**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Reference 8: Behavior Monitoring Procedure, the facility failed to ensure that three of five residents (R) (R17, R21, and R40) sampled for unnecessary medications were monitored for behaviors, side effects and efficacy of antipsychotic medications. This failure to monitor for adverse effects and efficacy had the potential to place R17, R21, and R40 at risk of medical complications and unmet needs. Findings Include: Review of the facility's undated policy titled, Reference 8: Behavior Monitoring Procedure, revealed 1. Each MAR (Medication Administration Record) will have three major lines (one for each shift), with four subdividing minor lines within each major line. 2. Inside the frequency column of each minor line will have directions. a. Line 1-will indicate the shift. This is where the nurse will enter her initials. b. Lines 2-4 will state Behaviors =__. In the blank, a number is to be entered, that corresponds to a behavior listed to side the side .Each shift will have room for 3 different behaviors to monitor, if needed. If an occasion arises when more than 3 behaviors need to be monitored, please use the next available blank space on the MAR .Side Effect Monitoring: 1. The nurse will indicate Y for yes and N for no, beside the appropriate shift and under the appropriate day, to indicate if a side effect is observed. 2. If a Y is entered beside that nurse's shift, then a corresponding number to describe the side effect is entered on the minor line that states 'S. E.' Review of a Food and Drug Administration (FDA) website titled https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/020592s052,021086s031,021253s037lbl.pdf, indicated . Elderly Patients with Dementia-Related Psychosis: Increased risk of death and increased incidence of cerebrovascular adverse events (e.g., stroke, transient ischemic attack).close supervision of high-risk patients should drug therapy. Hyperglycemia: In some cases, extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients taking olanzapine (Zyprexa). Patients taking olanzapine should be monitored for symptoms of hyperglycemia and undergo fasting blood glucose testing at the beginning of, and periodically during, treatment. Hyperlipidemia: Undesirable alterations in lipids have been observed. Appropriate clinical monitoring is recommended, including fasting blood lipid testing at the beginning of, and periodically during, treatment. Weight Gain: Potential consequences of weight gain should be considered. Patients should receive regular monitoring of weight. 1. Review of R17's electronic medical record (EMR) titled Resident Face Sheet located under the Resident tab indicated the resident was admitted to the facility on [DATE]. Review of R17's EMR quarterly Minimum Data Set (MDS) located under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 3/11/2025 indicated the resident's Brief Interview for Mental Status (BIMS) score of three out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident had no behaviors. Review of R17's Care Plan located under the RAI tab, dated 1/22/2024, indicated the resident was on an antipsychotic, and it was used for dementia with behavioral disturbances. The care plan indicated there was a potential for the resident to experience intolerance and/or adverse side effects and had no identified problems at this time. The approach was to administer the resident's medications as prescribed, to observe the effectiveness of the treatment, and to monitor adverse side effects. Review of R17's EMR titled Orders located under the Resident tab, dated 8/7/2024, indicated that the physician ordered Zyprexa one tablet, 10 milligrams (mg), to be administered twice a day at 9:00 am and 5:00 pm. Review of R17's EMR titled Medications Administration History, located under the Resident tab, dated 2/1/2025 through 4/2/2055 indicated the resident was administered Zyprexa for depression. Review of R17's EMR titled General Administration History, located under the Resident tab, dated 2/1/2025 through 4/2/2025, indicated the facility was monitoring the following behaviors: yelling, biting, scratching, refusal of care, spitting, cursing, and other abnormal behaviors. There were no specific targeted behaviors identified with R17's diagnosis of depression and the associated use of Zyprexa. In addition, there was no evidence the facility was monitoring the side effects from the use of an antipsychotic. During an interview on 4/2/2025 at 1:34 pm, the Director of Nursing (DON) stated that the behaviors of residents who were on psychotropic medication were to be documented at the end of the shift, and the behavior was to be documented whether it was observed or not. He said that the effectiveness was to be documented, as well as any side effects. 2. Review of R21's undated Face Sheet located in the EMR under the Face Sheet tab indicated the resident was initially admitted to the facility on [DATE], with a readmission on [DATE]. The resident had diagnoses of Parkinson's disease, Asperger's syndrome, schizophrenia, bipolar disease, and anxiety. Review of R21's quarterly MDS, with an (ARD) of 3/20/2025, located in the EMR under the MDS tab, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident is cognitively intact. R21 did not exhibit any behavior during the seven-day look-back period. Review of R21's Orders located in the EMR under the Orders tab revealed the following orders: duloxetine (selective serotonin reuptake inhibitors (SSRIs) for anxiety disorder, start date10/1/2021; Geodon (antipsychotic) for schizophrenia, start date 9/1/2022; hydroxyzine pamoate (antihistamine, sedative) for anxiety disorder, start date 12/30/2021, and Target Behavior: Monitor for yelling, biting, scratching, refusal of care, spitting, cursing and other abnormal behaviors, start date 10/1/2021, this order was not for specific medications. There was no order for the monitoring of adverse reactions for specific medications. Review of R21's Medications Administration History for January 2025, February 2025, and March 2025, located in the EMR under the Reports tab, indicated that although the facility is monitoring for behaviors. These behaviors were not specific to each medication ordered for different psychiatric behaviors. Additionally, there was no monitoring of the medication's adverse effects and efficacy. 3. Review of R40's undated Face Sheet located in the EMR under the Face Sheet tab indicated the resident was admitted to the facility on [DATE], with diagnoses including dementia, with severe agitation, and depression. Review of R40's quarterly MDS with an ARD of 3/25/2025, located in the EMR under the MDS tab, revealed the resident had a BIMS score of three out of 15, which indicated the resident was severely cognitively impaired. R40 was assessed as exhibiting delusions (misconceptions or beliefs that are firmly held, contrary to reality) but did not exhibit any other behaviors during the seven-day look-back period. Review of R40's Orders located in the EMR under the Orders tab, revealed the following orders: mirtazapine (anti-depressant) for depression, start date 9/7/2024; sertraline (anti-depressant) for depression, start date 9/7/2024; trazodone (anti-depressant) for insomnia, start date 12/13/2024; and Target Behavior: Monitor for yelling, biting, scratching, refusal of care, spitting, cursing and other abnormal behaviors, start date: 10/1/2021. This order was not for specific medications. There was no order for the monitoring of adverse reactions for specific medications. Review of R40's Medications Administration History for January 2025, February 2025, and March 2025, located in the EMR under the Reports tab, indicated that although the facility was monitoring for behaviors. These behaviors were not specific to each medication ordered for different psychiatric behaviors. Additionally, there was no monitoring of the medication's adverse effects and efficacy. During an interview on 4/2/2025 at 3:13 pm, the Director of Nursing (DON) confirmed the General Order, under Order Description, revealed Target Behavior: Biting, pinching, hitting, disruptive behaviors, or refusal of care. At the end of each shift mark Frequency-how often behavior occurred & intensity-how resident responded to redirection. Intensity Code: 0=Did not occur; 1=Easily altered; 2=Difficult to redirect was a blanket order for monitoring behaviors for all psychiatric medications. The DON also confirmed there was no monitoring for adverse side effects or efficacy of medications. During an interview with the Pharmacist on 4/3/2025 at 9:16 am, the Pharmacist was asked what his expectations were related to psychiatric medications and the monitoring of the resident's behaviors, adverse reactions, and efficacy for each medication. The Pharmacist responded that monitoring needs to be precise on what behaviors that are particular to the residents, adverse effects, and efficacy specific to the medications ordered. The Pharmacist added that in the past, there have been behaviors with associated numbers to indicate what behavior was being exhibited. Additionally, there should be a list of side effects for anti-psychotics and psychotropic medications. The Pharmacist was asked if he was aware of the facility not documenting the monitoring. The Pharmacist responded that he assumed they were monitoring for the behaviors, side effects/adverse reactions, and efficacy. During an interview on 4/3/2025 at 9:20 am, during medication pass, Registered Nurse (RN) 1 was asked if she had a resident on an antipsychotic that had a behavior or side effect where this would be documented. RN1 responded that she was unsure but would always document it in the nurse's notes. RN1 was asked how she knew the resident needed this medication (antipsychotic) and how she knew if it was effective. RN1 stated that she documented behavior daily. When asked if it was specific to the class of medications, RN1 stated it was just a general observation with a blanket list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policies titled, titled, Medications - Administration and Preparation and Policy and Procedure for Expired Drugs, the facility failed to ensure one of six residents (R) (R7) observed during medication pass medications were not expired. This deficient practice increased R7's risk of infection and exacerbation of R7's compromised respiratory status related to chronic obstructive pulmonary disease. Findings include: Review of facility-provided policy, revised 04/22/2024, titled, Medications - Administration and Preparation revealed . 15. check all medications .for expiration dates. Review of a facility-provided policy, reviewed and approved dated 04/22/2024, titled, Policy and Procedure for Expired Drugs, revealed, .During each medication pass, it is the nurse's responsibility to check medication labels for expiration dates, before dispensing drug.3. Any expired drugs will be removed from medication chart and be re-ordered . Review of R7's undated admission Record found in the electronic medical record (EMR) under the Profile Tab revealed an admission date of 11/8/2023, with diagnoses including unspecified systolic (congestive) heart failure and chronic obstructive pulmonary disease (COPD). Review of R7's Physician's Orders under Orders tab located in the EMR revealed an order for fluticasone propionate [over the counter (OTC)] spray suspension 50 microgram (mcg) /actuation; (amount) one spray each nostril; nasal special instructions: Instill one spray each nostril daily for allergies. Once a day at 9:00 am. The order was written on 8/15/2024 and dispensed to the facility on [DATE]. Further review revealed an order for Refresh Tears (carboxymethylcellulose sodium) [OTC] drops; 0.5 %; amt: 1 drop each eye; ophthalmic (eye). Special Instructions: Apply one drop into each eye PRN [as needed] dry eye syndrome as needed. During an observation of the medication pass on 4/3/2025 at 9:58 am with Registered Nurse (RN) 1, for R7, two medications were identified as expired. 1) Fluticasone propionate OTC spray suspension was identified as dispensed and began use on 11/15/2024 without an open date and without an expiration date. 2) Refresh Tears was identified as dispensed on 2/10/2025 and expired on 3/24/2025. RN 1 verified the dates on the medications. In an interview on 4/3/2025 at 12:25 pm, the Director of Nursing (DON) stated the expectation was for no expired medications ot be on the medication carts. The DON stated that expired nasal and ophthalmic drops could increase the risk of infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, review of the facility policy titled Immunizations, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to offer one of five residents (R) (R28) reviewed for flu and pneumonia vaccinations and/or their representatives the opportunity for the residents to be vaccinated in accordance with nationally recognized standards of 44 sample residents. In addition, the facility failed to update their immunization to reflect current CDC recommendations. These deficient practices had the potential to place R28 at risk of contracting pneumonia and other residents at risk of not being offered immunizations based on current CDC guidelines. Findings include: Review of the facility policy titled Immunizations, dated 5/22/2024, indicated .To provide guideline for administering Pneumococcal Vaccine - PCP13 (Previnar) [sic] pr PPSV23 (Pneumovacc) [sic]. Review of the CDC website titled, https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html, dated 10/26/2024, indicated .Based on shared clinical decision-making, adults 65 years or older have the option to get Prevnar 20 (PCV20) or PCV21, or to not get additional pneumococcal vaccines. They can get PCV20 or PCV21 if they have received both . PCV13 (but not PCV15, PCV20, or PCV21) at any age and .PPSV23 at or after the age of [AGE] years old. Review of R28's electronic medical record (EMR) titled Resident Face Sheet, located under the Resident tab, indicated the resident was admitted to the facility on [DATE]. The resident was over the age of 65 at the time of her admission. Review of R28's EMR titled Vaccination, located under the Resident tab, failed to indicate if the resident received any pneumococcal vaccination(s). There was no evidence that R28 had been offered the opportunity to be vaccinated with one dose of PCV20 or PCV21 after the final pneumococcal vaccination. Review of a document provided by the facility titled Georgia Registry of Immunization Transactions and Services indicated R28 received the Pneumovax 23 on 7/15/2010 and received the PCP13 on 12/8/2015. During an interview on 4/2/2024 at 8:30 am, the Director of Nursing (DON) stated the state had an online system that informed him that R28's pneumococcal vaccines were complete. The DON stated that the state online system did not have updated CDC guidance for the current recommendations. The DON stated it was important to follow CDC recommendations for the pneumococcal vaccines. During an interview on 4/3/2025 at 10:38 am, the Administrator stated the facility missed identifying current CDC recommendations and applying the recommendations to the current facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, review of the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHREA) and Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility document titled, Water Management Program for [NAME] County Nursing Home, the facility failed to have an adequate water management program. The facility's water management program was incomplete and was not consistent with the current ASHRAE Guideline, which specifically called for design and maintenance procedures for the potential exposure of Legionnaires' disease (a serious pneumonia infection) within a healthcare facility. This failure created the potential for the facility residents to be infected by Legionella. Findings include: Review of a website for ASHRAE titled Successfully Managing the Risk of Legionellosis dated 4/7/2021 indicated . Legionellae the biological classification name for a [NAME] of bacteria.is the plural, referring to more than one Legionella bacterium.Legionellosis: any illness (disease) caused by the exposure to Legionella. Legionnaires' disease (LD) and Pontiac fever (PF) are the two known types of legionellosis.Potentially fatal, multisystem respiratory illness, accompanied by pneumonia.Symptoms.high fever, chills, muscle pain, headache, dry cough, diarrhea, vomiting, confusion, and delirium common.Immune suppressed.transplant patients, cancer, cardiac, diabetes, steroid/drug therapy.Sick/in poor health. Elderly/infirm.Heavy smokers, lung/COPD diseases.Describe the building water systems using flow diagrams & a written description: Include details such as where the building connects to the (municipal) water supply, how water is distributed and used (processed), where hot tubs, water heaters, cooling towers, etc. are located. Review of the CDC website titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021, indicated . Describe the building water systems using text and flow diagrams. Identify areas where Legionella could grow and spread. Review of a facility document titled Water Management Program for [NAME] County Nursing Home, dated 5/28/2024, indicated . Identified Risks: Water shortages due to drought or municipal supply issues. Contamination risks from plumbing systems. Inefficient fixtures leading to water wastage. Increased costs due to water leaks or infrastructure issues. The document failed to address the facility's water system in text and a diagram which would then identify the areas of the facility's water system which were potential locations for the development of Legionella and other water pathogens. The document failed to address what control measures would be implemented and failed to identify how the facility would then monitor the control measures. Finally, the document did not indicate how the facility would document their efforts to maintain an effective water management plan/program. During an interview on 4/3/2025 at 9:31 am, the Maintenance Director stated the facility tested for Legionella and conducted a risk assessment. When asked if the facility had a water management plan, the Maintenance Director stated he tests all resident rooms for temperatures, and this was done on a weekly basis. The Maintenance Director stated there have been no Legionella outbreaks. During an interview on 4/3/2025 at 10:00 am, the Director of Nursing (DON) stated the facility did not have a water management plan, and his expectation was to follow CDC guidance.

Based on staff interviews, record review, and review of policy titled Bed Holds During Hospital Stays and Therapeutic Leaves, the facility failed to provide written documentation of bed hold to resident/family upon discharge to hospital for one of eight residents (R# 2) who was transferred to the hospital. Policy on Bed Holds During Hospital Stays and Therapeutic Leaves last revised 1/20/23: 1. Hospital stays: Medicaid will provide payment to hold the Resident's bed for a period of seven days while the Resident is hospitalized . List of transfers December 2022 through March 2023 indicated eight residents had been transferred during the identified time period. Electronic record review for R#2 revealed hospital leaves on 12/22/22 and 3/14/23. Review of the electronic medical record and the hard chart record did not reveal any evidence of the resident/family being notified in writing of the bed hold policy. During interviews on 3/17/23 at 10:55 a.m. with Licensed Practical Nurse (LPN) AA, LPN BB, and LPN CC who all reported that when a resident has to go out to the hospital there are specific documents that must be completed and sent to the hospital with the resident which included a face sheet, labs, and Health and Physical. LPN BB reported that if a bed hold is needed the Director of Nursing (DON) or Assistant Director of Nursing (ADON) will provide the document to the resident before exiting the facility to the hospital (even on night shift). LPN CC reported that the Office Manager probably would handle bed hold notification because that is not something that she would do but is aware that there is a seven day bed hold. Interview was conducted with the Office Manager on 3/18/23 at 12:55 p.m. who provided a blank copy Notice of Transfer or Discharge. She reported that nursing should be providing this document to the residents at the time of transfer. During a subsequent interview with LPN AA on 3/18/23 at 1:00 p.m. she acknowledged that she was the nurse on duty at the time that R#2 was discharged to the hospital on 3/14/23. LPN AA denied being educated to use the Notice of Transfer or Discharge document. LPN BB and LPN CC also denied being educated to use the Notice of Transfer or Discharge form that included bed hold information. During an interview on 3/19/23 at 11:58 a.m. with the Administrator, DON, and Administrator in Training, bed hold notification was discussed. The Administrator reported that bed hold is discussed during the admissions process at the facility and the Education nurse will provide education to the nursing staff moving forward. The DON reported that family members are typically notified via telephone call if a resident is admitted to the hospital. However, she acknowledged that the Admin Team (which consists of the Office Manager, Social Worker, and the Clinical Manager) was responsible for training nursing staff about the bed hold policy requirements.

Based on observations, interviews, and policy review, the facility failed to ensure that opened food items were labeled and dated in two walk-in refrigerators, the walk-in freezer, and the dry storage area. The facility census was 46, with 44 residents receiving an oral diet. Findings include: A review of facility policy, Labeling, Dating, and Storage, revised 1/8/21, revealed food items, once opened, would be stored in their original packaging or wrapped tightly with film and/or foil and clearly labeled with the name of the item and the date opened. A further review revealed that opened refrigerated items would be labeled and dated. An observation on 3/17/23 at 8:10 a.m. of the walk-in refrigerator #1 revealed a plastic container with approximately five pickles. The container was unlabeled and undated. An observation on 3/17/23 at 8:18 a.m. of the walk-in refrigerator #2 revealed a box of breakfast sausage. Inside the box was an opened bag of breakfast sausage that had not been labeled or dated with an opened date. Additionally, the breakfast sausage was in an unsealed bag, and the breakfast sausage was exposed to the open air. An observation on 3/17/23 at 8:21 a.m. of the walk-in freezer revealed an opened bag of breaded okra, onion rings, and French fries that were unlabeled and undated. A further inspection revealed a box of (name) Steak Patties. Inside the box was an opened bag of steak patties that were unlabeled and undated. The bag was unsealed, and the steak patties were exposed to the open air. A box of (name) Beef Patties revealed an opened bag of beef patties, which was unlabeled and undated. The beef patties were unsealed and exposed to the open air. A box of (name) Skinless Boneless Breasts revealed a bag of boneless breasts that was opened, unlabeled, and undated. The breasts were unsealed and exposed to the open air. An observation on 3/17/23 at 8:23 a.m. of the dry storage area revealed an opened 32-ounce bag of (name) Brownie Mix and an opened 2-pound bag of (name) enriched noodles, which were not labeled or dated. During an interview with Dietary Manager (DM), on 3/17/23 at 8:02 a.m., she acknowledged that the dry storage, refrigerators, and walk-in freezer items were not labeled and dated after they were opened. The DM explained she expected staff to label and date things after opening. She added that she also expected staff to seal opened items, so they were not exposed to the open air.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to obtain a concurring Physician's signature for a Physician Orders for Life Sustaining Treatment (POLST) for Do Not Resuscitate (DNR) consent for one of 16 residents (R) reviewed (R A). Findings include: Review of the document titled Guidance for Completing the POLST Form revealed the following: 5. If the patient lacks decision making capacity, the POLST form may be signed by an authorized person which includes, in the order of priority: a. the agent named on the patient's durable power of attorney for health care, or a health care agent named on the patient's advance directive for health care. b. spouse c. a court-appointed guardian d. son or daughter (age 18 or older) e. parent f. brother or sister (age 18 or older) When a POLST is signed by an authorized person and attending Physician: if section A indicated allow natural death - do not attempt resuscitation . a concurring Physician signature is required. Review of the medical record for R A revealed an admission date of 2/5/18. R A had diagnoses including Covid-19 onset 8/27/21, dementia, type 2 diabetes mellitus without complications, chronic kidney disease, Chronic Obstructive Pulmonary Disease, and hypertension. Brief Interview of Mental Status (BIMS) score at time of admission (Minimum Data Set -MDS dated [DATE]) indicated 0 unable to assess-severely cognitively impaired (cognition score range of 0 to 15). Review of the Physician's Do Not Resuscitate Order document dated 6/23/17 for R A listed and documented the signature of family of A as the designate authorized person. There was only one Physician signature on the document (signed and dated 6/26/17). The DNR form further stated This patient/resident does not have the ability to understand and appreciate the nature and consequence of an order not to resuscitate including the benefits and disadvantage of such an order and to reach an informal decision regarding the order. Review of the admission face sheet listed family of A as a contact person only. Further review revealed no documents to provide evidence that family of A had legal documentation as a Durable Power of Attorney for Health Care or Guardianship. Interview on 9/2/21 at 10:36 a.m. with the Business Office Manager/admission Staff (BOM) revealed that she was knowledgeable of the policy about DNR required documentations. The policy is to review all DNR at the time of admission for appropriate documents. BOM confirmed that she had failed to review the DNR documentation for R A to ensure two Physician signatures if the resident did not have a Durable Power of Attorney for Health Care or Guardianship. She reported that R A was admitted to the facility from the hospital. BOM reported that prior to his hospital admission, the resident was at another local nursing home facility and his DNR code status was completed at the former nursing facility.

Based on record review and staff interviews, the facility failed to ensure that the staff designated as Dietary Manager (DM) was a Certified Dietary or Food Service Manager or had a similar food service management certification or degree. This had the potential to affect 37 residents receiving an oral diet. Findings include: Review of the job description in the employee file of the DM documented Food Service Manager (FSM) and did not indicate the requirement of a certification. During a tour of the kitchen and interview on 8/31/21 at 11:21 a.m., the DM revealed his present food certification status as ServSafe certified and not certification as a Certified Dietary Manager. He stated that he is enrolled in a CDM course but could not provide a start date or a target date for completion of the CDM certification course. Review of the employee file for the DM revealed a hire date of March 2021. Record review of the DM's resume revealed no certification or education degree in culinary art or any other food service management degree. During an interview on 9/2/21 at 12:10 p.m., the Administrator verified that the current DM was not certified. The Administrator reported she figured the (contracted agency) had ensured certification of the DM prior to the hire date. Telephone interview on 9/2/21 at 10:58 p.m. with the consulting Registered Dietician revealed she is a consultant for the hospital and the nursing home. She is not full-time and only works 8 to 10 hours weekly for the nursing home.

Based on observations and staff interviews, the facility failed to maintain the cleanliness of one ice machine, label and date food items, discard expired food, prepare food in a sanitary manner, store food to prevent food borne illness, maintain a pest free environment, and ensure staff wear hair nets appropriately while in the kitchen. This had the potential to effect 37 residents that received an oral diet. Findings include: During the initial walk-through of the kitchen with the Dietary Manager (DM) on 8/31/21 at 9:29 a.m. through 10:33 a.m., the following concerns /issues were observed: 1. Observation of the ice machine revealed sticky dark watery brown substances on the inside panels of the ice machine. At the time of the observation, (the DM wiped the inside panel with a white cloth), the DM identified the substances as mildew. The DM could not provide a log date for the cleaning schedule for the ice machine. Record review showed the ice machine was cleaned on 3/20/21. 2. Observation of Refrigerator #1 revealed five ham sandwiches contained in a Ziploc bag, with no open date and no expiration date. 3. Observation of preparation counter located at the rear of the kitchen revealed a block of butter in a small plastic container exposed with no lid or covering. Further observation revealed a fly swarming around kitchen area near the butter. 4. Observation of food preparation counter attached to the vegetable and meat sink, revealed Dietary Aide (DA) BB making salad trays for lunch. Closer observation revealed a pan of lettuce uncovered on the counter, and a fly swarming around the pan. An open garbage can (with no lid) filled with trash was also positioned next to the preparation counter. 5. Observation of the flour bin revealed a scoop covered with dried clumpy flour laying on top of the lid of the bin. Further observation revealed a fly swarming around the bin and the scoop. 6. Observation of the walk-in-cooler revealed the following food items outside of the expiration dates: a large pan of macaroni salad expiration date 8/28/21 and a large pan of chicken salad expiration date 8/28/21. 7. Observation of the dry food pantry revealed the following: a large plastic gallon container of rice sitting on a shelf with no covering for the lid. Further observation revealed no label to show open date and expiration date. A roach was also observed crawling on the floor in the pantry. 8 Observation revealed DA BB and DA CC at the food counter prepping food. A closer observation revealed both DA BB and DA CC wearing hair nets that cover only the middle section of their head leaving the back of their hair exposed and hanging. During an interview on 8/31/21 at 9:55 a.m., the DM reported that all food items should be labeled and dated within a four days' time frame. DM reported that his expectations are for food to be discarded based on expiration dates. Food items should be sealed and closed. DM reported that it is the responsibility of dietary staff to check and monitor the refrigerator to ensure all food is properly stored and labeled. DM further confirmed and verified that two of his dietary aides' hair were not contained in the hair net. During an interview on 8/31/21 at 10:01 a.m., DA BB reported being knowledgeable of the hair net policy. DA BB failed to recheck the placement of her hair net to ensure that all her hair was contained in the hair net. DA BB verified receiving training on food labeling, dating, and storage. She reported that all expired food should be discarded after four days. During an interview on 8/31/21 at 9:59 a.m., DA CC reported that she was aware her hair was not contained in her hair net. She was aware of the policy and verified receiving training on discarding of expired food after five days, food labeling, dating, and storage.

Based on observation, record review, staff interviews, and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, the facility failed to implement corrective action plans that effectively addressed kitchen concerns including discarding expired food items and appropriately wearing hairnets in food preparation areas. The census was 37 residents. Findings include: Review of the facility policy titled QAPI Plan revised 4/7/2020 revealed: Purpose - all staff will participate in ongoing QAPI efforts which support our mission to enhance quality of life. Performance Improvement Projects - the QAPI team will review sources of information to determine if gaps or patterns exist in our systems that could potentially result in quality-of-care issues or if there are opportunities for improvement. QAPI Goals - the nursing home supports performance improvement by encouraging each staff member to be accountable for their own professional performance and practice. Observations of the kitchen on 11/8/2021 at 9:45 a.m. through 10:30 a.m. revealed expired food items in the cook's cooler and dietary staff inappropriately wearing hair nets. Review of facility daily audit tool titled Audit of Expired foods and Dry storage revealed audits were completed for the months of September, October, and the beginning of November 2021. There was no indication on any of the audits reviewed that any food items were expired or that any food item had been removed from the storage areas. Review of facility QAPI Sign- Sheet dated 10/28/2021 revealed no indication of results of monitoring that was conducted by the dietary staff. Further review revealed no evidence that any member from the dietary department participated in the QAPI meeting. Interview on 11/8/2021 at 12:00 p.m. with the Chief Executive Officer (CEO) revealed that currently they do not have a CDM (Certified Dietary Manager) on staff full time, but there is one candidate that is already certified that they are hoping to employ. Currently there are two Registered Dieticians that are in the facility at least 32 hours a week for consultation. Further interview revealed that it was his expectation that the dietary department participate in the QAPI process monthly and to make the changes that are needed to be in compliance. Interview on 11/8/2021 at 1:24 p.m. with [NAME] AA revealed the daily audits are conducted twice a day in the morning at the beginning of the shift and in the evening at the end of the shift. During the audit all food items are checked for expiration dates and if there are any foods that are expired, they are discarded at that time. Further interview revealed that an audit was completed on 11/7/2021 and the noted expired food items were not seen during the audit that was completed on that day. Continued interview also revealed that there was not an audit completed on 11/8/2021 at the beginning of the shift. Interview on 11/8/2021 at 1:52 p.m. with the Kitchen Supervisor revealed that the cook on duty for the day is responsible for checking the food in the cook's cooler for expiration dates at the beginning of their shift and are to document if there are any food items that are expired and remove them from the storage area. She stated she had not attended a QAPI meeting and had no knowledge of whether the Dietary Manager attended the meeting. Interview on 11/8/2021 at 2:24 p.m. with the Administrator revealed that there was no documentation that indicated that the dietary department participated in the QAPI process. Further interview also revealed that the issues with dietary were discussed but there was no written documentation that indicates the discussion was a part of the QAPI process. The Administrator revealed that dietary is supposed to be a part of QAPI but rarely to never participates. They only send in their reports, but there have not been any reports received at this time. Interview on 11/8/2021 at 3:00 p.m. with the Certified Dietary Manager (CDM) revealed that she started at the facility on 9/14/21 and had not been participating in the QAPI process but intends to attend the next scheduled meeting. The daily audits should be conducted by the supervisor or the CDM daily. During the audits if there is any food item that is noted to be expired it should be removed immediately and indicated on the audit tool. Further interview revealed that the next step in correcting the issues of expired food items is to walk around with the staff members and show them the correct way to label food and educate on when to dispose of food items.