**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, and record review, the facility failed to provide the necessary care and services to maintain good oral hygiene for one of 31 sampled residents (R) (R55) reviewed for Activities of Daily Living (ADLs). Specifically, the facility failed to provide the resident with oral hygiene supplies, staff assistance, and/or reminders to complete oral hygiene care. Findings included: A review of the electronic medical record (EMR) revealed that R55 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including but not limited to dementia with behavioral disturbance, metabolic encephalopathy, and Alzheimer's disease with late onset. A review of R55's annual Minimum Data Set (MDS) assessment, dated 5/21/2024, revealed R55 presented with a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) of the assessment indicated R55 was independent with oral hygiene. A review of R55's Care Plan revealed a focus area for self-care deficits related to Alzheimer's Disease and fatigue with intervention, dated 7/4/2023, directed nursing staff to assist and remind the resident to complete oral care in the morning and at night. During an observation and interview conducted on 6/19/2024 at 9:15 am, R55 was observed with a foul odor emanating from his mouth when he spoke, and an accumulation of a buildup of a thick discolored substance was observed on his teeth. The resident stated that the staff did not assist him with oral hygiene. He stated, They don't help me with a [expletive] thing! He confirmed that even if he asked, the staff did not assist with oral care. R55 was then asked whether he knew where his oral hygiene supplies (i.e., toothbrush, toothpaste, etc.) were kept and R55 stated, I have no idea. You can look in there, while pointing to his room. An observation of R55's s room and restroom revealed no oral hygiene supplies. During an interview conducted on 6/19/2024, at 9:35 a.m. with Certified Nursing Assistant (CNA) FF, she confirmed that she was familiar with R55's care needs. When asked whether he needed reminders to brush or assistance with brushing his teeth, CNA FF stated, He does that himself. When asked whether R55 had any difficulties with his memory, CNA FF stated, Yeah, he does forget some stuff and just wanders around pretty much all day. When asked whether R55 had a toothbrush and/or toothpaste in his room so that he would be able to brush his teeth if he remembered to do so, CNA FF looked in R55's room and restroom and confirmed there were no oral hygiene supplies. During an interview on 6/20/2024 at 11:45 am, Licensed Practical Nurse (LPN) II confirmed she was familiar with R55's care needs. However, when asked whether R55 was able to remember to brush his teeth or if he was able to physically carry out that task, LPN II stated, You know, I don't know. I'd have to check. During an interview on 6/21/2024 at 10:15 am, the Assistant Director of Nursing (ADON), reviewed R55's care flow records and confirmed there was no documented evidence that R55 was assisted with oral hygiene or encouraged to complete oral care.

Based on observations, interviews, record review, and review of the facility's policy titled Emergency Pharmacy Service and Emergency Kits, the facility failed to ensure that an emergency medication kit (E-Kit) was readily available for use in a resident emergency for one of two medication rooms (Medication Room West) observed. Findings included: A review of the facility's policy and procedure titled Emergency Pharmacy Service and Emergency Kits, dated 4/1/2016, indicated that emergency pharmacy services are available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from the provider pharmacy. An emergency supply of medications, including emergency drugs, antibiotics, controlled substances, and products for infusion is supplied by the provider pharmacy in limited quantities in portable, sealed containers, in compliance with applicable state regulations. As soon as possible the nurse records the medication on the medication order form and calls the pharmacy for replacement of the kit and flags the kit with a color-coded lock to indicate the need for replacement of kit. During an observation on 6/19/2024 at 11:18 am with the Assistant Director of Nursing (ADON) in the medication room West, a (red) color-coded E-Kit was observed in the refrigerator. Closer observation of the E-Kit revealed that it had been accessed and opened on 5/2/2024. The pharmacy record inside the E-Kit recorded Humalog (diabetes medication) was pulled out and utilized. During a concurrent observation and interview on 6/19/2024 at 11:20 am, the ADON stated that the refrigerated (red) color-coded E-Kit was opened, dated 5/2/2024, and was not replaced by the pharmacy. The ADON further stated that the process for replacing the E-Kit was to call the pharmacy and notify them of the usage and replacement needed as soon as possible to ensure there were always correct medications available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure adequate blood glucose monitoring for residents receiving insulin. This deficient practice affected one of five residents (R) (R55) reviewed for unnecessary medications. Findings included: A review of R55's medical record revealed an initial admission date of 6/15/2023. His medical history included type 2 diabetes, metabolic encephalopathy, and Alzheimer's Disease with late onset. An annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 5, indicating that R55 presents with severely impaired cognition. The MDS also indicated that R55 received insulin injections. During an interview on 6/19/2024 at 9:15 am, R55 stated that facility staff were not checking his blood glucose very often and that he would like it to be checked more frequently. A review of a medical provider progress note dated 3/18/2024 revealed an entry that indicated R55 would like his sugar checked more often, says he will cooperate with labs [sic]. A preliminary review of R55's physician orders revealed no active orders to monitor his blood glucose. Orders were noted for Levemir (a long-acting insulin) 20 units to be given subcutaneously at night and Novolog (a fast-acting insulin) six units to be given subcutaneously three times daily. A review of R55's discontinued physician orders revealed an order, dated 3/19/2024 to monitor his blood glucose. The order was discontinued on 4/23/2024 when R55 was transferred to the hospital. A preliminary review of R55's blood sugar flow records revealed the last entry was on 6/15/2024 at 11:12 am. The result was 256 mg/dL. Before this entry, the last documented blood glucose check was on 4/17/2024 at 6:31 am. The result was 375 mg/dL. On 6/20/2024 at 11:45 am, an interview was conducted with Licensed Practical Nurse (LPN) II. She confirmed that she was assigned to care for R55 and she was familiar with his care needs. LPN II confirmed that R55 did receive insulin injections and stated that nursing staff monitored R55's blood sugar every morning. When asked to review R55's blood glucose monitoring orders and results, LPN II reviewed the medical record and stated she would need to do some research. On 6/20/2024 at 12:05 pm, LPN II explained that R55 was transferred to the hospital due to an unrelated event in April 2024 and that the order to monitor the resident's blood glucose was not reinstated upon his return. On 6/21/2024 at 10:45 am, an interview was conducted with R55's Attending Physician (AP). The AP confirmed that the facility could be monitoring R55's blood glucose levels if he was receiving fast-acting insulin three times daily. The AP explained that R55 did have a history of refusing to have his blood glucose checked but added that attempts should be made, and refusals should be documented.

Based on observations, interviews, and record review, the facility failed to ensure expired medications were properly discarded in two of two medication rooms (Medication Room East and Medication Room West). Findings included: During an observation of the Medication Room East with a Licensed Practical Nurse (LPN) JJ on 6/20/2024 at 12:12 pm, there were 32 Acetaminophen (pain/fever medication) suppositories (an opened box) located inside the refrigerator with an expiration date of September 2023. During an observation of the Medication Room [NAME] with LPN JJ on 6/20/2024 at 12:15 pm, there were five Acetaminophen suppositories located inside the refrigerator with an expiration date of September 2023. During an interview on 6/20/2024 at 12:30 pm, LPN JJ stated that the expired Acetaminophen suppositories should not have been stored in either medication room refrigerator due to the risk of administering expired medications to the residents. A review of a record, provided by the facility, revealed that five residents (R2, R10, R33, R36, and R57) had physician's orders for Acetaminophen suppositories to be given every six hours as needed for elevated temperature.

Based on observations and interviews the facility failed the maintain the walk-in freezer in proper working condition as evidenced by ice build-up on a food storage rack. Facility census was 51. Findings include: Observation on 11/18/22 at 8:40 a.m. of the walk-in freezer revealed ice build-up adhered to the top shelf of the metal storage rack underneath the air condenser. The ice build-up was about two feet in length with four mounds of ice that were four to six inches in height and two to three inches in diameter. Continued observation revealed two cardboard boxes containing frozen food under the ice. During an interview on 11/18/22 at 8:40 a.m., the Certified Dietary Manager (CDM) stated that maintenance has knowledge of the ice build-up in the walk-in freezer. The CDM revealed it is unknown if a repair man has been contacted to look at the problem in the walk-in freezer and fix the issue. The CDM stated that the ice is removed by maintenance, and they remove the ice when she requests. Observation on 11/20/22 at 9:30 a.m. of the walk-in freezer revealed the ice build-up remained after CDM and maintenance have been notified. During an interview on 11/20/22 at 9:30 a.m. the CDM revealed that she spoke with the Assistant Director of Maintenance on 11/18/22 about the ice build-up and put in a work order. The CDM stated that maintenance is planning to remove the ice build-up during the week after kitchen hours. During an interview on 11/20/22 at 9:55 a.m. the Director of Maintenance revealed that he had no knowledge that the walk-in freezer had an ice build-up. He stated that the CDM submitted a work order for the walk-in freezer on 11/18/22.

Based on observations, interviews, and policy review, the facility failed to label, and date stored and opened food items; failed to ensure the three-compartment sink had proper sanitizing solution concentration; and failed to ensure dietary staff properly washed dishware in three-compartment sink to prevent food borne illness. 49 of 51 residents were receiving an oral diet. Findings include: 1) Review of the facility policy titled Food Storage Guidelines revealed: date, label, and cover all non-perishable food items upon delivery and as items are removed from the original box or package. Date, and label each large condiment container. Date, cover, and label all food items to be stored in the freezer and coolers. Observation on 11/18/22 at 8:32 a.m. of the reach-in refrigerator revealed several bags of liquid eggs out of the original box and placed in a large gray bin, there was no date on the bin indicating date liquid eggs were out of package. During interview on 11/18/22 at 8:32 a.m. the Certified Dietary Manager (CDM) confirmed that the bin with the bags of liquid eggs had no date when the bags were taken out of original box. The CDM revealed that staff are to put a date on food items when removed from the package. Observation on 11/18/22 at 8:35 a.m. of the dry storage area revealed the can rack had three large cans of sweet potatoes that had no date of when delivered and taken out of box. During interview on 11/18/22 at 8:35 a.m. the CDM confirmed that the three cans of sweet potatoes did not have a date of delivery and expects staff to date when putting stock away. Observation on 11/18/22 at 8:45 a.m. of the bulk flour, sugar, and corn meal storage revealed that they were in a storage drawer in the food prep area. A 22-pound sugar bag was opened with no date. During interview on 11/18/22 at 8:45 a.m., dietary cook AA confirmed that there was no date on the large sugar bag and the cook stated that it should have been dated after opening. 2) Review of the facility policy titled Pot & Pan Sink/Three Compartment Sink revealed: it is the policy of the facility that the proper procedure be followed to ensure cookware is washed, rinsed, and sanitized properly to avoid cross contamination. Continued review of the policy revealed: The dietary staff will check and record the amount of sanitizer in the third well to ensure the proper level of sanitizer has been achieved (200ppm). Review of the document titled Procedure for Sanitizing Sink revealed: add bleach until test strip reads between 50-100ppm. Observation on 11/18/22 at 8:55 a.m. of the three-compartment sink revealed that there was a poster over the sink with information for quaternary sanitizing solution and the concentration was indicated as 100-400ppm (parts per million). Dietary cook AA assisted with testing the concentration of the sanitizing solution. The test strips used were not for ppm but for pH (potential hydrogen). There was no information available for dietary staff know what pH the sanitizing solution should be. During interview on 11/18/22 at 8:55 a.m. the CDM do not realize that the test strips used to test the sanitizing solution concentration in the three-compartment sink had changed to pH. The CDM stated the test strips are new, they recently were delivered earlier in week. The CDM confirmed that she does not have any information for usage of the new pH strips and had no information for staff as to what the pH level should be of the sanitizing solution in the three-compartment sink. During interview on 11/19/22 at 8:55 a.m. the CDM revealed that she contacted the chemical supplier regarding the new test strips and information for using the new pH strips. The CDM revealed the information the chemical supplier provided was not for the new test strips they received. The CDM showed email attachment she received for staff education and the test strips shown in the poster are not the test strips that the facility currently has. Continued interview with the CDM revealed that she is not able to provide written guidelines as to the use and proper pH concentration of the sanitizer solution in the three-compartment sink. During an interview on 11/19/22 at 12:05 p.m. CDM revealed that she is no longer using quaternary sanitizing solution in the three-compartment sink due to not able to get verification on how to read the new testing strips. The CDM stated that she has changed to using bleach/chlorine and has in-serviced dietary staff on how to use the bleach for sanitizing in the three-compartment sink. Continued interview revealed the CDM obtain information on-line regarding the proper concentration level for using bleach/chlorine as a sanitizer. The CDM stated that they do have chlorine test strips to use. Observation on 11/20/22 at 9:10 a.m. of the dietary cook AA wash the food processor bowl, blade, and lid in the three-compartment sink revealed that she washed the dishware in soapy water and rinsed. Dietary cook AA then placed the bowl and blade back on the food processor base and was going to puree the next food item without putting dishware in the bleach/chlorine sanitizing solution. During interview on 11/20/22 at 9:10 a.m., dietary cook AA confirmed that she did not properly sanitize the food processor dishware before starting next puree food item. Dietary cook AA stated that she does this process often of not sanitizing food processor dishware between processing food items. During an interview on 11/20/22 at 9:15 a.m. the CDM revealed she expects staff to wash and sanitize the food processor bowl, blade, and lid between food items. She expects staff to wash like any other dish in the three-compartment sink. Observation on 11/20/22 at 9:43 a.m. of the three-compartment sink revealed dietary cook AA assisting with testing the bleach/chlorine sanitizing solution concentration. The test strip revealed 10ppm. Continued observation revealed dietary staff stirred the bleach/chlorine solution in the sink and re-tested and again concentration registered as 10ppm. This sanitizing solution was used to wash the food processor bowl, blade, and lid during puree observation. During interview on 11/20/22 at 9:43 a.m. dietary cook AA confirmed that the bleach/chlorine sanitizing solution registered 10ppm on the test strip and it should be 50-100ppm. During interview on 11/20/22 at 9:43 a.m. the CDM also confirmed that the chlorine test strip registered 10ppm and should be 50-100ppm. The CDM revealed that staff will drain the sanitizing sink and re-do the bleach/chlorine solution.