supervisor. He had his California Food Handlers Card, but he was not a Certified Dietary Manager (CDM). The Dietary Supervisor stated he was still taking the Certified Dietary Manager course. The Dietary Supervisor was asked to show where the carton of liquid eggs was kept. The Dietary Supervisor stated there was no liquid eggs used to cook omelets and scrambled eggs. The Dietary Supervisor stated he did the ordering for the kitchen but had missed ordering the cartons of liquid eggs. The dietary menu titled Good For Your Health Menus, dated 3/20/23-3/26/26, indicated the residents were going to be served a Denver Omelet on Thurs (3/23/23) and scrambled eggs on Friday (3/24/23). When the Dietary Supervisor was asked how the scrambled eggs for Friday was going to be made, the Dietary Supervisor stated he would normally go to the grocery store and buy a cartoon of liquid eggs. During an interview on 3/22/23 at 3:45 p.m., the Dietary Supervisor stated he was trained by the Rehabilitation Manager, the Dietary Supervisor from the facility's sister facility located in a nearby town, who was a Certified Dietary Manager, and the corporate Registered Dietician (RD) consultant, who came to the facility every few months. The Dietary Supervisor stated he could e-mail and call the corporate RD consultant as well. The Dietary Supervisor stated he trained [NAME] B. The Dietary Supervisor stated he had no training by the facility RD, who came every Thursday. The Dietary Supervisor stated the Dietary Supervisor oversaw the kitchen. The Dietary Supervisor stated he had never seen the RD oversee the kitchen and observe tray line. During an interview on 3/23/23 at 8:00 a.m. the Dietary Supervisor stated the Dietary Supervisor from the facility's sister facility and the Rehabilitation Manager taught him how to purchase food service supplies/kitchen supplies. The Dietary Supervisor stated there was hamburger in the freezer for the meatloaf, but the cook forgot to pull the hamburger out to thaw in time to make the meatloaf. The Dietary Supervisor stated he did not catch [NAME] B not cutting up mixed colored bell peppers for the Garden Fresh Meatloaf. The Dietary Supervisor stated the RD came every Thursday mainly to do her resident assessments. The Dietary Supervisor stated he could not recall the RD overseeing the kitchen in the past six months, since the Dietary Supervisor went from being a cook to being the Dietary Supervisor. The Dietary Supervisor stated the RD was new. During an interview on 3/23/23 at 8:50 a.m., the Dietary Supervisor stated he oversaw the cooks and when he went on vacation the Rehabilitation Manager would be checking on the kitchen and dietary staff. The Dietary Supervisor stated the Rehabilitation Manager hired him in this position, and when he was first hired in the cook position. The Dietary Supervisor started the Dietary Supervisor from the facility's sister facility did the dietary staff competencies. The Dietary Supervisor stated he worked as the Dietary Supervisor Monday through Thursdays and a cook on Fridays. During an interview on 3/24/23, at 1:26 p.m., the Administrator stated the facility had been without a certified dietary manager (CDM) since July 2021. Since then, the Administrator stated, the facility had not been able to hire a CDM. The Administrator stated around October 2022 the facility started training a cook (the Dietary Supervisor) to take on the role as CDM. A review of the dietary training document titled, Food and Nutrition Service In-Service, dated 1/19/23, indicated the Dietary Supervisor, who was not a CDM, had given an In-Service (training) on Review of Spread Sheets. A review of the dietary training document titled, Dietary In-service, dated 12/5/22, indicated the Dietary Supervisor, who was not a CDM, had given an In-Service on Menu Changes and Substitutions. A review of the Dietary Supervisor's employee file indicated Dietary Supervisor was hired as a cook on 9/23/21 and started in the job position of Director of Food Services on 10/1/22. The facility job description titled, Director of Food Services, signed by the Dietary Supervisor on 10/1/22, indicated: Purpose of Your Job Position: The primary purpose of your job position is to assist the Dietician in planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations, governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Equipment and Supply Functions: . Ensure that stock levels of staple/non-staple food, supplies, equipment, etc. are maintained at adequate levels at all times . Assist in the purchase of food services supplies, equipment, etc., as required. Education: . Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association . Handwritten next to qualification: In Training, signed and dated, 10/1/22 . Specific Requirements: Must be registered as Food Service Director in this state . 4) During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. The Dietary Supervisor stated he did in-services for the dietary staff, one per month. The Dietary Supervisor stated the Dietary Supervisor from the facility's sister facility would do an in-service when she came up to the facility. The Dietary Supervisor stated he would do the competencies on the dietary staff including the cooks as did the Dietary Supervisor from the facility's sister facility. The Dietary Supervisor stated if he had questions, he would e-mail the Dietary Supervisor from the sister facility. The Dietary Supervisor stated he would watch [NAME] B to see if he was doing the dietary processes correctly, such as following a recipe, in order to see if [NAME] B was competent in meal production, amongst other things. The Dietary Supervisor stared [NAME] B came in one day before being hired and shadowed (observed) him. The Dietary Supervisor stated [NAME] B shadowed him for two weeks while the Dietary Supervisor did the cooking. The Dietary Supervisor stated during those two weeks, he would ask [NAME] B to do various kitchen tasks. The Dietary Supervisor stated he oversaw [NAME] B for one to two months. During an interview on 3/23/23 at 2 p.m., the Rehabilitation Manager stated she was [NAME] a support for the kitchen. The Rehabilitation Manager stated she was the Director of the Rehabilitation Department. The Rehabilitation Manager stated in her scope she would be looking at the resident's diet orders, advising the dietary staff in changes to a resident's therapeutic diet, advising if the texture of the resident's pureed diet was not prepared correctly, amongst other things. A review of the Dietary Supervisor's Equipment Competency-Complete with New Employees and Annually, dated 3/1/22, indicated the Rehabilitation Manager signed off on the Dietary Supervisor's competencies, whose dietary position was a cook at the time, under DSS (Dietary Service Supervisor)/Manager signature title. A review of the Dietary Supervisor's Verification of Job Competency Demonstration - Cook, dated 7/27/22, indicated the Rehabilitation Manager signed off on the Dietary Supervisor's competencies, who was in the Dietary Supervisor In Training position. During a concurrent interview and review of dietary staff competencies on 3/24/23 at 3:45 p.m., the DON (Director of Nursing) was shown and asked why [NAME] B's, competencies titled, Verification of Job Competency Demonstration - Cooks, in his employee file had no date of completion of competencies for the Cook position. but the same competency document for [NAME] B handed to surveyor on 3/23/23, was dated 10/13/22, indicated [NAME] B was signed off on all competencies for Cooks in one day. The DON stated she saw the issue but did not have an answer. She said, I see that. A review of the Rehabilitation Manager's employee file indicated she was hired on 12/20/10 in the job position of Speech-Language Pathologist and hired on 12/20/12 in the job position of Director of Rehabilitation. The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Review and check competencies of dietary personnel and make necessary adjustments/corrections as required or that may become necessary . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . Conduct departmental performance evaluations in accordance with the facility's policies and procedures . The facility job description titled, Registered Dietitian, revised 10/2017, indicated: . Make written and oral reports/recommendations to the Food Service Supervisor and/or administrator as necessary/required concerning the operations of the Dietary Department . Develop and participate in the planning, conducting, and scheduling of timely in-services training that ensure a well educated competent dietary services department, as well as for other facility departments . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the Registered Dietician would monitor General Sanitation and Safety: . 17. Competency of the staff is routinely done and documented . 29. Fulltime FNS (Food and Nutrition Service Manager) credentials meet Title 22/CMS regulations, posted. 30. FNS manager has a current food safety certificate and is posted . Food Preparation: 1. Recipes and instructions for food preparation are being followed. 2. Spreadsheets are used for service of the correct food and portion. 4. Fortified foods guides used and are prepared and severed accordingly .

Based on observation, interview, and record review, the facility failed to prepare a meal tray with 1) the individual therapeutic portion size for 30 out of 33 residents, when 30 residents' meatloaf portion size was not followed per the residents' lunch meal card, and 2) 13 out of 13 residents on a Fortified diet did not have their mash potatoes fortified with one oz of gravy per Spring 2023 Week 3 Fortified Lunch. These failures to ensure nutritional content could result in decreased dietary intake and resulted in less calories and protein, which may result in weight loss and further compromise resident medical status. Findings: 1) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. [NAME] B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When the Dietary Supervisor was asked how [NAME] B was going to meet the portion size for 30 residents with six pounds of hamburger, the Dietary Supervisor stated he went to the store to buy the hamburger and did not buy enough. The Dietary Supervisor stated cook B would add the one pound of ground turkey, which was going to be used to make a meatloaf for the residents who did not like beef. [NAME] B then added the pound of ground turkey to the hamburger mix. This occurred after surveyor had to cue the Dietary Supervisor about there not being enough hamburger. The Dietary Supervisor was overseeing [NAME] B. [NAME] B had prepared the meatloaf following the recipe for 24 servings. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:15 a.m., [NAME] B added the one pound of ground turkey to the already mixed meatloaf. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:25 a.m. and 10:30 a.m., [NAME] B stated he had made two hamburger patties because one resident was allergic to onions and one resident could not have gluten (protein found in the wheat plant and some other grains). There were four loaves of meatloaf in a baking pan placed on the bottom oven rack, and the two hamburger patties were each in a baking dish placed on the top oven rack, baking at 400 degrees Fahrenheit. During an observation on 2/22/23 at 11:45 a.m., [NAME] B had placed a slice of meatloaf on a medal spatula and placed the spatula with the meat on the food scale. He was measuring the meat for the pureed diets. [NAME] B then pureed the meat using low sodium broth. During an observation during tray line on 2/22/23 at 12:20 p.m., one slice of meatloaf ( regular portion size) was seen on the shelf above steamtable. During a concurrent observation and dietary record on 3/22/23 at 12:30 p.m., the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the small portion of meatloaf should weigh three oz and the regular or large portion of meatloaf should weigh 4 oz. Plating the residents lunch meal ended at 12:30 p.m. and there was one of four loaves of meatloaf in the baking pan, which was full of grease. Grease had not been drained from then baking pan before plating the meatloaf. There was six pound (96 oz) of hamburger and one pound (16 oz) of ground turkey, total of 112 oz of meat used to serve 30 residents. A review of the residents Lunch Meal Card, indicated 118 oz of meat was needed to serve 30 residents, based on portion size. [NAME] B was short 6 oz of meat before he started plating the meatloaf and hamburger patties. There was a loaf of meatloaf leftover after the last slice of meatloaf was plated. During an interview on 3/23/23 at 8:00 a.m., the Dietary Supervisor stated he did not see [NAME] B weigh the meatloaf periodically. The Dietary Supervisor stated [NAME] B did have a slice of meatloaf on the shelf above the steam table for an example of the portion size he needed to slice. The Dietary Supervisor stated [NAME] B was slicing the meatloaf as he was periodically eyeballing the portion size example of meatloaf. The Dietary Supervisor stated to accurately weigh meat [NAME] B should have used cellophane to cover the scale, placed the slice of meat on the scale, and then weigh the meat. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. When asked how the Dietary Supervisor measured out meat, the Dietary Supervisor stated he usually sliced and measured a few pieces of meat. The Dietary Supervisor stated he would then eyeball the slices of meat he sliced against the meat he had weighed for his portion size example to make sure he was plating the correct portion size. The Dietary Supervisor stated if he felt he had not sliced enough meat he would remeasure a slice of meat to make sure he was slicing the correct portion size. The Dietary Supervisor stated [NAME] B felt rushed because he had to place the meatloaf back in the oven because it was not cooked. The Dietary Supervisor stated [NAME] B did not measure the meat out like he would normally. The facility Policy/Procedure titled, Food Preparation: Portion Control, dated 2018, indicated: Policy: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food . 3. A diet scale should be used to weigh meats . It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy. 2) During an observation on 3/22/23 at 12:20 p.m., [NAME] B was fortifying the meatloaf with gravy and extra liquid butter on the spinach for residents on a Fortified diet. During an interview on 3/22/23 at 1:20 p.m., [NAME] B stated the gravy on the meatloaf was for the Fortified diets. [NAME] B stated per the Fortified instructions, he should have fortified both the meatloaf and the mashed potatoes with gravy and fortified the spinach with additional butter. [NAME] B stated he missed putting gravy on the mash potatoes. A review of the dietary document titled, Fortified Lunch dated Spring 2023 Week 3, indicated for Wednesday's lunch, the mashed potatoes needed 2 oz of gravy and the Spinach needed ½ oz melted margarine. A review of the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the Garden Fresh Meatloaf for Regular, Mechanical Soft (includes foods that are soft and do not take a lot of effort to chew or swallow), Pureed and CCHO (Controlled Carbohydrate include sugars, fibers and starches) diet were supposed to have gravy on the meatloaf, not just the fortified diets. The facility P/P titled, Fortified Diet, dated 2020, indicated: Description: The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional Breakdown: The goal is to increase the calorie density of the foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day . Sample Fortified Meal Plan: . Lunch: Extra sauce or gravy on meat, extra margarine on potatoes, rice or paste . The facility P/P titled, Section 1: Purpose, dated 2018, indicated: .Therapeutic diets shall be prepared and served in accordance with the physician diet order . The facility job description titled, Registered Dietitian, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Monitor dietary services to assure that all residents' dietary needs are being met . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the Registered Dietician would monitor: Food Preparation: 1. Recipes and instructions for food preparation are being followed. 2. Spreadsheets are used for service of the correct food and portion. 4. Fortified foods guides used and are prepared and severed accordingly The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . The facility job description titled, Cook, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to prepare meals in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with established policies and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided at all times. Essential Functions and Responsibilities: . Ensure that all dietary procedures are followed in accordance with established policies . Review menus prior to preparation of food . Serve meals in accordance with established portion control procedures . Ensure that food and supplies for the next meal are readily available .

Based on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) frozen vegetables were not sealed, 2) dietary staff did not know quaternary (quat ammonium compounds designed to kill germs) wet time for sanitizer solutions, 3) cook did not sanitize countertop after preparing meat, and 4) the cook was not wearing appropriate aprons for cooking and washing cooking utensils and equipment per the facility's policy/procedure. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal distress, weight loss and in severe instances may result in death. Findings: 1. During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. the frozen corn and frozen peas located in the freezer in the main kitchen area were both stored in unsealed blue bags, which were in open cardboard boxes. During a concurrent observation and interview on 3/22/23 at 8:40 a.m., the frozen corn and frozen cauliflower located in the freezer in the main kitchen area were both stored in unsealed blue bags, which were in open cardboard boxes. The Dietary Supervisor stated the frozen vegetables are delivered in a compressed sealed bag inside a sealed cardboard box, but the frozen vegetables are not tied/sealed after they are opened. The facility Policy/Procedure (P/P) titled, Procedure for Freezer Storage, dated 2018, indicated: Subject: Freezer Storage: Procedure: . 5. Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn . 2. During an interview on 3/22/23 at 9 a.m., Dietary Aide D stated the procedure for cleaning the dirty kitchen countertops was as follows: First clean the dirty countertops with soapy water located in the green bucket, wipe with the clean water located in the blue bucket, and then sanitize the countertops with the sanitizer located in the red bucket. Dietary Aide D stated the sanitizer wet time (the time that a disinfectant/sanitizer needs to stay wet on a surface to ensure efficacy) for the quat sanitizer wet time was 10 minutes. During an interview on 3/23/23 at 8 a.m., the Dietary Supervisor stated the kitchen countertop needed to be sanitized after preparing meat such as the hamburger and ground turkey to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 3/23/23 at 9:20 a.m., when the Dietary Supervisor was asked what the contact/wet time was for the sanitizer used to sanitize the kitchen countertops, he stated he would have to look up the wet time. When the Dietary Supervisor returned, he stated the sanitizer wet time was 10 minutes. During a concurrent observation, interview and review of Purell's sanitizer directions on 3/23/23 at 9:15 a.m. Dietary Aide C stated she used the Purell spray to sanitize the meal tray carts, which appeared to be made of stainless steel. Dietary Aide C stated she sprayed the sanitizer throughout each cart and then wiped the sanitizer, so the solution was evenly spread throughout the carts, and then she let the sanitizer air dry. When Dietary Aide C was asked what the contact/wet time was for the sanitizer, Dietary Aide C stated she thought 10 seconds. The Purell sanitizer instructions on the back of the Purell (Foodservice surface sanitizer) indicated: Sanitization Directions to Sanitize Hard, Nonporous (a surface, such stainless steel, metal, glass, hard plastic, and varnished wood whereby any kind of liquid and air cannot penetrate the material, and they just remain on the surface) Food-Contact Surfaces: Visible soil must be removed prior to sanitizing. Wash surface and follow with potable water rinse. Spray, pour, or apply this product with a cloth, mop, or sprayer device until surface is thoroughly wet. For spray application, spray 6-8 inches from the surface. Treated surface must remain wet for 60 seconds. Wipe or allow to air dry. No rinse required. To Spot Sanitize Soft Surfaces: Visible soil must be removed prior to sanitizing. Spray this product 6-8 inches from soft surface until wet. Do not saturate. Let stand for 30 seconds. Allow to air dry. During a concurrent interview and review of the Shurguard Ultimate (Food Contact Sanitizer/Disinfectant) on 3/24/23 at 12:08 a.m., the surveyor met with the DON (Director of Nursing), Maintenance Manager, and the Rehabilitation Manager to go over the sanitizer solution dietary staff was supposed to use in the kitchen to clean the kitchen countertops. The Maintenance Manager stated the dietary staff were supposed to use the Purell spray bottle solution for the countertops per oversight with the Infection Preventionist. The Shurguard was supposed to be used for the three-sink compartment (manual procedure for cleaning and sanitizing the dishes). The Rehabilitation Manager stated she trained the dietary staff to use the Purell sanitizer to sanitize the kitchen countertops. The Rehabilitation Manager was asked if she was a qualified Certified Dietary Manager whose duties included training the dietary staff on sanitation procedures. The Rehabilitation Manager stated she was not qualified to act as the Dietary Manager. The Shurguard Ultimate directions were for both sanitizer (a quat solution, reduces the number of germs on a surface, safe for food to come in contact with, and does not need to be rinsed) and a disinfectant (kills most germs, the solution is a stronger concentration, not safe for food to come in contact with, so the surfaces that come in contact with food needed to be rinsed with potable water after using the sanitizer as a disinfectant) use on countertops. The wet time for using the Shurguard Ultimate solution as a sanitizer was 1 minute and use as a disinfectant was 10 minutes. The facility P/P titled, Shelves, Counters and Other Surfaces Including Hand Washing Sinks, dated 2018, indicated: Cleaning Procedure: . 3. Spray or wipe with Quaternary bucket solution containing sanitizer. Read sanitizer directions to learn how long surface is to remain wet. Use enough sanitizer to meet this time. Do not rinse. 3. During an observation on 3/22/23 at 10:25 a.m., [NAME] B used the soapy water in the green bucket to wipe the countertops off after finishing making the meatloaf with the added ground turkey. [NAME] B then used the clean water from the blue bucket to wipe the soapy countertops but stopped there and did not sanitize the countertops. During an interview on 3/22/23 at 10:35 a.m., the Dietary Supervisor was asked if [NAME] B should have sanitized the countertops after he finished preparing the meatloaf, whereby meat particles landed on the countertops. The Dietary Supervisor stated [NAME] B should have sanitized the countertops, but he forgot to. The Dietary Supervisor then cued [NAME] B to sanitize the countertops after preparing the meatloaf. [NAME] B stated he would normally sanitize the countertops, but he got busy with food preparation closer to tray line, his head went in multiple directions and he forgot to sanitize the countertops. The facility job description titled, Cook, revised 10/17, indicated: . Follow established Infection Control and Universal Precautions policies and procedures when performing daily tasks . 4. During and observation on 3/22/23 at 11:30 a.m., [NAME] B was observed not wearing an apron over his sweatshirt when cooking and/or for washing dirty utensils/equipment. [NAME] B was observed wearing a sweatshirt while cooking and going back and forth between cooking/the food prep area and the dirty dishwasher area where he was washing his cooking utensils/equipment and then going back to preparing the food/placing the food on the steamtable and plating the food for the residents' lunch. Both dietary aides and the 2nd cook had a cloth apron on while preparing the food/getting trays read for the tray line. During an observation and interview on 3/22/23 at 12:45 p.m., Dietary Aide C stated she used a cloth apron when working with food, when on the tray line and preparing the residents' meal tray. Dietary C stated she used a disposable plastic apron when washing dishes. Dietary Aide C pointed to her cloth apron placed on the hook near the coffee machine and kitchen door leading to the hallway. [NAME] B was observed washing his cooking utensils/dishes without a disposable apron over his clothes. During an interview on 3/23/23 at 8 a.m., the Dietary Supervisor stated the dietary staff used a disposable apron to wash dishes and a cloth apron while preparing foods such the hamburger and ground turkey and when cooking to prevent cross contamination. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD has never overseen him. The facility P/P titled, Dress Code For Women and Men, dated 2018, indicated: Purpose: Appropriate dress in the Food and Nutrition Department. Personal hygiene and appropriate dress are very important part of the total appearance of Food and Nutrition Services Department. All clothing should be in good repair. Appearance is very important in maintaining a high standard of food service. The following recommendations are made: . Men: . 5. Clean apron, plastic or cloth . The facility job description titled, Registered Dietician (RD), revision 10/2017, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the RD would monitor General Sanitation and Safety: . 17. Competency of the staff is routinely done and documented . Food Preparation: . 18. All food production surfaces are cleaned and sanitized after use. The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . The facility job description titled, Personnel Management, dated 2018, indicated: Policy: A qualified FNS (Food and Nutrition Service) Director, chosen by the Administrator, is responsible for the total operation of the Food and Nutrition Services Department. All Food and Nutrition service is performed under their direction. (Note the Dietary Supervisor was not a Certified Dietary Manger/had not completed the Dietary Management Program). Procedure: If a person is not a RD, he must meet the Federal and State laws and receive regular consultation from the RD or have met equivalent requirements. Responsibilities of FNS Director: . Food and Nutrition service orientation, staffing, supervision, staff training and in-servicing . Maintaining Acceptable standards of Sanitation and food safety. Responsibilities of the Consultant Dietician: . The Dietician will provide staff development programs, (in-servicing) for FNS . that assure the professional food and nutrition service needs of the facility are met. This will include, but is not limited to sanitation inspections . and enforcement/education of State, County and Federal regulations .

Based on interview and record review, the facility failed to designate a qualified staff member to function in the role of Infection Preventionist (IP) (individual responsible for the facility's activities aimed at reducing the spread of disease by collecting and analyzing data on healthcare-associated infections, identifying outbreaks, and using appropriate prevention strategies to prevent and control further spread), per the facility's assessment plan. This failure created potential for inability to implement programs and activities to prevent and control infections in a population of vulnerable residents, which placed 33 of 33 Residents at risk for infections. Findings: During an interview on 03/22/23 at 12 p.m., the Director of Nursing (DON) and Licensed Nurse A (LN A) were asked about the IP at the facility. The DON stated the IP had quit working at the facility approximately five to six weeks earlier. During and interview on 03/22/23 at 4:01 p.m., the DON stated the facility did not have a full-time IP Nurse, as the prior IP nurse left her position at the facility in early February, 2023. The DON stated the facility's goal was for LN A (who worked as an IP at another facility) to transition into the IP position in April, 2023. The DON stated two nurses were currently out on medical leave and LN A needed to work the floor (as a charge nurse) until their return. The DON stated the facility was able to, piece (IP duties) together. She stated LN A, Consultant E did some of the work and she (the DON) and other nurses, helped. Review of facility document titled, (Facility Name), subtitled, Facility Assessment, subtitled, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, further subtitled, Staffing Plan, (dated 1/25/2023) indicated, Nursing Service Staffing Plan . Infection Preventionist: 40 hrs. qwk (hours per week) . Review of the facility's IP job description titled, Infection Preventionist (CA), subtitled, Purpose of Your Job Position (reviewed 01/27/23), The primary purpose of your job position is to plan, organize, develop, coordinate, direct, and implement the facility's Infection Prevention and Control Program (IPCP) and its activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs . to ensure that an effective infection control program is maintained at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the call light system was accessible to residents while lying on the floor in the restrooms for residents in 19 of 21 rooms. This failure created the potential for residents, who fell while using the restroom, from activating the call light system and summoning help. Findings: During an observation and interview on 3/22/23, at 8:50 a.m., with the Director of Maintenance (DM), the restrooms used by residents in 19 of 21 rooms (Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 19, 20, 21, 2, 23, 24 and 25) were inspected. All the restrooms had the call light button located next to the toilet at elbow level from a resident sitting on the toilet. There was no string or cord from the call light button reaching the floor. The DM measured the height of the call light button in all restrooms and stated it was 36 inches from the floor. During a simulation of a fall from the toilet in the restroom used by residents in rooms [ROOM NUMBERS], it was not possible to reach the call light while lying on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify a physician of a change in condition for one of three un-sampled residents (Resident 45). This failure had the potential to result in physical decompensation of Resident 45, which could have contributed to discomfort and suffering during Resident 45's end of life process. Findings: A facility document titled, Face Sheet indicated that Resident 45 was admitted to the facility on [DATE] with Medical Diagnoses including Left Femur (Thigh bone) Fracture, Hearing Loss, and Cognitive Communication Deficit (Difficulty communicating). Resident 45's MDS (Minimum Data Set-U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes) dated 5/21/19 indicated her BIMS (Assessment tool. Range of MDS scores: 13-15= intact cognition, 8-12=moderately impaired cognition, 0-7=severely impaired cognition) score was 0, which indicated her cognition was severely impaired. A facility document titled, Change of Condition dated 6/15/19 at 6:27 a.m. written by Licensed Staff H revealed, Change in Condition: Symptoms or signs noted of condition change: Nausea/Vomiting .Notifications: reported to primary care clinician: [Physician E] Date and time of Clinician Notification: 06/15/19 6:45 AM. During a phone interview on 8/29/19 at 3:00 p.m., Licensed Staff H stated that Resident 45 had a small emesis during his shift on 6/15/19, therefore, he decided to initiate Change of Condition documentation for her. Licensed Staff H stated he faxed Physician E to notify her of Resident 45's episode of emesis but did not remember if he received verification that the fax went through. Licensed Staff H indicated although Resident 45 had a small emesis, based on his assessment, the change of condition did not warrant a call to Physician E since there were no alarming signals. Licensed Staff H stated that Resident 45 did not have fever, had good bowel sounds and exhibited no obvious signs or symptoms of pain or discomfort. Licensed Staff H, stated he shared all the information on the change of condition with the oncoming shift (Morning shift). A facility document titled, Change of Condition dated 6/15/19 at 3:26 p.m., written by Licensed Staff F, assigned to Resident 45 on 6/15/19 for morning shift indicated, Monitoring for emesis, (+) emesis (positive for emesis) this shift, encouraged to have sips of water, appears to be dehydrated. During an interview on 8/29/19 at 8:21 a.m., Licensed Staff F confirmed she received report (from the night shift nurse) indicating that Resident 45 was having emesis. Licensed Staff F stated that she let Resident 45 stay in bed and ordered hot chicken noodle soup to help relieve her upset stomach. Licensed Staff F stated that she checked Resident 45 periodically during her shift. Licensed Staff F stated that Resident 45 did not have an episode of emesis (threw up) during her shift (contrary to her documentation on 6/15/19 at 3:26 p.m. in which she documented, (+) emesis this shift). Licensed Staff F also stated that she was not sure if Resident 45 was dehydrated, although she tried to give her fluids (contrary to her documentation on 6/15/19 at 3:26 p.m. in which she documented, [Resident 45] appears to be dehydrated). Licensed Staff F stated that she did not call the Physician E to notify her of Resident 45's change of condition. Licensed Staff F stated she understood Physician E had already been faxed. An Incident Note dated 6/15/19 at 6:49 p.m., written by a Licensed Nurse assisting Licensed Staff G indicated, At approx. (approximately) 1615 (4:15 p.m.) the side 2 nurse asked me to come to room [ROOM NUMBER]C. When I entered the room and observed the resident, it appeared she was not breathing. I checked apical, carotid and radial pulses which were absent .I then phoned [Physician E] and explained resident [Resident 45] had no vital signs .She [Physician E] wanted to know why she was not notified of her [Resident 45's] change of condition. Noc nurse in fact placed resident on change of condition and notified MD via fax .The local police department along with ambulance showed up and agreed there was an absence of vitals .The coroner released the body to the mortuary. During an interview on 8/29/19 at 8:38 a.m., Licensed Staff G, Resident 45's assigned Licensed Nurse during PM shift on 6/15/19, confirmed resident 45 definitely had a change in condition compared to prior shifts. Licensed Staff G stated the day before Resident 45's death, Resident 45 had an episode of emesis but her breathing was regular. Licensed Staff G stated on 6/15/19 Resident 45 was, Having work of breathing and pale. Licensed Staff G stated the Certified Nursing Assistants expressed concern. Licensed Staff G stated she did not call Physician E because she thought it had already been done. Licensed Staff G confirmed she received report from the previous shift regarding Resident 45's change of condition. Licensed Staff G stated she was not able to take Resident 45's vital signs prior to her death because she was busy passing medications. While she did not take Resident 45's vital signs, Licensed Staff G stated she did go into Resident 45's room and completed an assessment. During the assessment, Licensed Staff G noted that Resident 45 was having difficulty breathing and looked pale. Licensed Staff G stated she thought about calling Physician E if this situation continued, but the resident passed away before any further actions could be taken. Licensed Staff G stated she took this incident as a learning opportunity because she knew she had failed. Licensed Staff indicated she knew that even if the previous shift mentioned having called the physician, she personally had to follow up on it during a change of condition. During a phone interview on 8/29/19 at 11:20 a.m., Physician E stated she was not notified of Resident 45's change in condition until Resident 45 had passed away, and was very surprised about the information given. Physician E stated she had a conversation with the nurses about the lack of notification. Physician E stated Resident 45 had a similar incident the week before in regards to having emesis and similar symptoms but the daughter did not want anything done for the resident. Physician E stated the nurses documented that they faxed the physician, but Physician E never received any faxes from the facility about Resident 45. Physician E stated there was poor communication, and this needed to not happen again. Physician E stated in this case, Resident 45 was receiving comfort care, and her death was expected. However, Physician E indicated she needed to be notified of changes in condition and told facility staff, You need to call me. A facility document titled, Care Plan on Nutrition initiated on 3/20/19 indicated, Monitor and report to MD (Medical Doctor) as needed for any s/s(signs/symptoms) of: decreased appetite, N/V (nausea/vomiting), unexpected weight loss, c/o (complaints) stomach pain, etc. During an interview on 8/29/19 at 9:04 a.m., the Director of Nursing (DON) stated the physician could be faxed or called for a change of condition, and it depended on the assessment and history of the resident. The DON stated that in this case, she would have expected one of the assigned Licensed Nurses (on 6/15/19) to call the physician about Resident 45's change of condition, and had a conversation with the Licensed Nurses that evening. The DON stated the Licensed Nurses did not realize they should have called. During an interview on 8/30/19 at 9:25 a.m., the Director of Staff Development (DSD) stated if a Resident was having difficulty breathing and looked pale the physician had to be notified by phone, even if the resident was on comfort measures. Facility policy titled, Change of Condition, last revised in May of 2015, indicated, Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The Licensed nurse in charge will notify the physician .If unable to reach physician, all calls to physicians or exchanges requesting callbacks will be documented on the nursing progress notes .If unable to contact attending physician or alternate timely, notify Medical Director for response and follow-up to change in resident status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate Nursing Plans of Care for two fractures for one of five sampled residents (Resident 44). This failure had the potential to result in inability to provide effective person-centered care of the resident and meet professional standards. Findings: A facility document titled Face Sheet, revealed Resident 44 was initially admitted to the facility on [DATE] with Medical Diagnoses including Lack of Coordination, Unsteadiness on Feet and Hearing Loss. Resident 44's MDS (An assessment tool) dated 7/10/19 indicated his BIMS (An assessment tool) score was 3, which indicated his cognition was severely impaired. Resident 44's MDS also indicated he required extensive assistance with transfers, and limited assistance while walking in his room. Resident 44's MDS, signed by MDS Coordinator on 8/20/19 at 4:54 p.m., indicated Resident 44 had not had any falls in the facility. During an interview on 8/27/19 at 2:33 p.m., Resident 44's wife stated he had two falls in the facility that resulted in fractures. She stated that as a result of one fall, Resident 44 broke his hip, and as a result of another fall, Resident 44 broke his right femur (Thigh bone). First Fall with Fracture: Nursing Notes dated 7/22/19 (no time documented) indicated, Resident was sitting in his w/c (wheelchair) amongst peers in front of the nursing station at 1940 (7:40 p.m.), he proceeded to stand up which resulted in him falling .He fell on his R (right) side .Resident exhibited s/s (signs/symptoms) of pain to his R hip .MD (Medical Doctor) was notified & gave order to send to ER (Emergency Room) for Eval (evaluation). A facility document titled, admission Note dated 7/26/19 at 5:14 p.m. revealed, Resident being admitted for therapy for hip fracture. Nursing Plan of Care for falls dated 7/26/19, indicated the Plan of Care was revised, and a new intervention was added, Pressure pad alarm for bed and wheel chair. Floor mat alarm to right side of the bed. A comprehensive Nursing Plan of Care for Resident 44's hip fracture was not initiated after the fall with fracture on 7/22/19. Second Fall with Fracture: A facility document titled, Change of Condition dated 8/11/19 at 5:46 p.m. indicated, At 1045 (10:45 a.m.), the resident was found ambulating without assistance, transferring from his wheelchair to his bed. His chair alarm was sounding, which alerted staff. LN (Licensed Nurse) had just begun to physically support him, when the resident fell to his right side from a standing position .Resident had some difficulty moving his RLE (Right lower extremity) at the hip. He later c/o (complained) worsening pain to his right hip. Given the prior Fx (fracture) and risk of re-injury, his wife at the bedside, requested he be evaluated by the ER. A facility document titled, Interdisciplinary Note dated 8/15/19 at 10:25 a.m., revealed Resident 44 suffered a femur fracture as a result of the fall on 8/11/19, Resident returned yesterday from [Acute Care Facility] with dx (diagnosis) of fx (fracture) right femur. A facility document titled, Care Plan dated 8/11/19 revealed Resident 44's comprehensive care plan was revised and updated with new interventions after the fall on 8/11/19. The interventions included, Room assignment close to the nurses station .Therapy consult for strength and mobility. However, a Care Plan was not initiated for the resident's right femur fracture. During an interview on 8/29/19 at 11:43 a.m., the Director of Nursing (DON) confirmed that there were no care plans for the femur and hip fractures. The DON stated that the expectation was to initiate care plans on all residents' fractures. The DON stated that they were very weak in that area, and needed to work on it. The facility policy titled, Care Planning, last revised in May of 2015, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. The facility policy titled, Charting and Documentation, last revised in July of 2017, indicated, All services provided to the resident, progress toward the care plan, goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise and update a Nursing Plan of Care for one of five sampled residents after Resident 20 suffered a fall at the facility. This had the potential to result in further falls for the resident, with possible injuries, due to the lack of guidance for how to care for the resident after the fall. Findings: A facility document titled, Face Sheet, revealed Resident 20, a [AGE] year-old female, was admitted to the facility on [DATE] with Medical Diagnoses including Spondylosis (Degenerative changes in the spine), Difficulty in Walking, Weakness, and Lesion of the Sciatic Nerve (Main nerve traveling down the legs). Resident 20's MDS (Minimum Data Set-An assessment tool) dated 6/11/19 indicated her BIMS (An assessment tool) score was 0, which indicated that her cognition was severely impaired. Resident 20's MDS also indicated she required extensive assistance with bed mobility, transfers, and locomotion in the unit. An facility document titled, Incident Note dated 7/29/19 at 3:37 p.m. indicated, At 1100 (11:00 a.m.), Resident had a fall incident. She was lying on her bed and may have wanted to get up. Bed alarm sounded off & Pt (patient) was sitting on the floor with the floor mattress on. Call light was not on as Pt has decreased cognition & cannot turn on call light. There was no foreign object around the area, W/C (wheelchair) was beside her bed, no shoes yet as she came out from bed. Pt was mumbling to self, distressed and disoriented. A facility document titled, Fall committee IDT Note dated 7/30/19 at 10:18 a.m. indicated, resident had an unwitnessed fall on 7/29/19. Staff was notified by alarm sounding. Resident was found on the floor next to her bed, sitting on her bottom. No injuries were noted, neuros (neurological assessments) were started .Resident will be placed on a toileting schedule as well as Q15 (every 15) minute monitors. A facility document titled, Fall Risk Evaluation dated 7/29/19 at 4:22 p.m., indicated Resident 20 was at high risk for falls. Resident 20's Nursing Plan of Care for falls, initiated on 11/27/18, only had one new intervention after the fall on 7/29/19. The new intervention, initiated on 7/30/19 indicated, Q15 minute monitors, and was documented by the MDS Coordinator. The other interventions to prevent further falls initiated before the fall on 7/29/19 did not indicate to have been revised or updated after the fall. During a interview on 8/30/19 at 8:54 a.m., with the MDS Coordinator and the Social Services Director (SSD), the MDS Coordinator confirmed that she had added the intervention, Q15 minute monitors, to Resident 20's Nursing Plan of Care on 7/30/19 (one day after Resident 20's fall at the facility). The MDS Coordinator stated the intervention was added following a resident to resident altercation and not for a fall, therefore she did not know why this intervention was put in the Nursing Plan of Care for falls. The SSD stated that currently Resident 20 was not on fifteen minute checks. The MDS Coordinator stated that the Nursing Plan of Care was not always updated after a resident's fall if the resident already had interventions in place. The SSD confirmed that the Nursing Plan of Care for falls had not been updated after the fall on 7/29/19. During an interview on 8/29/19 at 9:11 a.m., the Director of Nursing (DON) stated that the facility's expectation after a resident's fall at the facility was to update the care plan or modify it depending on the root cause of the fall. The facility policy titled, Care Planning, last revised in May of 2015, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. The facility policy titled, Fall Management System, last revised in June of 2018, indicated, When a resident sustains a fall, a physical assessment will be completed by a licensed nurse, with results documented in the medical record .Review of the fall incident will include investigation to determine probable causal factors .Resident's care plan will be updated.

Based on observation and record review, the facility failed to ensure unnecessary drugs were not part of the drug regimen for one of 12 sampled residents (Resident 5). This failure resulted in Resident 5 receiving 14 doses of antibiotics without adequate indication for use. Findings: A review of the clinical record titled, Facsimile Transmittal, dated 4/1/19, revealed a request to Physician A for a penis culture or UA (urinalysis [a test of the urine, used to detect and manage and wide range of disorders and infections]) for Resident 5. The document indicated, Situation: May have UTI (urinary tract infection) or penis infection, discharge noted in brief. MD A responded, Yes to the request. Subsequent Microbiology report of the urine culture dated 4/4/19 revealed, Final Report: >100,000 cfu/ml Escherichia coli, and >100,000 cfu/ml Enterococcus faecalis (positive presence of two microorganisms in the urine sample). During a concurrent interview and record review on 8/29/19 at 2:37 p.m., the Director of Nursing (DON) stated the report was faxed to Physician A. The DON verified the fax was returned to the facility 4/8/19, with a handwritten antibiotic order from Physician A. The facility document titled, Order Recap Report indicated, Cefdinir (an antibiotic in the cephalosporin drug class prescribed to treat infections) Capsule Give 300 milligrams by mouth two times a day for UTI related to PERSONAL HISTORY OF URINARY (TRACT) INFECTIONS for 7 Days ordered by [Physician A] on 4/8/19. A facility document titled, Infection Note, dated 4/12/19 revealed, MD ordered Cefdinir 300 milligrams BID (twice a day) x 7 days on 4/08/19 for UTI. UTI did not meet criteria due to symptoms manifested. MD sent antibiotic acknowledgment due to symptoms manifested . Remains on Cefdinir. An undated facility document titled, Physician Antibiotic Acknowledgment indicated, symptoms manifested do not meet the established criteria for defining infection according to McGreer's criteria .making a medical decision that the benefits outweigh the risks in treating my Resident with antibiotics at this time. The document was signed by Physician A. During an interview on 8/29/19 at 3:44 p.m., Physician A stated he waited for lab and/or culture results before prescribing antibiotics for UTI. Physician A stated he would start a resident on antibiotics before labs or culture results only if they were having signs or symptoms. When queried about Resident 5, Physician A was unable to state why he ordered Cefdinir for him. The facility document titled, Medication Administration Record, dated April 2019, revealed Resident 5 received the antibiotics at 4 p.m. on 4/8/19, twice a day from 4/9/19 to 4/14/19, and at 8 a.m. on 4/15/19. During a concurrent interview and record review on 8/29/19 at 3:56 p.m., when queried about the facility's policy on antibiotic use for UTIs, the DSD was unable to provide a specific policy but stated the facility followed the McGreer Criteria (a standardized guidance for infection surveillance activities and research studies in nursing homes and similar institutions) to evaluate infections. The DSD stated the expectation was to wait for lab and culture results and for residents to exhibit signs and symptoms before they could be started on antibiotics. The DSD stated Resident 5 did not meet the McGreer Criteria for UTI, and verified there was no documented indication for the antibiotic use.

Based on observation, interviews, and record reviews, the facility failed to implement its policies and procedures on storage of medications. This failure resulted in four days of oral administration of an expired over-the-counter medication to one of four sampled residents, Resident 195. Findings: During the medication administration observation and concurrent interview on 8/28/19, at 8:12 a.m., Licensed Staff O prepared and administered six medications to Resident 195. After Licensed Staff O administered the medications to Resident 195, she was asked to review the expiration date of the aspirin EC-Enteric Coated 325 mg tablet that she administered to Resident 195. Licensed Staff O stated it was expired since 5/19. Licensed Staff O also stated she was not checking for expiration dates while she was pouring the medications because she thought that her medication cart was already free from expired medications. She also stated the facility usually has a nurse who check for expired medications from the medication cart and took them out for destruction. During the observation and concurrent interview with the Director of Nursing (DON) on 8/28/19, at 9:35 a.m., inside the medication storage room, three unopened bottles of aspirin EC 325 mg which had expired on 5/19,(the same expired medication that was administered to Resident 195), one unopened bottle of calcium antacid 500 mg, which had expired on 4/19, and ten pre-filled IV (Intravenous) normal saline 0.9% in 10 cc syringes which were expired since 11/2018, were discovered as active supplies in this medication storage room. The Director of Nursing stated that Licensed Staff P was the nurse usually assigned to check for expired medications in the medication carts and in the medication storage room during the weekends. The director of nursing also stated that expired medications were destroyed by two licensed nurses inside the medication room. During an interview on 8/29/19, at 2:35 p.m., Licensed Staff O stated she had been working for the past four days and was giving the same expired aspirin EC 325 mg tablets to Resident 195. Licensed Staff O also stated after the discovery of the expired medication, she brought the medication to the medication storage room and destroyed the contents in the presence of Licensed Staff R. During a review of the clinical record for Resident 195, a facility document titled, Medication Administration Record, (MAR) dated 8/29/19, revealed Licensed Staff O administered the same expired medication from 8/25/19 to 8/28/19. The facility policy and procedure titled, Medication Storage in the Facility, last revised on 8/14, revealed . Outdated, contaminated, or deteriorated medications, and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal.

The facility failed to ensure efficacy of its pest control program when a fly was observed in the kitchen. This failure had the potential to spread bacteria causing gastrointestinal illnesses in an area where food is prepared and served to all 42 residents. Findings: On 8/28/19 at 3:05 p.m., a fly was observed in the kitchen. [NAME] C confirmed the presence of the fly, and stated flies did not belong in the kitchen. During an interview on 8/28/19 at 3:12 p.m., the Certified Dietary Manager (CDM) stated the fly could have flown in when the kitchen doors were propped open when food deliveries came in. During an interview on 8/29/19 at 9:41 a.m., Unlicensed Staff D acknowledged that the facility had one or two flies around once in a while, and stated it has been an ongoing issue though a pest company came in monthly. The facility's policies titled Miscellaneous Areas, dated 2018, indicated Flies are carriers of disease and are a constant enemy of high standards of sanitation in the Food & Nutrition Services Department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide necessary barber/beautician services to the residents of the facility for over three months affecting Resident 28 and Resident 31, who were unable to obtain a routine hair trim for comfort and maintenance. This had the potential for loss of dignity, and feelings of helplessness and discomfort to the residents affected. Findings: A facility document titled, Face Sheet revealed Resident 28 was admitted to the facility on [DATE] with Medical Diagnoses including Parkinson's Disease (A progressive nervous system disorder that affects movement) and Need for Assistance with Personal Care. During a concurrent observation and interview on 8/26/19 at 4:06 p.m., Resident 28 stated they did not have a barber at the facility and he had not had a haircut in four months due to the lack of barber services. Resident 28's hair was covering his ears by about one inch. During a second interview on 8/30/19 at 9:38 a.m., Resident 28 stated he would get a haircut if the facility had a barber. He stated nobody had offered to take him out (of the facility) to get a haircut. A facility document titled, Face Sheet revealed Resident 31 was admitted to the facility on [DATE] with Medical Diagnoses including COPD (Chronic obstructive pulmonary disease- a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing) and Muscle Weakness. During a concurrent observation and interview on 8/28/19 at 12:23 p.m., Resident 31 stated she would like a haircut, but had not been able to get one because the facility did not have a beautician/barber. She stated her hair was one inch-and-a-half too long and she did not like it that long. Resident 31 stated she notified the Social Services Director (SSD) about wanting to get a haircut. Resident 31 stated that the SSD told her they were currently looking for a beautician, and did not offer any type of transportation to town to get a haircut. During an interview on 8/29/19 at 3:59 p.m., Licensed Staff F stated both Resident 28 and Resident 31 were able to express and verbalize their needs and could alert staff of their dislikes. During an initial interview on 8/27/19 at 3:01 p.m., the Administrator stated the facility had been without a barber/beautician for about one month. She stated they had advertised through a social media site but had not been able to find one. During a second interview on 8/28/19 at 9:34 a.m., the Administrator stated volunteer Licensed Barbers/Beauticians sometimes provided haircuts for the facility residents, but no barbers/beauticians had provided services within the last month. During a third interview on 8/28/19 at 11:47 a.m., the Administrator stated the last day that the barber/beautician worked at the facility was on May 24, 2019. The Administrator stated she had posted advertisements in social media sites on 5/24/19, 6/11/19 and 7/4/19. She stated these advertisements were public. The Administrator confirmed no barbers from the community had come to offer services to the residents since May 24, 2019. The Administrator stated if residents communicated they needed a haircut, the facility could arrange transportation to take them to a shop in town, but no residents in the facility had communicated to them that they needed a haircut, therefore, transportation arrangements had not been made. The Administrator provided evidence of the advertisements, but only one was dated, with the date 7/4/19. During record review on 8/28/18 at 12:15 p.m. it was noted that the facility's social media site had two advertisements for a barber, one dated 7/4/19, and another one dated 8/27/19 (one day after the issue was identified during the survey). Another social media site only had one advertisement for a barber (from the facility), and it was dated 8/28/19 (days after the issue was identified during the survey). During an interview on 8/28/19 at 3:50 p.m., the SSD confirmed Resident 31 approached her stating that she wanted a haircut. The SSD stated she told Resident 31 that they were actively looking for a barber/beautician. The SSD stated the plan in regards to routine hair trims for residents was to just wait. The SSD stated she had not arranged transportation for residents to get their hair services outside of the facility. The SSD stated she told Resident 31 that she could ask her friend to take her out for a haircut in town, but the friend stated she did not feel comfortable taking Resident 31 out of the facility because of the risk for falls. The facility policy titled, Resident Rights, last revised in October of 2014, indicated, You have the right to be treated with respect and dignity, including the right to: reside and receive services in the facility with reasonable accommodation of your needs and preferences except when to do so would endanger your or other residents' health or safety. The undated facility document titled, Supplies and Services included in the Basic Daily Rate for Medi-Cal Residents, included in the admission packet for newly admitted residents, indicated, Personal hygiene items and services such as periodic hair trim (are included in the Supplies and Services in the Basic Daily Rate for Medi-Cal Residents).

Based on observations, interviews, and record reviews, the facility failed to provide a safe and effective use of medication to one of four sampled residents when an expired over-the-counter medication (aspirin EC-Enteric Coated 325 mg 1 tablet) was administered to Resident 195. This failure had the potential to cause an adverse drug reaction (an injury from taking medications following a single dose or prolonged administration) to Resident 195. This failure also had the potential to cause ineffective pain relief to Resident 195 who just had a left hip replacement. Findings: A facility document titled, admission Record of Resident 195 dated 8/30/19 , indicated that she was admitted to this facility on 8/20/19. Resident 195's diagnosis included aftercare following a joint replacement surgery, presence of artificial left hip joint, essential hypertension, and pain, unspecified. During medication administration observation and concurrent interview on 8/28/19, at 8:12 a.m., Licensed Staff O prepared and administered six medications to Resident 195. After Licensed Staff O administered the medications to Resident 195, she was asked to review the expiration date of the aspirin EC 325 mg tablet that she administered to Resident 195. Licensed Staff O stated it was expired since 5/19. Licensed Staff O stated she was not checking for expiration dates while she was pouring the medications because she thought her medication cart was already free from expired medications. She also stated the facility usually has a nurse who check for expired medications from the medication carts and took them out for destruction. During an interview the Director of Nursing (DON) on 9/29/19, at 9:46 a.m., she stated it was the responsibility of Licensed Staff O to check for the expiration dates of the medications that she was giving. The Director of Nursing also stated Licensed Staff P was usually assigned to check for expired medications from the medication carts and the medication room. The Director of Nursing also stated that Licensed Staff P checked for any expired medications during weekends. During an interview on 8/29/19, at 2:35 p.m., Licensed Staff O stated that she had been working the past four days and was giving the same expired medication to Resident 195. Licensed Staff O also stated after the discovery of the expired medication, she brought the medication to the medication storage room and destroyed the contents in the presence of Licensed Staff R. During a review of the clinical record for for Resident 195, a document titled, Order Summary Report, dated 8/30/19, revealed Resident 195 was ordered aspirin EC 325 mg 1 tablet by mouth daily for 30 days for prophylaxis (preventive treatment). During a review of the clinical record for resident 195, a facility document titled, Medication Administration Record (MAR) revealed Licensed Staff O administered the same expired medication from 8/25/19 to 8/28/19. The facility policy and procedure titled, Medication Storage in the Facility, last revised on August 2014, revealed . E. The nurse will check for the expiration date of each medication before administering it. F. No expired medication will be administered to a resident. G. All expired medication will be removed from the active supply and destroyed in the facility regardless of amount remaining. The medication will be destroyed in the usual manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A facility document titled,Medication Administration Record (MAR), dated 8/29/19, revealed Resident 33 received a PRN (as needed) hydrocodone/acetaminophen 5-325 mg tablet (a combination of opioid 5 mg and Tylenol 325 mg tablet) on 8/26/19, at 9:15 p.m. for pain. The medication was administered by Licensed Staff H. On 8/27/19, at 3:56 a.m., Licensed Staff Q administered the same medication to Resident 33 for his pain. A facility document titled,Controlled Substance Accountability Sheet for hydrocodone/acetaminophen 5-325 mg tablet which started on 8/1/19, revealed on 8/26/19 and 8/27/19, Licensed Nurse H and Licensed Staff Q did not chart on this document that Resident 33 received these pain medications. The document revealed, Charting on the medication record is required for each dose administered. During an interview with the director of nursing (DON) on 8/29/19, at 3:50 p.m., she stated that it was her expectation that the licensed nurses were documenting on the Controlled Substance Accountability Sheet for each dose that was administered to Resident 33. 3. During an interview on 8/26/19, at 4:24 p.m., Resident 42 stated she has been at this facility since 7/25/19. When she was asked if she has a wound on her right foot, she stated, I have a pressure sore on my heel. When asked if this wound was present prior to being admitted to this facility, she stated, Yes, I had this sore even before I was admitted to the acute care hospital. During a dressing change observation and concurrent interview on 8/30/19, at 10:32 a.m., in Resident 42's room, Licensed Staff P measured the wound at 2 cm x 0.6 cm x 0.1 cm. Licensed Staff P was asked if this pressure wound was present on admission, he stated, Yes. A facility document titled,Licensed Nurse Initial Assessment Record dated 7/25/19, at 11:30 a.m., revealed Resident 42 did not have any pressure ulcers upon admission. During an interview on 8/30/19, at 11:20 a.m., Licensed Staff P stated he remembered doing the initial skin integrity assessment on Resident 42. He stated that Resident 42's heels were red but blanching (skin returning to its normal color after pressure was applied to the affected area and then released). He also stated that the heels were boggy(soft) but was not fluid filled or purple in color indicating deep tissue injury. A facility document titled,Physician's Progress Notes, dated 7/26/19, written by Resident 42's primary physician revealed he reviewed the History and Physical and Discharge Summary of Resident 42 and wrote the following: Left Acetabular (hip socket) Fracture, Type 1 Diabetes Mellitus, History of CVA (cerebrovascular accident) with right sided weakness, Hypertension, Chronic Kidney Disease, Right Foot Drop, and Pressure Blisters on Right Heel. The facility's policy and procedure titled, Charting and Documentation, last revised on 7/17, revealed that: Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Based on interview and record review, the facility failed to ensure that complete and accurate medical records were kept when: 1) Showers/baths were not documented for one of five sampled residents on the resident's scheduled shower days, 2) Two narcotic medications were not documented on the control substance accountability sheet, and; 3) admission assessment documentation was inaccurate for one un-sampled resident that had pressure wounds on the heels. This failure resulted in care, services and assessments not documented accurately, which in turn did not reflect the care, services and assessments provided across all disciplines, potentially placing the residents at risk for inadequate care. Findings: 1) A facility document titled, Face Sheet) revealed Resident 30 was initially admitted to the facility on [DATE] with Medical Diagnoses including Osteoarthritis (A condition that occurs when the protective cartilage that cushions the ends of the bones wears down over time), Hypertension (High blood pressure) and Muscle Weakness. Resident 30's MDS (Minimum Data Set-An Assessment tool) dated 7/9/19 indicated his BIMS (An assessment tool) score was 10, which indicated his cognition was moderately impaired. Resident 30's MDS also indicated he required extensive assistance with personal hygiene, and physical assistance in part of the bathing activity. Resident 30's Nursing Plan of Care on Activities of Daily Living initiated on 4/2/14 indicated, Dressing, personal hyg (hygiene), Grooming: Extensive assist (assistance). A facility undated document titled, Assignment Sheet indicated Resident 44 was scheduled for showers Wednesday and Saturday of every week. Review of a document titled, Activities of Daily Living dated 8/10/19 and 8/21/19 revealed no showers/baths were documented on 8/10/19 and 8/21/19, Resident 30's shower days. The documentation did not indicate that he received a shower/bath, or refused the service. During an interview on 8/29/19 at 11:30 a.m., the Director of Staff Development (DSD) stated the two Certified Nursing Assistants who were assigned to Resident 30 on 8/10/19 and 8/21/19 inadvertently (accidentally) documented the baths/showers incorrectly. The DSD stated on 8/10/19 Resident 44 refused the shower, and on 8/21/19, a shower was given but the Certified Nursing Assistant forgot to document it. During an interview on 8/29/19 at 12:00 p.m., Unlicensed Staff L, assigned to Resident 30 on 8/10/19, stated Resident 30 refused the shower on 8/10/19 but she accidentally clicked the wrong button when documenting the refusal, therefore the documentation did not reflect the shower refusal. During an interview on 8/29/19 at 11:03 a.m., the DSD stated that shower refusals had to be documented. During an interview on 8/29/19 at 12:05 p.m., Unlicensed Staff M, Certified Nursing Assistant assigned to Resident 30 on 8/21/19, stated she did provide Resident 30 with a shower on 8/21/19 but forgot to document it. She stated that the requirement was to document residents' showers when they were given. Unlicensed Staff M stated she did not check her documentation at the end of the day for accuracy and completeness and knew her documentation was horrible. The facility policy titled, Charting and Documentation, last revised in July of 2017, indicated, All services provided to the resident, progress toward the care plan, goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record .Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate .Documentation of procedures and treatments will include care-specific details including: e. Whether the resident refused the procedure/treatment.

4. During the medication administration observation on 8/28/19 at 11:45 a.m., Licensed Staff N was observed handing Resident 10 her inhaler which was ready for inhalation. After Resident 10 did one inhalation, Resident 10 closed the cover of the inhaler and handed it back to Licensed Staff N. The mouthpiece of the inhaler was not wiped dry by Resident 10 or Licensed Staff N prior to closing the cover of the inhaler. Licensed Nurse N then placed the inhaler inside the pocket of her scrub top. Licensed Staff N was observed placing a small container of glucometer test strips and a pair of gloves inside the same pocket of her scrub top. During an interview on 8/28/19, at 3: 46 PM, Licensed Staff N was asked if placing Resident 10's inhaler, a small container with glucometer test strips, and gloves in her pocket was an appropriate infection prevention and control practice, she stated, That was a no-no. Licensed Staff N also stated she was not supposed to put any medications in her pockets because of infection control issues. During an interview on 8/29/19, at 9:46 a.m., the Director of Nursing (DON) stated it was her expectation that licensed nurses were not supposed to be putting resident's inhalers in their pockets for infection prevention and control practices. The facility's policies and procedures titled,Infection Prevention and Control Program, last revised on 5/17, indicated in its policy statement: a. The infection Prevention and Control Program is a facility-wide effort involving all disciplines and individuals, and is an integral part of the quality assurance and performance improvement program. b. The elements of the Infection Prevention and Control Program consist of coordination/oversight, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The goals of the Infection Control Program are to: a. Decrease the risk of infection to residents and personnel b. Recognize infection control practices when providing care c. Identify and correct problems relating to infection control practices d. Ensure compliance with state and federal regulations relating to infection control. e. Promoting resident's rights and well-being while trying to prevent and control the spread of infection f. Monitor employee health and safety. Based on observation, interview and record review, the facility failed to follow infection control procedures when: 1) Two Certified Nursing Assistants were observed contaminating their hands and continuing to work without sanitizing them while assisting residents with dinner, 2) A clean linen cart was observed partially open and unattended in one of the facility's hallways, 3) Vital signs equipment was not disinfected between resident uses, and; 4) A Licensed Nurse was observed placing medical supplies in the pocket of her scrubs while provided direct resident care. This had the potential for causing food-borne illnesses, and spread of infections to the residents of the facility. Findings: 1) During an observation on 8/26/19 at 5:36 p.m., two Certified Nursing Assistants were observed feeding two residents simultaneously without performing hand hygiene in between residents. Unlicensed Staff B was observed touching a first resident's wheelchair, and proceeding to use a second's resident's spoon to assist her with dinner, without sanitizing his hands in between residents. Unlicensed Staff B was observed assisting a third resident with dinner, therefore using the resident's spoon without sanitizing his hands. At one point during the observation, Unlicensed Staff B got up from his chair to check on a fourth resident at another table, and during the process touched the resident's oxygen concentrator (A medical device that concentrates oxygen from environmental air and delivers it to a patient in need of supplemental oxygen), and proceeded to return to his table to continue assisting residents with meals without sanitizing his hands. Unlicensed Staff I, who was also sitting in the same table with Unlicensed Staff B, was observed assisting two residents simultaneously with meals, including spoon feeding them, touching their water cups and napkins, without sanitizing her hands in between residents. During a second observation on 8/26/19 at 5:48 p.m., Unlicensed Staff B was observed wiping a resident with a fabric napkin, since the resident has spilled food on her clothes. During the process, the soiled napkin fell on the floor and Unlicensed Staff B picked it up with his bare hand. At that moment, Unlicensed Staff I asked him to get her a clean fabric napkin for another resident. Unlicensed Staff B was observed picking up and delivering the clean napkin to the resident without sanitizing his hands after having picked up the dirty napkin from the floor. During an interview on 8/27/19 at 2:46 p.m., Unlicensed Staff B confirmed feeding two residents simultaneously without sanitizing his hands in between. Unlicensed Staff B stated he usually washed his hands when they had touched food or were visibly soiled. Unlicensed Staff B confirmed not sanitizing his hands after picking up the soiled napkin from the floor on 8/26/19 during dinner. Unlicensed Staff B stated he should have placed the soiled napkin in the laundry bin and washed or sanitized his hands prior to delivering the clean napkin to the other resident. 2) During an observation on 08/26/19 at 4:41 p.m., Laundry Staff J was observed putting away clean personal residents' clothes. He was using a linen cart that was covered, but had been left partially open on the right side by about two inches. The cover had Velcro strips to keep it closed, but the strips were left unattached. Laundry Staff J left the cart unattended on several occasions as he entered the residents' rooms to distribute the clothing. When asked if the cart should be partially open, Laundry Staff J manually attached the Velcro strips and stated that the cart should be closed all the way. 3) During an observation on 08/27/19 at 3:11 p.m., Unlicensed Staff K was observed using vital signs equipment, including the blood pressure cuff, oxygen saturation finger probe and vital signs monitor on a resident without disinfecting the equipment first. She was observed taking the vital signs equipment from the facility hallway, where it had been sitting unattended for a while, exposed to air, and at risk for being touched by wondering residents and staff. Unlicensed Staff K was then observed taking vital signs, including the blood pressure, pulse, and oxygen saturation on another resident without disinfecting the equipment in between residents. Unlicensed Staff K confirmed that she did not disinfect the equipment prior to taking vital signs on the first resident, but stated that she did disinfect it prior to taking the vital signs on the second resident. She stated that she used a disinfecting wipe, which had a two-minute contact time according to manufacturer's instructions written on the label, for disinfecting the vital signs equipment. Unlicensed Staff K was not observed to have waited two minutes between the two residents during the process of taking vital sings. During an interview on 8/30/19 at 9:25 a.m., the Director of Staff Development (DSD) stated that if staff had touched resident medical equipment, they were expected to sanitize their hands right after. The DSD also stated that if staff picked up a dirty napkin from the floor, they were expected to sanitize their hands before returning to work. The facility policy titled, Prevention of Infection, indicated, Use al alcohol-based rub containing at least 62% alcohol; or, alternatively soap (anti-microbial or non-anti-microbial), and water for the following situations: l. After contact with objects (e.g. [for example] medical equipment) in the immediate vicinity of the resident; p. Before and after assisting a resident with meals. The facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment revised in October of 2018 indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control-A federal agency that conducts and supports health promotion, prevention and preparedness activities in the United States, with the goal of improving overall public health) recommendations for disinfection and the OSHA (The Occupational Safety and Health Administration, an agency of the US government under the Department of Labor with the responsibility of ensuring safety at work and a healthful work environment) Blood-borne Pathogens(Infectious microorganisms in human blood that can cause disease in humans) standard .Durable medical equipment (DME- equipment which can withstand repeated use) must be cleaned and disinfected before reuse by another resident .Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturer's instructions.