**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the physician and resident representative were notified promptly of a change in condition for one resident (#105) out of 21 residents sampled. Findings included: Review of the admission Record for Resident #105 revealed he was admitted to the facility on [DATE]. A review of the contact information showed the resident had a responsible party designated as the POA (Power of Attorney) and Emergency Contact #1. Review of a progress note for Resident #105, dated [DATE] at 05:59 a.m. showed the following: Note Text: Resident experiencing SOB [Shortness of breath], wheeled himself to the nurses' station, CNA [Certified Nurses Assistant] noted that the resident put himself to the floor, and laid down in the nurse's station. Nurse notified, resident assisted to w/c [wheelchair] as SOB increased. Returned to room with assist of 2 staff nurses. Vital Signs were 114/72 97.8 76 26 O2[oxygen] saturation 64%. Audible gurgling sounds in lungs, resident was unable to expectorate. CMO [Comfort measures only] noted, prn [as needed] medications were given at 0415. Staff alerted to observe resident. CNA completed personal care with resident, left room. Nurse entered room, few minutes later, resident appeared to have ceased to breathe-no heart beat noted on auscultation-time of death 0513. MD notified. Significant other notified, gave name & number of Cremation Center-[name of Center]. A care plan, initiated [DATE], showed the resident had expressed code status and had advanced directives in place, including POA designation. On [DATE] at 10:26 AM, an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The DON and ADON reviewed the progress notes for the day the resident expired. The DON stated the progress note showed the resident had a change in condition. She stated the progress note did not show the resident's family/POA and physician were notified at the point of change in condition. The DON stated the family and physician should have been called at that point. The DON stated the nurse who wrote the note was unavailable. On [DATE] at 02:09 PM an interview with Resident #105's attending physician was conducted. He stated he could not remember if he was notified of the resident's change in condition. He said, If a resident had a change in condition, someone should contact their physician and family. If he was on Hospice, Hospice should have been notified to ensure he was comfortable. The attending physician stated the facility should follow their own policies on documentation. A review of a facility policy titled, Acute Condition Changes-Clinical Protocol, Revised [DATE], showed the following: 5. The nursing staff will contact the physician based on the urgency of the situation. For emergencies they will call or page the physician and request a prompt response. 6. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. (a.). The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. 7. The nurse and physician we'll discuss and evaluate the situation.

Based on interviews and record review, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis for one resident (#63) of 8 residents sampled for PASRR's. Findings included: A review of the admission record for Resident #63 revealed an original admission date of 12/30/21 with diagnoses including major depressive disorder, anxiety disorder, Traumatic Brain Injury (TBI), and epilepsy. A review of Resident #63's Level I PASRR, dated 12/15/21, showed only a diagnoses of substance abuse and epilepsy were checked. A review of Resident #63's medical record revealed a new diagnosis of schizoaffective disorder, on 05/22/22, and no documentation a PASRR Level II was completed. A review of Resident #63's medical record revealed a new diagnosis of paranoid schizophrenia, on 05/17/24, and no documentation a PASRR Level II was completed. During an interview on 05/30/24 at 04:22 PM, the Social Services Director, (SSD) consultant stated the PASRR was not correct. She stated if the residents had a new diagnosis of schizophrenia or dementia on the record, they should have resubmitted another PASRR screening. She stated anytime a new diagnosis comes up, or if nurses were reviewing orders and notify a concerning diagnosis, the PASRR should be reviewed and if they needed a Level II assessment, it should be submitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure appropriate use of antibiotics for one resident (#79) out of six residents reviewed for unnecessary medication. Findings included: Review of Medication Administration Records for Resident #79 revealed she was on antibiotics in January, February, and March of 2024 for a urinary tract infection (UTI). Review of admission records showed Resident #79 was admitted on [DATE] with diagnoses including Huntington's Disease, UTI, and hematuria. Review of Resident #79's Lab Results Report, dated 1/10/24 showed the resident had a UTI with bacteria resistant to Levofloxacin. Review of Resident #79's Physician orders showed the resident was ordered Levofloxacin 500mg for a UTI 5 days starting on 1/12/14. Review of Resident #79's Lab Results Report, dated 2/2/24, showed the Urinalysis had no growth. Review of Resident #79's Physician orders showed the resident was ordered Levofloxacin 500mg for a UTI for 5 days starting on 2/1/24. Review of Resident #79's Lab Results Report, dated 3/2/24, showed the resident had bacteria in her urine, however no culture and sensitivity was completed. Review of Resident #79's Physician orders showed the resident was ordered Levofloxacin 500mg for a UTI for 5 days starting 3/1/24. Review of Resident #79's progress notes showed no documentation a provider was called regarding changing or discontinuing antibiotics. An interview was conducted on 5/30/24 at 2:13 p.m. with Resident #79's primary care physician. He stated if he had been called by the facility and notified the resident's culture came back as resistant to Levofloxacin he would have changed the antibiotic. He said with Resident #79's urinalysis that had no growth, the facility should have called, and he would have stopped the antibiotic. He said if he wasn't called, he wouldn't know until a week or two later, when he came to the facility and reviewed the results. He said he did not recall being notified about the antibiotic concerns, and if he was notified there should have been a progress note in the resident's record. An interview was conducted on 5/30/24 at 5:43 p.m. with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP). She reviewed Resident #79's lab results and orders from January, February, and March 2024 and said, These issues should have been caught. She said antibiotic orders are monitored through morning clinical meetings and order listings. The ADON said the doctor should have been notified the bacteria was resistant to the antibiotic ordered and when the urinalysis came back with no growth. She said a culture and sensitivity should have been completed with the urinalysis on 3/2/24 to see what antibiotic was appropriate to use. The ADON said she would expect nurses to look at the lab results and read them completely, making sure they understand what they are reading. She said these concerns should have been caught by the nurse or during the clinical meeting review and the doctor contacted. Review of a facility policy titled Antibiotic Stewardship, revised December 2026, showed the following: Policy Statement Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. Policy Interpretation and Implementation 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. . 9. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as possible to determine if antibiotic therapy should be started, continued, modified, or discontinued.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure one resident (#94) out of one resident sampled was offered timely dental services from an outside source. Findings included: On 5/28/24 at 12:20 p.m. Resident #94 was observed in bed in an upright position, conversing with her roommate Resident #82. Resident #94 expressed she had tooth pain from a broken tooth. Observed Resident #94 touching slightly above her lip and verbally indicated that is where the pain is. She stated she was using over the counter medication provided by a family member. She stated the facility would take the medication away if staff knew about it. During the interview, observed Resident #94 with a swab in her mouth and a small blue bottle labeled [vendor name] on the bedside table in front of her. She stated the swab was dipped in [vendor name] and the medication is to help alleviate the tooth pain. Review of Resident #94's admission Record revealed an original admission date of 2/4/24 and a re-admission date of 5/8/24. Review of Resident #94's current care plan revealed diagnoses to include: chronic pain syndrome, dorsalgia, unspecified, other low back pain, muscle spasm of back, spondylosis without myelopathy or radiculopathy, thoracic region, Type 2 Diabetes Mellitus without complication. Further review of current care plan did not reveal any focus, goals or interventions related to dental care. Review of Resident #94's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, cognitively intact. On 5/29/24 at 12:28 p.m. an interview with Resident #94 revealed she continues to have tooth pain. She stated the tooth pain started months ago. She stated she communicated with facility staff about the tooth pain. Resident #94 stated her tooth broke recently. An observation revealed her touching the right side of her lip and mouth area identifying where she is having pain. She stated she thinks she has an active infection. Resident #94 stated, I've gone through two bottles of [vendor name]. An observation of the bedside table in front of her revealed a clear medicine dispensing cup. An observation revealed a caramel-colored liquid inside the cup, with cotton swabs dipped in the liquid. She stated she had a dental appointment scheduled in December 2023 but could not attend due to being hospitalized . She stated when she was admitted to the facility, she filled out paperwork about services provided which included dental. She stated she filled out the admission paperwork with the Social Service assistant and communicated to her she wanted dental services. She stated, I wasn't put on the list to receive dental services. Resident #94 stated there was no follow-up after talking to the Social Services assistant regarding dental services. She stated she doesn't receive pain medication from the facility for tooth pain. At the time of interview, an observation revealed a lunch meal was brought by the Certified Nursing Assistant (CNA) and Resident #94 started eating. Observed Resident #94 eating shrimp and moving the food to the left side of her mouth. She stated she eats on the left side of her mouth due to the tooth pain. Review of Resident #94's Order Summary Report revealed an order, dated 5/8/24, to include, Ophthalmology/Podiatry/Dental/Psych Services as needed. Review of Resident #94's progress notes revealed no evidence of tooth pain, a broken tooth, or mention of dental services. A review of Social Service's progress notes revealed no documentation regarding offering dental services to Resident #94. A further review of Social Service's progress notes revealed no documentation for rationale of why the resident did not have access to dental services. Review of Resident #94's medical record for assessment documents revealed no evidence related to dental services. Review of Resident #94's medical record revealed an evaluation titled, Social Service admission Evaluation, dated 2/9/24 completed by the Social Service Director. The Social Service admission Evaluation revealed no evidence regarding dental services. Review of Resident #94's MDS Section L - Oral/Dental Status, dated 5/12/24, revealed no response for mouth or facial pain, discomfort, or difficulty with chewing. On 5/29/24 at 3:25 p.m. an interview with the Social Service Director revealed the contracted dental service is with [vendor name]. She stated residents can be referred to dental from nursing or through the residents' request. The Social Service Director stated a referral and permission slip is sent to dental services. She stated the dentist and hygienist come once a month. She stated Social Service's monitors the dental list. The Social Service Director stated the hygienist will send a list to the facility of who was seen by the doctor and/or hygienist. She stated the list of residents seen by the hygienist and doctor can be obtained from Social Service's. She stated dental services through [vendor name] are for residents with Medicaid. A review of [vendor name's] list of scheduled cleanings, dated February to May 2024, showed no evidence of Resident #94 on the list. A review of facility visits from [vendor name] dated 2/19/24, 3/20/24, and 4/24/24, revealed the resident was not treated by the dentist or hygienist. An interview on 5/29/24 at 4:51 p.m. with the Social Service Assistant revealed Resident #94 communicated with her on 5/28/24. She stated the resident is Medicaid pending. She stated [vendor name] sometimes provides Pro bono services. The Social Service Assistant stated Resident #94 had not mentioned to her, prior to 5/28/24, that she wanted dental services. She stated she communicated via email with [vendor name's] appointment scheduler and received an email response on 5/29/24 at 3:00 p.m. that Resident #94 has a dental appointment scheduled on 6/4/24. She stated she has not let the resident know yet. The Social Service Assistant stated she did not have a conversation with Resident #94 upon admission about dental services. She stated the resident may have had a conversation with the Social Services Director that she didn't qualify for dental services through [vendor name], which is why she was not on the dental list. An interview on 5/30/24 at 12:45 p.m. with Staff B, UM/LPN confirmed Resident #94 told her about her tooth pain and wanting to see a dentist. Staff B, UM/LPN stated she cannot recall when the resident told her. She stated she, Carried it on, to Social Service's. Staff B stated Resident #94 may not have been seen by dental previously due to being an, insurance thing. She stated certain times a month dental services will come to the facility. She stated if Resident #94 could not be seen by dental services through the facility, then she should have been referred to outside services. Staff B confirmed the resident does take pain medication. She stated the pain medication is mostly for lumbar back pain. Review of a facility policy titled, Availability of Services, Dental, revealed the following in the Policy Statement: Oral healthcare and dental services will be provided to each resident. The policy further revealed, in the policy interpretation and implementation, the following: .3. Social services will be responsible for making necessary dental appointments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I assessments were completed accurately for five residents (#94, #47, #79, #90, and #87) of forty-four residents sampled. Findings included: 1. Review of Resident #94's admission Record revealed an original admission date of 2/4/24, and a re-admission date of 5/8/24. Resident #94's admission Record revealed diagnoses to include major depressive disorder, recurrent, mild with an onset date of 4/2/24, generalized anxiety disorder with an onset date of 4/2/24, and major depressive disorder, recurrent, moderate with an onset date of 2/4/24. Review of Resident #94's PASRR Level 1, dated 2/13/24, revealed no qualifying mental health diagnosis. A review of the active Clinical Physician Orders, as of 5/30/2024, revealed the following: Duloxetine HCI 30 MG two times a day related to major depressive disorder, recurrent, mild. Start date 5/14/24. 4. Review of the admission Record, dated 5/30/2024, for Resident #90 revealed the resident was admitted on [DATE] and readmitted on [DATE]. The resident diagnoses included brief psychotic disorder (4/10/2024), persistent mood disorder (4/4/2024), anxiety disorder (4/4/2024), mood disorder (12/1/2023), and dementia (10/11/2023). Review of the Minimum Data Set (MDS), dated [DATE], for Resident #90 revealed in Section C - cognitive patters, a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. Review of Resident #90 Pre-admission Screening and Resident Review (PASRR) , dated 9/6/2023, revealed the following: a. Under Section I B - Finding is based on (check all that apply) only documented history is checked. b. Under Section II question 6 - Does the individual have a secondary diagnosis of dementia, related neurocognitive disorder (including Alzheimer's disease) and the primary diagnosis is a serious mental illness or intellectual disability? Yes, is the response c. Under Section II question 7 -Does the individual have a validating documentation to support the dementia or related neurocognitive disorder (including Alzheimer's disease)? The response is yes and other is checked specified to history and physical. d. Under Section IV PASRR Screen Completion: Individual may be admitted to an nursing facility. No diagnosis or suspicion of serious mental illness or intellectual disability indicated. Level II PASRR evaluation not required. 5. Review of the admission Record, dated 5/30/2024, for Resident #87 revealed the resident was admitted on [DATE] and readmitted on [DATE]. Resident diagnoses included schizoaffective disorder, bipolar type (6/6/2023). Review of the Minimum Data Set (MDS), dated [DATE], for Resident #87 showed in Section C - cognitive patterns, a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. Review of Resident #87 Pre-admission Screening and Resident Review (PASRR), dated 5/25/2023, revealed in Section I: PASRR Screen Decision-Making no diagnosis of schizoaffective disorder or bipolar disorder was checked. A review of the facility policy titled, Pre-admission Screening and Resident Review, dated April 2020, revealed the following: Policy Statement: Our facility complies with Pre-admission Screening and Resident Review screens for all new and re-admissions. Policy Interpretation and Implementation. 1. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. 2. The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident are outlined in the evaluation. 3. The preadmission screening program requirements do not apply to residents who, after being admitted to the facility, were transferred to a hospital. 3. Review of the admission record showed Resident #79 was admitted on [DATE] with diagnoses including major depressive disorder and anxiety disorder., and on 3/22/24 diagnoses of paranoid schizophrenia and dementia were added. Review of Resident #79's Preadmission Screening and Resident Review (PASRR) Level I Screen, dated 2/14/24, showed anxiety disorder and depressive disorder. An updated PASRR Level I Screen was not completed when a new diagnoses was added on 3/22/24. An interview was conducted on 5/30/24 at 4:22 p.m. with the facility's Social Services Consultant. She reviewed Resident #79's PASRR and confirmed it should have been resubmitted. She said all new admission PASRR's are reviewed at the Monday through Friday morning meetings and errors should be corrected. She said if a resident goes out to the hospital and receives a new diagnosis, the hospital should do a new PASRR before the resident returns, but if a new diagnosis is received in-house, the provider should let social services know so a new screening can be completed. The Social Services Consultant said social services should also be reviewing the psychiatric providers notes. 2. Review of the admission record for Resident #47 showed an admission date of 04/16/24 with diagnoses to include major depressive disorder, mood disorder, unspecified psychosis, and seizure disorder. Review of a Level I PASRR for Resident #47, dated 04/16/24, revealed a blank PASRR with no qualifying diagnosis checked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During an observation made on 05/28/2024 at 10:00 a.m., Resident #8 was observed sitting in her wheelchair in the hallway. She was presented well-groomed with her hair comb and no signs of distress. Further observation revealed Resident # 8 with a bruise on her right hand. During an observation made on 05/29/2024 at 3:00 p.m., Resident #8 was observed lying down in bed resting with her call light within her reach. Review of Resident # 8 admission record showed she was originally admitted on [DATE] and readmitted on [DATE] with diagnoses to include but not limited to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, paranoid schizophrenia, bipolar disorder. Review of a Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 03 which indicated Resident #8 was severely cognitively impaired. Review of multiple weekly skin assessments, dated 05/14/2024, 05/21/2024, and 05/28/2024, showed Resident #8's skin description was noted as good, skin color normal for ethnic group, and skin condition normal. Further review of the skin evaluation showed Resident #8 had no new skin impairments, note signed by Staff G, License Practical Nurse, LPN Review of a progress note, created on 5/29/2024 by the Director of Nursing, showed Resident #8 was not assessed for discoloration on her right hand until 5/29/2024. During an interview on 05/28/2024 at 10:20 a.m., with Staff F, a Certified Nursing Assistant, CNA, she stated she was the aide assigned to Resident #8. She said she did not know how Resident #8 got the bruise on her hand because it was not on her hand before. During an interview on 05/28/2024 at 10: 40 a.m., with Staff G, License Practical Nurse, LPN, she stated she was the nurse responsible for Resident #8. She stated she did not know Resident #8 had a bruise on her hand. She stated she would notify the Director of Nurses because she does not know what happened to the resident hand. During an interview on 05/29/2024 at 11:00 a.m., with Staff G, License Practical Nurse, LPN. She stated she did not assess the resident's hand and complete a new skin assessment because she told the Director of Nursing about the resident, but she would do a skin assessment when she gets a chance to do it. During an interview on 05/29/2024 at 1:00 p.m., with the Director of Nurses, DON. She stated the nurse that was assigned to Resident #8 reported to her about the bruise on the resident's right hand. She said she and the Assisted Director of Nursing went to assess the resident's hand, but they did not document any of their findings. They concluded that they did not know what happened to her hand. She reviewed the resident's medical record to see if she was on any blood thinner, but after her record review she determined the resident had not taken any anticoagulants or any medication that may have caused her to have discoloration on her skin. The DON stated the expectations were that a skin assessment should have been documented in the resident medical record at the time the assessment was done. Review of the facility policy titled, Skin Assessment Guidelines, undated, showed the following: Purpose: The purpose of this procedure is to provide information regarding identification of skin impairment risk factors and interventions for specific risk factors. Monitoring 1. Evaluate report and document potential changes in the skin Photographic evidence obtained 5. Review of the admission record showed Resident #79 was admitted on [DATE] with diagnoses including Huntington's Disease. Review of Resident #79's progress notes, dated 2/23/24, explained the resident was observed lying on the floor by the nurses' station on her back. The resident had blood coming from the back of her head. The resident was alert and oriented. 911 was called and the resident was sent to the hospital. A second progress note, dated 2/23/24 at 3:29 p.m., explained EMS arrived at 3:36 p.m.; the resident was stable and responding. A progress note, dated 2/23/24 at 9:00 p.m., showed the resident returned to the facility from the hospital. Review of Resident #79's evaluations and progress notes did not show any post fall notes or neurological checks after the fall with head injury on 2/23/24. An interview was conducted on 5/30/24 at 6:55 p.m. with the ADON. She reviewed Resident #79's medical record and confirmed there were no neurological checks or post fall notes documented after the resident's fall on 2/23/24. The ADON said no records came back from the hospital with the resident showing a CAT scan was done and the resident had no bleeding or head injury, therefore neurological checks and notes should have been completed for three days post fall. Review of a facility policy titled Neurological Assessment, revised October 2010, showed the following: Purpose The purpose of this procedure is to provide guidelines for a neurological assessment: 1) upon physician order, 2) when following an unwitnessed fall; 3) subsequent to a fall with suspected head injury; or 4) when indicated by resident condition. Based on observations, interviews, and record reviews, the facility 1) failed to ensure medications were available for two residents (#101 and #19) out of four residents sampled, 2) failed to assess a skin condition for one resident (#8) out of one resident sampled, and 3) failed to ensure neurological checks were completed for two residents (#105 and #79) out of four residents sampled. Findings included: 1. An observation and interview was conducted on 05/28/24 at 2:30 p.m. with Resident #101. He stated he used to be on antiretroviral medications and would like to be on them again. He stated he did not have a way to get his medications. He stated he wanted to stay on the medications. He stated he was taking them prior to a hospital stay but had not taken them since admission to this facility. A review of the admission record showed Resident #101 was admitted to the facility on [DATE] with a diagnosis of [immune deficiency syndrome]. A review of Resident #101's admission Minimum Data Set (MDS), revealed in Section C-Cognitive Patterns, a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. A review of the May 2024 physician orders for Resident #101 showed the resident had no orders for [immune deficiency syndrome] medications. A review of a hospital document titled, Discharge Instructions, dated 04/12/24, showed Resident #101 was discharged from [Name of Hospital] with follow-up instructions as: Go to [name of clinic] - Specialty care center in 1 week. Resume [immune deficiency syndrome] therapy. You can show up on Monday - Friday without an appointment between 8AM and 3PM. The instructions included the address and phone number of the location. A review of a history and physical progress note from [name of Hospital], dated 04/01/24, showed .Patient reports he takes antivirals for his [immune deficiency syndrome] but does not remember the name and has not been to the health department recently. Assessment and plan: He was also found to have CD4 count of 45 for which ID (Infectious Disease) recommended Bactrim and follow-up with the health department. 2. Review of the admission record for Resident #19 revealed a re-admission date of 03/19/22 with a diagnosis of [immune deficiency syndrome]. During an observation and interview on 05/29/24 at 2:45 p.m., Resident #19 was in his room. The resident did not make eye contact during the interview. The resident kept his head down. He stated he was aware of his [immune deficiency syndrome] status and had previously spoken to another physician about his diagnosis. He stated he was not currently taking medications for this diagnosis. He stated he had not been on them for a while and had not had labs to determine his viral load. The resident stated he did not want to take his medications and did not want to interview any further. Review of Resident #19's quarterly MDS, dated [DATE], revealed in Section C-Cognitive and Patterns a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. Review of Resident #19's care plan, dated 04/29/24, showed: Resident was at risk for decline in mental or physical condition related to diagnosis of [immune deficiency syndrome] and the disease process. Resident is undetectable, currently not on any anti-viral medications. Interventions included observing new onset of signs/symptoms of disease progression and for complications related to disease progression and to update physician if noted. An interview was conducted with the Social Services Director (SSD) on 5/29/24 at 3:21 p.m. She stated she did not refer residents for outside services because nursing would do so. She stated if a new admission came and they had a diagnosis such as [immune deficiency syndrome], they review in their clinical meeting. She said, Some type of assessment would follow, usually an initial assessment with nursing. We ask them where they came from, we ask to see if they have psychosocial needs that need to be addressed. We as an IDT (Interdisciplinary team) identify if they need access for medications with particular diagnosis. The SSD stated nursing staff would tell her if the resident required psychotherapy, and she would get the resident help. She stated at this time there were no residents who required outside referral for [immune deficiency syndrome] care. She said, No, I don't know there are residents without medications. Nursing would tell me if someone needed a referral. They have not told me. An interview was conducted on 05/29/24 at 3:44 p.m. with the facility's Psychiatric ARNP (Advanced Registered Nurse Practitioner). She stated she had not discussed Resident 19's [immune deficiency syndrome] diagnosis with him. She said, I have seen him for psych reason, depression, I believe. I did not know if he needed medications. I would not discuss these kinds of diagnoses with them, I think it would be inappropriate. The ARNP stated unless a resident or a staff member brought up a concern, she would not have a reason to discuss it with them. She said, I let them choose what they want to discuss. I don't know if or why he [Resident #19] does not want medications. The ARNP stated the facility should provide the appropriate follow-up regarding [immune deficiency syndrome] treatment for their residents. On 05/29/24 at 4:08 p.m., an interview was conducted with the Primary Care Physician (PCP) listed for Residents #101 and #19. He stated he had not seen Resident #101 but was scheduled to see him the following Thursday. He stated he would not be the one to address [immune deficiency syndrome] treatment. He stated [immune deficiency syndrome] residents should be seen by an [immune deficiency syndrome] specialist at an [immune deficiency syndrome] clinic. He stated he did not do the referral, but the facility should refer the residents. The PCP said, If someone comes in with a [immune deficiency syndrome] diagnosis, they should be handled like any other diagnoses such as diabetes or dialysis. On 05/29/24 at 4:30 p.m., an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). The ADON stated if a resident was admitted with [immune deficiency syndrome] diagnosis, they run their labs to determine where they are. She said, We make sure they have medications. We start with an assessment to determine their needs. The DON stated the SSD should assess the resident to make sure their psychosocial needs are being met. She said, We review their medications with the provider. If they do not have medications, we contact pharmacy and consult with SSD to see about a referral for specialty medications from the community. The ADON stated she was not aware there were residents who did not have medications. The DON, ADON and this surveyor reviewed the resident records for Resident #101 and #19 and confirmed there were no lab orders or a documented process for referral for [immune deficiency syndrome] care. The review showed there was no care plan for Resident #19's refusal for medications. The record further showed these resident's psychosocial needs related to the [immune deficiency syndrome] diagnosis were not documented as being addressed. In a follow -up interview conducted on 05/30/24 at 10:28 a.m. The DON and the ADON confirmed this was a missed opportunity. They stated the two residents should have been connected with a specialist for care and services. The DON stated their expectation was to assess the residents upon admission and schedule a consultation for external services. She stated if a resident needed specialty medications, they would make it happen. She confirmed they did not refer Resident #101 to the health department per the hospital discharge instructions. She said, We should have done it. The ADON stated for Resident #19, I spoke with him yesterday [05/29/24] upon learning he was not on [immune deficiency syndrome] medications. He did say he was on medications before, but not since admission in 2022. I don't know why he does not want medications. Psych should assess him for that. She stated either way, he [Resident #19] should have been assessed and care planned accordingly. Review of a facility policy titled, admission Assessment and Follow up: Role of the Nurse, dated September 2012. showed the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purposes of managing the resident, initiating the care plan, and completing required assessment instruments including the MDS. Steps in the procedure showed: 10. Reconcile the list of medications from the medication history, admitting orders and the previous MAR (Medication Administration Record) if available and the discharge summary from the previous institution according to established procedures. 11. Contact the attending physician to communicate and review the findings of the initial assessment and any other pertinent information and obtain orders that are based on these findings. 13. Contact outside services such as laboratory or diagnostic services as necessary. 3. Review of the admission Record for Resident #105 revealed he was admitted to the facility on [DATE] with diagnoses to include history of falling. A review of the care plan showed a focus initiated on 11/08/23, Resident #105 was at risk for falls and/or fall related injury related to generalized weakness, is impulsive, attempts transfers, has a history of falls, and has poor safety awareness. Review of a document titled, SBAR (Situation, Background, Assessment, and Recommendation) communication Form, dated 02/20/24 showed an evaluation was conducted related to falls. The summary of observations and evaluation showed: The CNA (certified nursing assistant) came and told me that the patient was in the hall and told her that he fell in the bathroom and hit his head. I went to the patients room and found him with a red area on the left side in front of his head. He told me he slipped in the bathroom and bumped his head and was noted with the small scratch and red bump. Called POA and MD and Don. Nurse practitioner was on call, and she ordered head X-ray. Review of a neurological evaluation for Resident #105, dated 02/20/24, showed under instructions: This form should be completed for any unwitnessed fall or other accident/injury with possible head trauma or when indicated by the residence condition. The physician should be notified of any neurological change that requires further evaluation. This evaluation should be completed every 15 minutes x 4, every 30 minutes x 4, then every 1-hour x 4, then every four hours x 4, then every eight hours x 4. The review showed 7 neurochecks were not completed as required. 14 Q4H Check 2 - missed check. 15 Q4H Check 3 - missed check. 16 Q4H Check 4 - missed check. 17 Q8H Check 1 - missed check. 18 Q8H Check 2 - missed check. 19 Q8H Check 3 - missed check. 20 Q8H- Final Check - missed check. On 05/30/24 at 10:26 a.m., an interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). They stated the Neuro checks should have been completed to the final check. The DON stated there should have been post fall assessments to monitor the resident especially after he hit his head. The ADON stated the nurses should have continued with skilled assessments post fall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure medical records were complete for two residents (#104 and #106) out of three residents reviewed for leaving the facility against medical advice (AMA). Findings included: 1. An interview was conducted on 5/29/24 at 11:35 a.m. with a family member of Resident #104. She said Resident #104 signed out of the facility AMA and she was not notified. She said when she spoke with the Nursing Home Administrator (NHA) she was told they did not have any healthcare proxy on file. The family member stated Resident #104 had a history of mental illness and dementia and she doesn't feel like the facility assessed the resident's mental health. The family member said after the resident's admission, they emailed the facility the healthcare proxy as well as some medical history documents. Review of admission Records for Resident #104 showed she was admitted on [DATE] with diagnoses including Hemiplegia affecting left dominant side, dizziness and giddiness, ataxia, cerebral infarction, and ataxia. No mental health diagnoses were mentioned upon admission. Review of Resident #104's medical record did not show any documentation of medical history or healthcare proxy in the electronic record or paper record. The facility confirmed they had no additional records for the resident. Review of emails provided by Resident #104's family showed on 5/8/24 a family member emailed a healthcare proxy and contact information for both resident's children to the Social Services Director (SSD). The SSD confirmed receipt of the email on 5/8/24 and asked for a PDF format of the proxy. On May 9, 2024, at 10:16 a.m. the family member emailed the requested PDF format of the healthcare proxy along with some medical history records. The email also stated I talked with my mother yesterday evening and the conversation did not go well. She was stating that she was leaving the facility and asked me for money so she could leave. I don't know how her behavior was after talking with her but that's why I asked for her to be on the elopement list there. Please have an assessment done on her for elopement risk. Also, please call me and/or my brother with any updates about my mother. On May 9, 2024 at 12:41 p.m. the SSD confirmed receipt of the email. Review of the healthcare proxy showed it was signed/dated 11/27/2021 and signed by two nurse witnesses in New York. In the emailed medical history there was a document, Certificate of Examining Physician, dated 8/29/23, showing [AGE] year old female traveling from city to city due to paranoia and delusional beliefs. Psychosis is interfering with patient's ability to care for herself. Pt needs in pt. stabilization. A second Certificate of Examining Physician, dated 8/29/23, showed The patient is exhibiting signs of paranoia and delusions, believing she is running an investigation for the U.S. Military. She could benefit from inpatient psychiatric care. I concur. An Application for Involuntary admission on Medical Certification, dated 9/1/23, was included in history sent to the facility. An interview was conducted on 5/29/24 at 3:11 p.m. with the SSD. She said she remember Resident #104. She said the resident stated she was oriented and did not want her daughter involved in her care. The SSD confirmed she had communicated with the family and was given information about past psychiatric diagnoses for the resident. The SSD said they tried to do a psych evaluation, but the resident wanted to leave. The SSD said Resident #104 did not come from the hospital with any medical history and the records the family sent in were given to the Interim Director of Nursing (DON) at the time for her to review. The SSD said if the resident had a healthcare proxy it would be in her medical record, both electronic and paper records. An interview was conducted on 5/30/24 at 12:14 p.m. with the Social Services (SS) Assistant. She said when documents are sent to social services they are loaded into the documents section of the electronic medical record and a healthcare proxy would be listed under advanced directives. She said the documents should be put in as soon as they touch our hands. An interview was conducted on 5/30/24 at 12:33 p.m. with the NHA. He said he would have expected whoever received the documents from Resident #104's family to have uploaded them to the resident's medical record. 2. Review of the admission Record for Resident #106 showed she was admitted on [DATE] with diagnoses including seizures, Rhabdomyolysis, and anemia. The resident was discharged AMA on 3/9/24. Review of progress notes showed the following: -3/7/2024 6:00 p.m. Narrative Nurses note Writer was told by a staff member that this resident had her hand in her roommate's face. -3/7/2024 6:39 p.m. Narrative Nurses note Writer called in room by CNA due to this resident being aggressive to her roommate. Writer entered room and observed resident standing on the side of her bed yelling, cursing and screaming. She was shaking and threatened to physically strike writer. She would not state what happened and commented that she is extremely upset with both fist balled. Writer immediately placed this resident on one to one. Police were called and are in route. Risk manager notified (advised he will notify DCF and AHCA). Psych notified - no med orders, okay 1:1 and room change as resident was seen yesterday and will refuse psych meds. -3/7/2024 6:45 p.m. Narrative Nurses note Resident refused to provide a statement regarding the situation that occurred with her roommate and stated she will speak with police directly. There are no additional Nurses' notes in the Resident #106's medical record from 3/7/24 at 6:45 p.m. through her leaving the facility AMA on 3/9/24. An interview was conducted on 5/30/24 at 5:45 p.m. with the Assistant Director of Nursing (ADON). She reviewed Resident #106's medical record. She confirmed there was no documentation after the resident-to-resident situation on 3/7/24 as to what happened or why the resident left two days later. The ADON said there should be a note in the record about the resident leaving AMA. She said if a resident is leaving AMA, staff should try to find out why the resident wants to leave or if there is something they may not understand. She said the nurse should call the doctor then see if they can coach or educate the resident about trying to do a proper discharge. She said if the resident is adamant about leaving the nurse should ensure they know the risk for leaving and sign the AMA documentation. She said the nurses should document the entire situation and everything they did during the process. She said she did not know what happened with the resident and why there was no documentation. She said there is no way to know if the doctor was called or family notified. Review of a facility policy titled Discharging a Resident without a Physician's Approval, reviewed October 2022, showed the following: Policy Statement A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice. Policy Interpretation and Implementation 1. Should a resident, or his or her representative (sponsor), request an immediate discharge, the resident's attending physician is promptly notified. 2. An order for an approved discharge must be signed and dated by a physician and recorded in the resident's medical record no later than seventy-two (72) hours after the discharge. The facility was no able to provide a policy related to incomplete medical records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. An observation on 5/28/24 at 9:50 a.m. revealed an enhanced barrier precaution sign on the door for room [ROOM NUMBER]. Upon observation, there was no evidence of personal protective equipment (PPE) for room [ROOM NUMBER]. Observations of other rooms in the unit with precaution signs revealed PPE supplies hanging on the door to include gloves, masks, and gowns. Further observation of room [ROOM NUMBER] revealed Staff C, Certified Nursing Assistant (CNA) stated out loud she was going into room [ROOM NUMBER] to change the resident. An observation revealed Staff C did not put on PPE when entering the room, as indicated on the precaution sign when staff is providing direct care to residents. An observation on 5/28/24 at 9:51 a.m. of the resident's name outside room [ROOM NUMBER] revealed a pink sticker next to the resident's name. During an interview on 5/28/24 at 9:52 a.m. Staff D, CNA revealed the pink sticker indicates fall risk. She stated the pink sticker does not indicate who the precaution sign is for. Further observation revealed an enhanced barrier precaution sign on the door of room [ROOM NUMBER]. When asked who was on enhanced barrier precautions in rooms [ROOM NUMBERS], Staff D stated, To be honest, I'm not sure. Staff D stated sometimes they are not sure who is on the precaution and why. An observation on 5/29/24 at 12:25 p.m. revealed room [ROOM NUMBER] had a contact precaution sign on the door. An observation on 5/29/24 at 12:57 PM revealed a contact precaution sign was no longer on the door for room [ROOM NUMBER]. An observation on 5/29/24 at 12:58 p.m. with the Assistant Director of Nursing (ADON), Infection Preventionist (IP) revealed she had contact precaution signs in her hand. The ADON/IP stated she just removed the contact signs for room [ROOM NUMBER]. She stated room [ROOM NUMBER] previously had contact precaution signs as recommended by the health department. She stated the resident had Candida Auris (C. Auris). She stated the resident acquired C. Auris from the hospital and that is why he was on enhanced barrier precautions on 5/28/24. She stated the Department of Health (DOH) called her. She stated, The contact from the health department was very persistent that [the resident] needed to be on contact precautions for C. Auris. She stated she spoke to her regional who then communicated with the DOH. She stated because of the regional's and health department's conversation, she was instructed by her regional to take the contact precaution sign down. A further interview with the ADON/IP regarding staff education revealed staff members receive verbal communication about what they need to do for residents who are on enhanced barrier or contact precautions. She stated enhanced barrier precautions is for residents who have wounds, Foley, and/or tube feeding. She stated if there is prolonged contact with the resident who is on enhanced barrier precaution, then the expectation is to wear PPE. An observation of room [ROOM NUMBER]'s bedside table on 5/29/24 at 1:04 p.m. revealed a urinal, containing urine, next to the food from lunch. The meal tray was not observed. The food observed next to the urinal included a bowl, with no lid, containing a soup-like liquid and a wrapped bake good. Based on observations, interviews, and record review, the facility 1) failed to ensure an effective infection control program related to isolation orders for one resident (#95) out of two residents sampled on contact precautions, 2) failed to properly use personal protective equipment (PPE) on two out of four units, and 3) failed to use proper hand hygiene during tray pass on one out of four units. Findings included: 1. An observation was conducted on 5/28/24 at 9:26 a.m. of a housekeeper in room [ROOM NUMBER] with no PPE on. The room had a contact precaution sign posted on the door with no PPE cart at the door. (Photographic evidence obtained). Contact precaution signs were observed to be on room [ROOM NUMBER] and room [ROOM NUMBER], however they were not on the list provided by the facility as being on isolation precautions. An observation of meal service was conducted on 5/28/24 at 12:35 p.m. on the northwest hall. A CNA picked up a tray and delivered it to a resident. She set up the resident's food tray and proceeded to move the resident's personal fan and items on her tray table. The CNA performed no hand hygiene before going to pick up another tray. The CNA delivered that tray and set it up for the resident. She took a bag of trash from that resident's room, disposed of it, went to the common area to speak to someone then returned to the cart to grab another tray without performing hand hygiene. The CNA was observed delivering two more trays and setting them up for residents before performing hand hygiene. Review of admission Record for Resident #95 showed he was re-admitted to the facility on [DATE] with diagnoses including Methicillin Resistant Staphylococcus aureus (MRSA) and Extended Spectrum Beta Lactamase (ESBL). Review of Resident #95's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form, dated 5/21/24, showed the resident was screened and tested positive for Clostridium difficile (C-diff) on 5/19/24 and was on contact isolation precautions. Review of Resident #95's physician order showed the order for Contact Isolation Precautions for C-diff and MRSA were not put in until 5/28/24, 1 week after the resident was re-admitted . An interview was conducted on 5/30/24 at 5:52 p.m. with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP). She said hand hygiene should always be done by staff in between each room while passing trays to residents. She said when any staff in the facility sees a contact precaution sign on the door, they should know what the sign means. She said if the sign is for contact precautions, PPE should be worn anytime someone goes in the room. When discussing doors that have contact precaution signs that may not have contact precaution orders due to a mix up, she confirmed if the sign is on the door, the PPE should be worn because all staff do not know the resident's orders. The ADON reviewed Resident #95's medical record and confirmed the contact precaution order was not put in until one week after he was admitted . She said it should have been put in immediately upon his arrival. She confirmed they have no way of knowing if the sign was put up and PPE was being used in the week prior to the order being entered in the computer. Review of a facility policy titled Handwashing/Hand Hygiene, revised August 2019, showed the following: Policy Statement The facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 2. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents l. After contact with objects in the immediate vicinity of the resident p. Before and after assisting resident with meals Review of a facility policy titled Isolation-Categories of Transmission-Based Precautions, revised September 2022 showed the following: Policy Statement Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection, or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Policy Interpretation and Implementation 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. 5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precaution(s), instructions for the use of PPE, and/or instructions to see a nurse before entering the room. Contact Precautions 7. Staff and visitors wear gloves (clean, non-sterile) when entering the room . 8. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (Resident #15) of 45 sampled residents by not scheduling a physician ordered appointment in a timely manner. Findings included: An interview was conducted with Resident #15 on 02/22/2022 at 2:38 p.m. Resident #15 stated that late in November 2021, she noticed a lump in the lower right-side of her abdomen. She stated that she had a hernia that was growing fast and she suffers from pain in her abdomen. She stated she expressed her concern to a nurse and asked her if she could schedule an appointment for her. She stated Staff C, Registered Nurse (RN) Unit Manager had informed her that the facility doctor did not take her medical insurance but would continue to see if she could find one that accepted her insurance. Resident #15 stated she had suggested to Staff C that she could go to the local hospital where she had originally been treated. Resident #15 stated the doctor there accepted her insurance. She stated the facility did not want her to travel to her home area to see that doctor. She stated the appointment had not been scheduled and she had not received any follow-up care related to the hernia. Review of an admission record printed on 02/23/22 showed Resident #15 was admitted to the facility on [DATE]. Resident #15 was admitted with diagnoses to include chronic heart failure with hypoxia, Type 2 diabetes, chronic obstructive pulmonary disease, and Gastro-esophageal reflux disease without esophagitis. A quarterly minimum data set (MDS) dated [DATE] showed Resident #15 had a brief interview for mental status (BIMS) of 15, which indicated intact cognition. Review of active physician orders dated 02/23/22 showed Resident #15 did not have any scheduled appointments related to her hernia and abdominal pain concerns. Review of the electronic medical record (EMR) showed a scanned document, a physician script order dated 11/27/21. The order stated to schedule a GI (Gastrointestinal) consult for hernia. A handwritten part of the script showed four doctors listed with notation that they did not take the resident's insurance. Further review of Resident #15's EMR revealed no other documented information related to the scheduling of the appointment or any follow-up. Review of the EMR showed care notes related to visits made by the Advanced Registered Nurse Practitioner (ARNP) dated 11/08/2021 and 12/13/2021. Resident #15 was seen for complaint for abdominal pain. It further mentioned that the resident was still experiencing pain with a severity of 6 out of 10 on a pain scale with a goal to continue current pain medications. A follow -up was expected in 4 weeks. Review of Resident #15's progress notes dated 01/21/22 to 02/21/22 did not show documentation of attempts to schedule the appointment. An interview was conducted on 02/23/22 at 10:03 a.m. with Resident #15. She stated a nurse had informed her that she would be going to the ER (emergency room) for an assessment of her medical condition. She said the nurses had been aware of the growing hernia and the on-going abdominal pain. During observation and interview on 2/23/22 at 10:30 a.m., with Resident #15, she confirmed she had not been assessed by the physician or nurse practitioner since last year when Staff C, RN, UM brought someone in to look at her. Resident #15 stated she was told the doctor was here three days ago but never came to see her and no one had looked at her growing lump. The resident was provided privacy and she pulled up her gown to expose her right lower abdomen while sitting in her wheelchair. The area of her abdomen appeared distorted, extended, and protruded out while sitting down. The lower portion of the lump was observed with a pink color that the resident confirmed was painful. She stated she got pain medications and let them know it was for her abdomen, but they were all agency nurses, and no one had looked at her. The resident stated that she must use pillows to rest her abdomen on to maintain comfort while lying in bed. On 2/24/22 a review of Resident #15's medical record showed she returned from the hospital on 2/23/2022 at 5:30 p.m. Review of hospital discharge record dated 02/23/22 showed findings on abdominal wall which indicated there were rectus diastases with a ventral hernia along the lower abdomen containing non-obstructed segments of small and large bowel. The hernia sac measured at 12.6 x 7.6 cm (centimeters) transverse and the neck measured 5 x 6 cm. An interview was conducted on 2/24/22 at 4:24 p.m. with Staff C, RN and the Social Services Assistant (SSA). Staff C stated Resident #15 had been sent to the ER to assess abdominal pain related to the hernia. Staff C stated that Staff M, Scheduler, was responsible to schedule appointments. Staff C stated that if a resident needed to see the doctor, they put the information on the communication board. Staff C stated that it was also entered as a physician order so that everyone could follow-up. An attempt to interview Staff M was unsuccessful. The Director of nursing (DON) reported that the employee was out of the building. During an interview with Resident #15 on 2/25/22 at 12:50 p.m., Resident #15 stated that she had been notified that an appointment had been secured in August 2022. Resident #15 expressed frustration with the timing. Resident #15 was noted teary during the interview. She said, why would it take that long? I need medical attention. Review of a change in condition evaluation form for resident #15 dated 02/23/22 showed that signs and symptoms identified abdominal pain that was new or worsening. The evaluation showed a start date of 01/21/22. An interview was conducted with the Director of Nursing (DON) on 2/25/22 at 4:00 p.m. The DON stated that she was aware that Resident #15 had a hernia. The DON stated that she was not aware that it was worsening. The DON stated that if a resident needed to see a doctor, they were to inform the nurse. The DON stated that the nurse communicated with the social services department and Staff M tried to set the appointment. The DON stated that they consider the severity of the medical condition and how soon the appointment needed to be made. The DON further stated they had a hard time trying to secure an appointment for Resident #15. The DON said that the delay was due to not being able to find a surgeon who took the resident's current insurance. DON stated that documentation related to the attempts being made to schedule the appointment would be documented in the EMR. The DON said that the documentation should show on-going physician assessments and hernia changes noted in the nursing assessments. The DON stated that the facility had issues with documentation and that she would be conducting in-services. Review of a facility policy titled, acute condition changes - clinical protocol, revised March 2018, stated that the physician will help identify individuals with a significant risk for having changes of condition during their stay. In addition, the nurses shall assess and document or report all active diagnosis. Review of a facility policy titled, Transfer or discharge, emergency, revised August 2018, showed (9.) the nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. Under treatment and management (3.) If it is decided after sufficient review, that care or observation cannot reasonably be provided in the facility, the physician will authorize transfer to the appropriate setting. Under monitoring and follow -up, the staff will monitor and document the resident / patient's progress and response to treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure respiratory equipment was maintained in a sanitary manner, for one (Resident #29) of 14 sampled residents. Findings included: During a facility tour on 02/22/22 at 11:01 a.m., Resident #29's nebulizer mask and oxygen cannula were observed stored inside an open drawer, the nasal cannula was observed on the floor, and the oxygen tubing was noted tangled inside the drawer and partly on the floor. Photographic evidence was obtained. On 02/22/22 at 2:30 p.m. a second observation of the nebulizer mask, oxygen tubing, and cannula was made and were in the same condition as noted earlier in the day. Review of an admission record for Resident #29 showed that she was admitted to the facility on [DATE] with a diagnosis to include chronic obstructive pulmonary disease (COPD) with acute exacerbation. A quarterly minimum data set (MDS) for Resident #29, dated 12/15/21, showed she had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. On 02/23/22 at 3:26 p.m., a third observation of the nebulizer mask and oxygen cannula was made. The nebulizer mask was stored in an open drawer, exposed to the elements. The nasal cannula and tubing were noted dangling on the floor. On 02/23/22 at 3:28 p.m., an interview was conducted with Resident #29. She said, my nebulizer is usually in this drawer, pointing to where it was. She said, The staff used to keep in a bag. I have not seen one in a while. She stated she did not know when the mask was last changed. She said, I don't know if it has been cleaned recently. Review of physician orders for Resident #29 printed on 02/25/22 showed orders to: change oxygen / nebulizer tubing weekly and PRN (as needed) for prophylaxis. Albuterol sulfate nebulization solution (2.5 mg / 3 ml) 0.083% milliliter inhale orally via nebulizer at bedtime for shortness of breath. Oxygen via nasal cannula as needed - titrate to maintain 2 saturations greater than 92% every shift for COPD. Review of the treatment administration record (TAR) dated 02/01/22 - 02/28/22, indicated to change oxygen and nebulizer tubing weekly and PRN. A care plan with a goal initiated on 05/31/2019 showed Resident #29 had a potential for complications of respiratory distress related to diagnosis of COPD, asthma, chronic hypoxic respiratory failure, emphysema and OSA (obstructive sleep apnea.) Interventions include nebulizer treatments and oxygen saturations as ordered. On 02/24/22 at 8:46 a.m., Resident #29's nebulizer mask and oxygen cannula were observed not stored appropriately, stashed in a drawer, not covered. On 02/25/22 at 10:20 a.m., an interview was conducted with Staff D, LPN (licensed practical nurse). Staff D stated the nebulizer mask and oxygen cannulas, and tubing should be stored in dated bags. On 02/25/22 at 10: 27 a.m., an interview was conducted with Staff E, LPN. Staff E stated that the day nurses monitor storage of equipment. She stated that the nurse should bag the equipment after nebulization treatments. She stated the night nurses were expected to change the tubing. An interview was conducted on 02/25/22 at 10:39 a.m. with staff C, Unit Manager. Staff C stated that the expectation was to maintain the cannulas and mask in a sanitary manner, clean as needed, and change as ordered. Staff C stated that Resident #29 usually moved things around and she should have a bag for her cannula and mask. Staff C looked around and could not find a bag. Staff C stated that the oxygen tubing was too long and that she would ensure that it was changed to the right size. She stated the cannula and mask would be replaced too. She stated the expectation was for the nebulizer mask and nasal cannulas to be bagged and dated. An interview was conducted on 02/25/22 at 11:27 a.m. with the director of nursing (DON). The DON stated that she would expect the nasal cannula, tubing, and nebulizer mask to be stored individually in a bag and dated. The DON stated that the 11:00 p.m. - 7:00 a.m. nurses were supposed to change the cannulas and tubing. She stated that the nurse administering medication should ensure proper storage after administering medication. She reviewed the photographic evidence and stated, that does not look good. She stated the expectation would be to follow the policy and physician orders. The DON said, I expect the nurses to change and store respiratory equipment as ordered. Review of a facility policy titled, respiratory therapy - prevention of infection revised in 2011, showed under steps and procedure #8. to keep the oxygen cannula and tubing in a plastic bag when not in use. Review of a training checklist titled, Oxygen competency check-off dated 03/2020 showed an expectation to secure oxygen tubing in a plastic bag when not in use.

Based on observations, interviews, and policy reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during three of four days of the survey. Findings included: On 02/22/2022 at 9:20 a.m., the initial kitchen tour was conducted with the Certified Dietary Manager (CDM), Staff A, Dietary Aide and Staff B, Cook. An observation was made of the reach in cooler thermometer, located in the back of the cooler on the third shelf, showing a temperature reading of 48 degrees. The digital thermometer on the top of the right door showed a reading of 52 degrees. Staff A, Dietary Aide stated that she was in and out putting items away for lunch and that was why the temperature was off. Inside the same cooler, a stack of white American cheese slices was observed wrapped in clear plastic without a label or date. An observation was made of food debris in the small creamer containers, and sugar packs found behind the reach in cooler. There were two opened and half used bottles of hot sauce with no date, and a container of spices, parsley flakes opened and not dated. An observation was made of a pan on the cook's counter noted with a white grainy substance. The CDM stated it was food thickener. The pan was undated and not covered. On the bottom shelf of the counter was a pan of several unpeeled yellow onions in an open plastic bag. Three of the onions were noted with green bio-growth substance growing on the surface. An observation was made of the kitchen daily cleaning schedule posted on the side of the reach-in refrigerator with a date of 02/10/2022. The cleaning schedules were noted without signatures to confirm that cleaning had been completed. An observation was made of the fryer with cooked food debris and hardened oil splatters. An interview was conducted with the CDM on 02/22/22 at 9:44 a.m. The CDM stated that she was not sure the last time the fryer was used or cleaned. An observation was made of the juice machine nozzle noted clogged with as syrup looking substance. During a tour of the dry storage room, two large cans of food that had dried food stains and dirt on the lids, were observed propping the door open. Further observation revealed three white storage bins on wheels containing a product with no label or dates. One of the three containers had food spillage on the bottom along with a white foam cup. There were no scoops in the bins. Additional observations during the tour revealed in the cook's prep sink, portions of raw chicken sitting in an 8-inch full size steam table pan. The chicken was piled above the water line of the pan and water was running from the faucet over one end of the pan. Staff B, [NAME] confirmed the water had been running for five minutes and stated the chicken was still frozen and needed to get it ready as it is on the menu for fried chicken today. Underneath the cook's prep sink was loose floor tiles and a puddle of water over the loose tiles. An interview was conducted with the CDM. She stated that work orders had been submitted but nothing had been resolved. An observation was made of a cook's prep table located in the middle of the kitchen with a puddle of water around the dish washing floor area. The observation revealed that there were no yellow signs warning of slippery / wet floors. An observation was made of staff walking around the puddle without anyone cleaning it. In an interview with the CDM on 02/22/22 at 10:08 a.m., she stated that work orders had been submitted but nothing had been resolved. In the main kitchen area, an observation was made of a 4- tier open wire rack storing various clean stainless-steel pans used to cook with and store food. The rack was placed between the employee's hand washing sink and the dirty side of the 3-bay sink area. At the time of walk-through there were no splash guards on the rack to prevent possible contamination or splatters of chemicals and food. During the ongoing kitchen tour, five-gallon chemicals were observed underneath the dish washing area noted with dirt, dust, and food debris. The floors were soiled with hardened food remnants which extended to against the walls. An observation was made of the air vent located above the dish machine and clean dish area and was noted with dirt and dust. The vent was noted not allowing for proper ventilation and concerns with dirt and dust blowing over clean dishes. An interview was conduced with the CDM on 02/22/22 at 10:08 a.m. The CDM stated that she would have staff clean it right away. The CDM said, I don't know how we missed that. It should be cleaned due to contamination. On 02/24/2022 at 11:15 a.m., a second tour of the kitchen was conducted. During the tray line and food temperature checks, Staff A was asked to check the temperature of the sour cream. The reading was noted at 51 degrees. A test of the milk cartons that were about to be served showed a temperature reading of 48 degrees. Staff A and the CDM removed the items from the tray line and stated that they would not serve them like that. The CDM said, that temperature reading is not right. Review of the facility's temperature form with a date of 02/20/22 to 02/26/22 revealed a statement of, Record of food temperatures Prior to service, and AGAIN after half of the meals have been served. Review of the document showed that second temperatures were not recorded for any days of the week for any of the meals served per their own policy. On 02/25/22 at 1:30 p.m., an interview was conducted with the CDM, regarding the sanitation, safety and dietary concerns identified during the survey. The CDM confirmed that food items should be labeled and stored in sanitary conditions per regulation and policy. She stated the cleaning tasks should be completed daily. The CDM further stated that she would follow up with reported maintenance concerns. She said she would in-service her team on proper thawing and cooling methods. Review of the of facility policy titled, Food Storage-Dry Goods-Policy 18, revised October 2019, showed that it is their policy to insure all dry goods will be appropriately stored in accordance with guidelines of the FDA Food Code. (5) Ensures that all packaged and canned food items shall be kept clean, dry, and properly sealed. Review of a facility policy titled, Food Storage-Cold- Policy 19, revised October 2019, showed an expectation to insure all Time /Temperature Control for Safety (CS) frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA Food Code Under (2.) Ensures that all perishable foods will be maintained at temperatures of 41 degrees or below except during necessary periods of preparation and service. Ensures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination Review of a facility policy titled, Storage of Chemicals- Policy 20, dated October 2019, showed an expectation to ensure all chemicals will be properly stored for safety and to prevent cross contamination with food. Under (1.) Ensures that all chemicals are stored in a separate/secured area. Review of a facility policy titled, Safety- Policy 26, dated October 2019, showed an expectation to ensure that kitchen equipment is properly maintained, and that staff follow safe operating practices. All equipment and physical plant maintenance issues are promptly reported and according to center protocol. (1.) Ensures that the environment will be maintained in good repair with appropriate light and ventilation. (2.) Ensures that all equipment is in proper working condition and equipped with safety guards as appropriate. Review of a facility policy titled, equipment- Policy 27, dated October 2019 showed that all food service equipment is clean, sanitary and in proper working order. (1.) Ensures that all equipment is routinely cleaned and maintained in accordance with manufacturer directions and training materials (2) Ensures that all staff members are properly trained in the cleaning and maintenance of all equipment (4.) Ensures that all non-food contact equipment is clean (5.) Ensures request for maintenance or repair to the administrator and/or Maintenance Director as needed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure accurate Minimum Data Set (MDS) assessments were completed for two (Resident #4 and Resident #10) out of 36 sampled residents. Findings: 1. Resident #4 was initially admitted to the facility on [DATE] with the most recent readmission date being 11/11/2020 for diagnoses that included urinary tract infection, acute kidney failure, major depressive disorder and anxiety. The resident's physician orders for December 2020 included: -Apply Collagenase Ointment 250 unit/gm (gram) topically every day and evening shift for wound care. Cleanse with NS (normal saline) and pat dry. Apply collagenase to wound bed. Loosely pack with sterile gauze roll and cover with dry dressing. Apply to coccyx topically as needed for soiling dated 12/3/2020, -Apply air cell cushion in (wheelchair) when OOB (out of bed) dated 11/11/2020 -Low air loss mattress to bed. Check settings and function every shift for skin care dated 11/11/2020 Resident #4 was care planned to have a wound on her coccyx. Interventions included Low air loss mattress to bed; pressure reducing cushion to wheelchair; and perform wound treatments as ordered. Resident #4 had a wound evaluation dated 12/14/2020 that indicated the resident had a stage 4 pressure ulcer that measured 5.5 cm (centimeters) x 1.6 cm x 2.3 cm and undermining 3 cm. It also noted that the resident was seen by wound care nurse and physician, who updated the wound care orders. The quarterly MDS assessment dated [DATE] indicated the resident was assessed to have a pressure reducing device for her bed, and to receive pressure ulcer care, but did not have a pressure ulcer. 2. On 12/15/20 10:05 a.m., Resident #10 was observed. Resident #10 was in bed, the side rails were up and her bed was against the wall Resident #10 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, schizophrenia, major depressive disorder, anxiety disorder, dementia without behavioral disturbance, dementia with behavioral disturbance, and anoxic brain damage. The resident's December 2020 physician orders included bilateral 1/4 side rails up while in bed as enabler dated 6/16/2020. The resident was care planned to use padded side rails as ordered because she was at risk for injuries or complications related to a seizure disorder. The quarterly MDS dated [DATE] indicated the resident was assessed to not use bedrails or any other restraints in the bed. In an interview with Staff J, Licensed Practical Nurse (LPN)/MDS nurse on 12/18/2020 at 1:45 p.m., she acknowledged that Resident #48 had an order for side rails, but that it was not on the MDS assessment. She also acknowledged that Resident #4 had a stage 4 wound, and was being seen by wound care, but that there was no wound mentioned in the resident's MDS assessment. She stated it was an oversight, and the assessments needed to reflect the correct resident status. In a policy titled, Resident Assessment Instrument, noted to be revised on September 2010, under Policy Interpretation and Implementation #3 read, The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capability.

Based on observation, interview and record review, the facility failed to create and implement personalized care plan interventions for one (Resident #41) of two sampled residents related to an identified safety concern. Resident #41 was identified as an elopement risk due to exit seeking behaviors. The facility failed to ensure the Resident's care plan and facility elopement identifier books were updated to reflect the known behavior. Findings: During an observation on 12/16/20 at 8:40 a.m. Resident #41 was seen walking down the unit hallway with a direct care staff member walking with her. Positioned outside of the Resident's room was a single cloth chair. During an interview on 12/16/20 at 2:01 p.m. Staff F, Certified Nursing Assistant stated Resident #41 requires one-to-one due to wandering behaviors. A review of Resident #41's admission Record revealed an original admission date of 9/25/20 and a re-admission date of 11/16/20 with medical diagnoses of encephalopathy, malignant neoplasm of major salivary gland, bipolar disorder, anxiety disorder, and other abnormalities of gait and mobility. Her comprehensive Minimum Data Set [MDS], dated 10/11/20, Section C: Cognitive Patterns revealed the Resident has a constant behavior without fluctuation of disorganized thinking. Section G: Functional Status revealed the Resident is independent with walking and locomotion on and off the unit. A review of Resident #41's Progress Notes, dated 10/05/20, revealed [Resident #41] has been deemed incapacitated by her doctor. Dated 10-5-20. A progress note dated 10/31/20 revealed Pt [patient] on 1:1 precaution for elopement risk, in lounge area. Pt became pre occupied with buying a printer and push the emergency latch and walked out, assigned staff at 6 ft distance at all times notified of incident and return pt to facility safely. [Doctor Name] notified verbal order to re-enforce monitoring precautions. POA [Power of Attorney] . notified of incident and ok with measures that are being taken. A progress note dated 11/7/20 revealed Pt alert with confusion at times. Pt currently on 1:1 precautions for elopement risk and safety. Pt informed that her eye glasses are ready for pickup. LOA [leave of absence] authorized by management with escort supervision. A progress note dated 11/19/20 revealed Pt appeared to be exit seeking last shift, was monitored closely by this Nurse. A progress note dated 11/20/20 revealed SSD [Social Services Director] has been in constant contact with [Resident #41]'s family regarding safe placement for her, as she refuses to cooperate with staff, refuses medication, and is abusive. She has poor insight into her health problems, and needs a secure facility. A progress note dated 11/21/20 revealed Pt alert and able to make needs known. Pt push exit doors until they open, said she was going to the bank. Pt advised that bank was closed and that it could be handle Monday. Pt proceeded to exit building and began walking away from premises. Pt informed that authorities would be notified to return her to the facility safely . A progress note dated 11/24/20 revealed SSD made arrangements with [Resident #41]'s family, to discharge her to a more secure facility . A review of Resident #41's Nursing Comprehensive Evaluation dated 11/16/20, Section 7: Elopement Evaluation revealed a score of 13. A score of 13 indicates Resident #41 is at risk for elopement. A picture of the Resident should be placed within the elopement book, and a wander guard should be applied. A review of Resident #41's care plan, date initiated 10/08/20, revealed a focus related to a self-care deficit with dressing, grooming, and bathing due to terminal status with an expected decline . A care plan focus, date initiated 11/17/20, revealed there is a risk for injury due to a seizure disorder with included interventions that staff should stay with the resident during observed seizure activity to provide safety. A review of Resident #41's care plan revealed no interventions related to her elopement risk status, or exit seeking behaviors. During an interview on 12/17/20 at 9:00 a.m. Staff G, CNA stated Resident #41 was on one to one because she tries to escape the building. During an interview on 12/17/20 at 9:08 a.m. Resident #41 stated she had numerous outside facility appointments due to her cancer and the doctors . Are attempting to get to the route of the problem. An observation of Resident #41 revealed no elopement bracelet in place on any exposed body part. Resident #41 stated Staff G was her nanny for the day. She stated I don't need a nanny. I used to be on Seroquel [a medication used to treat schizophrenia, bipolar disorder, and sudden episodes of mania] but it made me a zombie, so I stopped taking it. During an interview on 12/17/20 at 9:18 a.m. Staff A, Licensed Practical Nurse (LPN) stated Resident #41 had cognitive and psychosocial problems with some behaviors of attempting to leave the building. Resident #41 would call taxis or other car services to leave the building so facility staff were constantly redirecting her. Staff A said, I'm not sure if she has always had those behaviors but at least since I have been here, which is about 2 months. On 12/17/20 at 9:30 a.m., an observation of nursing station 1 and nursing station 2 elopement identification books revealed no picture of Resident #41. The identification books did not have any of Resident #41's information in the event of an elopement. During an interview on 12/17/20 at 9:36 a.m. Staff H, LPN stated Resident #41 had behaviors of being verbally abusive to people she did not like. Staff H had known Resident #41 for about three months. Resident #41 had behaviors of walking around and so staff had to redirect her back to her room. Staff H stated the procedure for if a resident was an elopement risk was the nursing staff would attempt to get a physician order to place an elopement bracelet. During an interview on 12/17/20 at 10:19 a.m. the Director of Nursing (DON) stated the facility rarely accepts residents that are elopement risks. She stated the elopement books were used for anyone at risk for elopement, That is how they are identified. She stated the facility had morning meetings where residents that were identified as elopement risks were discussed and a care plan was created. The MDS Coordinator would trigger a care plan and create interventions. She stated Resident #41 would be considered an elopement risk. The MDS Coordinator was called into the interview on 12/17/20 at 10:19 a.m. by the DON to discuss Resident #41's care plan. The MDS Coordinator said, [Resident #41] does attempt to elope but I would not consider her to be an elopement risk. The DON stated that when Resident #41 first entered the building, she had a high cognitive functioning rating. However, due Resident #41's brain cancer her mental state has been deteriorating so she was put on one to one for safety reasons. Both the DON and the MDS Coordinator reviewed Resident #41's medical chart and confirmed she was identified as an elopement risk on 11/16/20, they confirmed that Resident #41 did not have an individualized elopement care plan in place. The DON confirmed on 12/17/20 at 10:25 a.m. through observation that none of the elopement books throughout the facility had Resident #41's information. A policy review of Wandering and Elopement, revised March 2019, revealed The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A policy review of Care Plans, Comprehensive Person-Centered, revised December 2016, revealed A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .

Based on observation, interview, and policy review the facility failed to ensure one medication cart was locked, and failed to follow their policy to secure medications appropriately in three of four medication carts. Findings: On 12/15/2020 at 09:51 a.m. an observation of the Persons Under Investigation Hall (PUI) was conducted. The medication cart was observed to be open and not locked. Random staff were seen to quickly pass the unsecured medication cart. One maintenance staff member was observed running an industrial floor cleaning machine right next to the unsecured medication cart. Staff B, Licensed Practical Nurse (LPN) was seen exiting a nearby room and was interviewed. Staff B (LPN) confirmed the medication cart was not locked. On 12/17/20 11:45 AM an observation of medication cart located on the Low Hall Station #1 was conducted. Observed were two small white tablets, one large round white tablet and 1/4 white tablet loose in the second drawer from the top of the cart. On the right side of the drawer next to the Narcotic box observed were one green capsule, one round white tablet and one round beige tablet. Staff A, (LPN) confirmed the presence of the 6 and 1/4 loose medications in the drawers. (Photographic Evidence Obtained.) On 12/17/2020 at 1:35 p.m. an observation was conducted of medication cart Station #1 on High Hall. Observed were one white and beige capsule, one oblong white tablet, one round white tablet, one dark yellow tablet and 1/2 of a yellow round tablet loose in the second drawer from the top of the medication cart, located on the right side of the drawer next to the Narcotic box. Staff B (LPN) confirmed the presence of loose medications in the drawer. On 12/17/2020 at 12:20 p.m. an observation of the Medication cart #2 on High Hall was conducted. Observed were one loose pink tablet located in the second drawer, on the right side of the draw next to the Narcotic box. Staff C (LPN) confirmed the presence of the loose medication. On 12/17/20 at 04:04 p.m. an interview with the Nursing Home Administrator (NHA) was conducted. During the interview she was informed of the observation made on 12/15/2020 of the unlocked medication cart. She stated That is not proper, and they are supposed to close their carts when they walk away from them. A review of the facility's policy and procedure titled, Storage of Medications, effective April 2007 included under Policy Statement: The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Under Policy Interpretation and Implementation read: 1. Drugs and biologicals shall be stored in the packaging containers or other dispensing systems in which they are received. 2. The nursing staff shall be responsible for maintaining medication storage.

Based on observation, interview, policy review, and the facility failed to ensure 1) dishware and food equipment designated for resident usage was stored as clean, and 2) potentially hazardous cooked food was cooled to 41 degrees Fahrenheit within an appropriate timeframe to prevent foodborne illness. Findings included: 1. During the kitchen comprehensive tour on 12/18/20 at 8:55 a.m. a food processor was observed on the countertop next to the stove. Staff I, [NAME] stated she used the food processor at 6:00 a.m. in the morning and that the area where the food processor was stored in would be considered clean. The food processor blade from lifted from the equipment base and examined. Food debris was observed on the inside of the blade rotator. Water was observed on the inside of the food processor base. The [NAME] stated she placed the food processor into the sink earlier, but she was still in the process of cleaning the equipment. The [NAME] removed the food processor from the location and placed it into the 3-compartment sink. Observation of dishware stored on the clean storage rack next to the dishwasher revealed old food debris on the inside of three cups. The Certified Dietary Manager (CDM) stated cups stored on the rack were considered clean. The cups were examined by the CDM and passed to a kitchen aide standing by the dishwasher. the CDM examined additional five cups, which were determined to be unclean. The CDM removed the entire clean cup storage tray and placed it by the dishwasher for re-cleaning. 2. During an observation on 12/18/20 at 9:25 a.m., a large, deep pan was seen double wrapped in saranwrap in the outside walk-in cooler. The CDM stated the food item was soup, which was made the day before that .would be served to residents' today. She stated the soup was made in-house, cooked, and stored in the walk-in cooler to be cooled down. An internal temperature of the food item was measured by the CDM using a metal stem probe thermometer. The CDM cleaned the thermometer using an alcohol wipe, lifted the saranwrap, and inserted the thermometer into the soup. The thermometer measured the food item at 50 degrees Fahrenheit. The CDM stated the food item was not cooled properly and would need to be discarded. She stated food that is not cooled properly and served to residents could result in making the residents sick. During an interview on 12/18/20 at 9:30 a.m., the [NAME] stated she did not make the soup that was stored in the walk-in cooler. The process for cooling down a food item is to leave the food item on the stove top for four hours, transfer the product to a new container, cover the item, and store it into the walk-in cooler. The CDM stated that there is no cooling log that is kept logging the temperatures of food items that are being cooled down. Therefore, the original time the food was cooked and cooled was unable to be determined. A policy review of Equipment, no date, revealed It is the center policy that all food service equipment is clean, sanitary, and in proper working order . The Dining Services Director will ensure that all equipment is routinely cleaned and maintained in accordance to manufacture directions and training materials . The Dining Services Director ensures that all food contact equipment is cleaned and sanitized after every use . the Dining Services Director ensures that all non-food contact equipment is clean. According to the United States Food and Drug Administration (FDA) Food Code, 2017, page 94, revealed .Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57°C (135°F) to 21°C (70°F); and (2) Within a total of 6 hours from 57°C (135°F) to 5°C (41°F) or less . Cooling shall be accomplished in accordance with the time and temperature criteria . by using one or more of the following methods based on the type of food being cooled: (1) Placing the food in shallow pans; (2) Separating the food into smaller or thinner portions; (3) Using rapid cooling equipment . Loosely covered, or uncovered if protected from overhead contamination during the cooling period to facilitate heat transfer from the surface of the food .