Based on observation, interview and document review the facility failed to appropriately administer and accurately reconcile 1 of 1 resident's (R35) medication (lisinopril) (used for high blood pressure) when the order was changed and prior to administering any medication. Findings include: Observation, interview, and Medication Administration Record (MAR) review on 8/27/24 at 9:14 a.m., with trained medication aid (TMA)-A as she prepared to administer morning medications to R35 identified TMA-A removed R35's medication cards from the medication cart and placed them on top of the cart. She accessed the electronic medical record (EMR) which Displayed R35's current medication orders. TMA- A picked up a card, looked at the order on the screen, and popped the medication into a waiting medication cup. When TMA-A picked up the card containing the lisinopril she looked at the card, glanced at the screen, and prepared to place the lisinopril into the medication cup with the meds to be administered. TMA-A was asked what the order was for the lisinopril and looking at the EMR responded, the order listed 5 milligrams (mg) by mouth (PO) daily (QD). She was then asked what the medication label on the card containing lisinopril for R35 and responded it contained 10 mg tablets. Review of the printed Physician Order Review identified an order dated 6/24/24 for lisinopril 10 mg PO QD. The bubble packaged medication card had no label, or identification of a change in order, and had been stored in the cart with his other current medications. Interview on 8/27/24 at 9:19 a.m. with TMA-A reported she had been administering 10 mg of lisinopril to R35 QD and she had not been informed of a change in his dose. TMA-A confirmed she would have administered the 10 mg tablet to R35 if she had not been questioned. She reported the medication card should have been pulled from the cart, given to the charge nurse and the pharmacy contacted to provide the correct dose of medication. TMA-A reported this type of incident had occurred intermittently with other medications, she had informed the charge nurses, but the issues had not been clarified or acted upon. Interview on 8/27/24 at 9:23 a.m. with licensed practical nurse (LPN)-A (charge nurse) identified the order on the EMAR and the bubble packaged medication card did not match, and she was not aware of when the order had changed. LPN-A reported the procedure that staff were to follow was when a medication dose was changed, the medication card should have been pulled out of the medication cart, the pharmacy notified of the change and a card with the correct dose provided. She confirmed staff were supposed to be checking to ensure the orders and medication cards matched, but the old card should not have been left in the cart and it would have been possible for an error to occur. Interview on 8/27/24 at 9:53 a.m. with the director of nursing (DON) reported R35's lisinopril order had changed on 8/26/24 and the medication card should have been pulled from the cart, the pharmacy notified and a card with the correct dose provided. She reported staff were supposed to follow the checks for each medication administered, but the process had not been followed, and the order had been entered into the EMR, but the process was not completed when the card with the incorrect Lisinopril dose should have been removed from the cart, to avoid an error. The DON did provide a new Physician Order Review document which contained an order dated 8/26/24 with a start date of 8/26/24 for Lisinopril 5 mg PO QD. She confirmed the procedure for a medication order change had not been followed and R35 should have received 5 mg of Lisinopril on 8/26/24 instead of the 10 mg tablet. Review of the Nursing Policies and Procedures Transcribing MD/NP orders identified the nurse who received an orders was responsible to transcribe and follow the process for any orders received. Medication orders: 1. Were to be entered into the EMR. 2. The new medication or dose change was to be ordered from the pharmacy by either phone or fax. 3. Document the order and/or changes in the progress notes. 4. Make care plan changes if indicated. 5. Apply a label change sticker the medication card if appropriate.

Based on observation, interview, and document review, the facility failed to ensure an accurate labeling of three medication for two residents (R35 and R38), who had medication package labels and orders that did not match or give clear direction, to avoid the potential medication errors. Findings included: R35's current 8/26/24 physician order for lisinopril ( a blood pressure medication) listed 5 milligrams (mg) by mouth (PO) daily (QD). The medication card located with R35's active medications contained 10 mg tablets. The bubble packaged medication card had no label, or identification of a change in order, or dosage. R38's current Physician Order Summary contained a 6/18/24 order for Gabapentin ( used to treat neuropathic pain) oral capsule 100 mg, 3 capsules PO twice daily (BID) (7:00 a.m.-10:00 a.m. and 7:00 p.m. - 10:00 p.m.) and 100 mg PO QD (12:00 p.m.-2:30 p.m.). The current medication card contained 300 mg capsules and directed staff to administer one capsule PO BID. The card failed to contain any label or notation to draw attention to the dosage of the medication in the active card, and the orders. R35 also had a 8/13/24 order for Lidoderm External Patch 5% 1 patch QD on (7:00 a.m. - 11:00 a.m.) off at bedtime (HS). The current pharmacy package label directed to apply 1-3 patches to skin QD. Leave on for up to 12 hours in a 24 hour period. Interview on 8/27/24 at 9:19 a.m. with trained medication aid (TMA)-A confirmed the order listed in the electronic medical record (EMR) listed Lisinopril 5 mg PO QD, and the current medication card contained 10 mg tablets with directions to administer 1 tablet PO QD. She reported she had been administering the 10 mg daily and confirmed she had not been notified of a change in the dosage. TMA-A reported when an order was changed the process was to pull the card and request a new card from pharmacy. She reported she would not have attempted to break the 10 mg tablet, but would have waited for a new correct dose medication to be sent from the pharmacy. She identified she would have administered the 10 mg tablet, as that was the dose R35 had been receiving. Interview on 8/27/24 at 9:23 a.m. with licensed practical nurse (LPN)-A (charge nurse), confirmed R35's active Lisinopril medication card contained 10 mg tablets and the order had been changed in the EMR, but she was not aware of a change in dosage. LPN-A reported the order change should have been communicated, the card pulled from the medication cart, and a new card requested from the pharmacy. She identified the process for medication changes, had not been followed and could have resulted in a medication error. Interview on 8/27/24 at 9:53 a.m. with the director of nursing (DON) reported R35's Lisinopril order had changed on 8/26/24 to Lisinopril 5 mg PO QD and the medication card should have been pulled from the cart, the pharmacy notified and a card with the correct dose provided. The change in order should have also been communicated during shirt report to avoid a potential error. Review of the Nursing Policies and Procedures Transcribing MD/NP orders identified the nurse who received an orders was responsible to transcribe and follow the process for any orders received. Medication orders: 1. Were to be entered into the EMR. 2. The new medication or dose change was to be ordered from the pharmacy by either phone or fax. 3. Document the order and/or changes in the progress notes. 4. Make care plan changes if indicated. 5. Apply a label change sticker the medication card if appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food under sanitary conditions, discard food that had been expired, ensure all foods were labeled and dated, and ensure the freezer door had been shit to prevent potential spoiling of food. This had the potential to affect all 39 residents. During observation and interview with cook-A and later joined by the dietary manager on 8/25/24 at 11:30 a.m., the following was observed during the initial tour of the kitchen: 1. Mrs. Gerry's Parmesan Pepper Corn Pasta Salad had been previously opened with an expiration date of 8/17/24. 2. Mustard with a use by date of 12/10/22 3. Bag of California Sun Dried Raisins, best before 4/6/24. 4. Minced garlic in a squeeze bottle with no visible expiration date, bottle had a dark brown substance on the inside of the lid and around the opening and a black substance on the outside of the bottle. 5. A second bottle of minced garlic with a use by date printed on the bottom of 8/11/23 6. A bottle of [NAME] Lynch Dressing with a use before 10/17/23 7. A plastic container of strawberry smoothie mix with no expiration date and no open date. 8. Boursin Cheese with a use by date of 4/26/23. 9. a zip lock bag of pepperoni with an expiration date of 4/13/24. The following items were observed in the walk-in cooler with no date or label. 1. A Bowl containing a white creamy substance loosely wrapped with plastic Cook-A was unsure what the bowl contained; however, she thought it may be ranch dressing. 2. A plastic squeeze bottle with a solid white substance Cook-A was unsure what the bowl contained; however, she thought it may be sour cream 3. A plastic squeeze bottle, the contents had separated, an oily substance on top, a solid yellow substance in the middle, and a brown liquid on the bottom. 4. A glass jar with a screw top cap, the contents were a yellow creamy like consistency. The jar had no label and was not dated. 3. A partial head of lettuce loosely wrapped in plastic with one side exposed. The lettuce appeared brown and wilted. There was no label or date. 4. A zip lock bag containing lettuce with no label or date. 5. A plastic lidded container with a white solid block of unknown product, with no label or date. The walk-in freezer had copious amounts of frost build up on the first 2 shelving units closest to the door and did not contain an internal thermometer. The stove top had a piece of long hair and food particles, the front of the stove had dried brownish drip marks, the side of both stoves also had a brownish/yellow substance that had dried in a drip pattern. The wall behind the griddle had a yellow and brown substance that had dried. Interview 8/25/24 at 11:30 a.m., with Cook-A identified she was not certain of the contents of any of the unlabeled bottles but said most of the items were used for resident Happy Hour. She identified that the kitchen has had a lot of staff turnover and they have not had time to get their cleaning done or check for expired foods. Follow up interview on 8/27/24 at 8:20 a.m., with Cook-A identified when she came in for her shift on Friday morning on 8/23/24, the walk-in freezer door was open, the frost was much worse then it is now. She identified that she did not notify anyone that morning of the incident, she did not check the temperature of the freezer, and did not check to ensure the foods had not thawed. She had told the dietary manager later that day, however, nothing was ever directed to staff to check the food to ensure it had not thawed out overnight. Review of the 5/11/24 through 8/14/24, daily cleaning schedule sign off sheets provided by the dietary manager identified the following tasks: 1. Wipe up spills in oven. 2. Wash off stove tops. 3. Wipe out convection oven. 4. Wash out microwave. 5. Wipe off shelves below cook's station. 6. Wash can opener. 7. Wash food processor/Robot Coupe. 8. Clean and Sanitize work surfaces. 9. Scrub 3 compartment sink. 10. Clean and sanitize work counters. 11. Take out garbage. At the bottom of the sheet were notes to Make sure all tasks listed are completed before you leave your shift. All cooks watch for outdated foods and discard. None of the listed kitchen cleaning tasks had been signed off as completed for the following days: Week of 5/11/24, Monday, Tuesday, Wednesday, or Saturday. Week of 5/19/24, Sunday, Monday, Friday, or Saturday. Week of 5/26/24, Sunday, Tuesday, Wednesday, Thursday. Week of 6/2/24, Monday, Friday, or Saturday. Week of 6/9/24, Sunday, Monday, Tuesday, Wednesday, Thursday. Week of 6/16/24, Monday, Friday, or Saturday. Week of 6/23/24 Sunday, Monday, Tuesday, Wednesday, Thursday. Week of 6/30/24, Monday, Thursday, Friday, or Saturday. Week of 7/7/24, Sunday, Monday, Wednesday, Thursday. Week of 7/14/24, Monday, Friday, or Saturday. Week of 7/21/24, Sunday, Tuesday, Wednesday, Thursday. Week of 7/28/24, Monday, Wednesday, Friday, Saturday. Week of 8/14/24, Friday. Review of monthly cleaning schedule form January of 2024 through August of 2024, identified a task to wipe out walk in cooler. The task had not been signed off as completed on any of the months provided. Interview on 8/25/24 at 12:06 p.m., with the dietary manager identified she agrees with the above findings. Cooks are supposed to keep an eye expiration dates and should throw them away and order new if needed. We do not have any system to ensure staff are checking for expired foods, we discussed doing audits and competencies with staff, but we have never completed any. We wipe the cooler down monthly and once a year we pull the racks out and clean them. We have sign off sheets for cleaning the cooler, but I have not been checking them. The frost in the freezer was caused by the freezer door being left open over-night last week. Interview on 8/25/24 at 3:30 p.m., with the director of dietary services identified she had been in this position for about 15 months, she oversees 14 facilities for this corporation and most of her work is done remotely. She reviews weights monthly and assesses high risk residents like people on dialysis The dietary manager does most of the nutritional assessments on site. She had been at the facility in May and had done a tour of the kitchen, she had a conversation with the dietary manager about completing audits and competencies with staff but had not heard if she had completed them yet. Interview on 8/25/24 at 2:56 p.m., with the administrator identified she would expect the dietary manager would have a system in place to ensure staff were completing all kitchen duties including cleaning, removal of expired foods and appropriate labeling to prevent harm to residents. Review of the 1/30/20, Labeling of Foods/Grocies facility policy identified all foods need to have a label and date to indcate what is in the package and when it expires and when it was opened. The policy lacked any indication of what system the facility should use to ensure the policy is being followed. Review of the 4/3/17, Using Sanitary Practices to Prepare, Serve, and Store Food facility policy identified staff were to follow cleaning list to ensure all equipment is cleaned regularly, and employees will label, and date all opened food and items pulled out to be thawed. The policy lacked any indication what system (such as audits or competencies) should be used to ensure staff were following the policy.

Based on interview and document review the facility failed to implement 1 of 1 facility assessment protocol related to ensuring staff competencies were identified and completed respective to staff duties performed. The facility assessment protocol further failed to solicit input from staff, residents, representatives, or family members. Refer to F812 Findings include: Review of the 8/8/24, facility assessment identified changes which were highlighted in yellow that went into effect on 8/8/24. The changes included solicitation of feedback: questionnaire to resident/representative related to staffing, suggestion boxes throughout facility, annual notices to residents/representative prior to annual review, review during resident/family council meeting, departmental/all staff meetings. Accepting residents not on the assessment-add prior to admission. Competencies-knowledge and skills able to prove (demonstration) for hired staff, temporary staff, volunteers, and vendors. On the page identified as authorizations and resident profile listed persons assisting in completing assessment, including QAA/QAPI review and approval to include the administrator, director of nursing, SFHS regional director/governing body representative, medical director, and pharmacist. Highlighted in yellow was additional people including infection preventionist, licensed nurse, nursing assistant, resident/family council, and other. With identification that the facility assessment had been reviewed on 4/15/24 at QAA/QAPI and the next review would be October. The facility assessment further identified that staff competencies had been completed for licensed nurses, nursing assistants, dietary staff, and other staff. Review of a sample of staff competencies for licensed nurses, nursing assistants, and dietary staff identified the nursing staff had their competencies completed. The dietary staff sampled for competencies on sanitation and modified diets revealed that cook-A and cook-B had no competencies completed. Interview on 8/27/24 at 2:31 p.m., with dietary manager identified the dietary staff complete their training on educare. She stated competencies were only completed annually and she did not have any for the two staff requested. She reported the one staff went to part time and the other staff she would be completing soon. Interview on 8/27/24 at 4:31 p.m., with the administrator identified that the facility had not yet implemented input from residents or representatives as the regulation had just went into effect. She revealed that the facility had discussed the changes that went into effect during their leadership call with the corporate office. She reported that the facility would be adding residents, vendors, and staff input on next year's facility assessment. She confirmed that there had been no questionnaires sent out, no notices to residents/representatives had been sent, and the facility had not had a resident/family council yet to discuss the changes. She identified the area's highlighted in yellow on the facility assessment were the changes that the facility would be implementing by the next review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to have evidence of measurable goals and documentation of an analysis and evaluation of the data submitted to the QAPI committee to ensure areas identified had oversight for their perspective outcomes brought forth for 1 of 1 Quality Assurance Performance Improvement (QAPI) program. Findings include: Review of the 2/14/24, monthly QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to document a measurable goal and/or analyze the data identified: 1) Quality improvement Incentive Program (QIIP) Bowel incontinence with toileting plan identified residents with bowel incontinence triggering would be reviewed for toileting habits and interviews with staff would be completed. The individualized toileting plans would be reviewed. The director of nursing (DON), assistant director of nursing (ADON) and the MDS coordinator would be assigned the review. Completion date was ongoing. Follow up area identified to assess toileting plan if effective and meeting goals. Information on QIIP by breakroom for all staff to review. There was no documentation of a measurable goal, no documentation to support the QAPI committee analyzed the data brought forward, how they were going to achieve their compliance, if further education was needed, or if the action plan required revision. 2) Performance-Based Incentive Payment Program (PIIP) identified task 2023 [NAME]-Employee Recruitment and Retention (UKG [NAME] Implementation) Reduce turnover by 2%, increase employee satisfaction, increase applications for open positions, fall grant, facility will continue to work on their fall reduction and prevention. Person assigned would be the HR/Grant Coordinator. Completion date identified as ongoing. Follow up education and communication was ongoing with any concerns noted with UKG. Next step was plans to be advanced scheduling. There was no documentation to support the QAPI committee had data to analyze brought forward, no action plan as how the facility would achieve their compliance, or if revisions were needed. Review of the 3/13/24, QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to document a measurable goal and/or analyze the data identified: 1) Quality improvement Incentive Program (QIIP) Bowel incontinence with toileting plan identified residents with bowel incontinence triggering would be reviewed for toileting habits and interview staff. Individualized toileting plans would be reviewed. The director of nursing (DON), assistant director of nursing (ADON) and the MDS coordinator would be assigned the review. Completion date was ongoing. Follow up identified assess toileting plan if effective and meeting goals. Information on QIIP by breakroom for all staff to review. There was no change from last meeting and no documentation of a measurable goal, no documentation to support the QAPI committee analyzed the data brought forward, how they were going to achieve their compliance, if further education was needed, or if the action plan required revision. 2) Performance-Based Incentive Payment Program (PIIP) identified task 2023 [NAME]-Employee Recruitment and Retention (UKG [NAME] Implementation) Reduce turnover by 2%, increase employee satisfaction, increase applications for open positions, fall grant, facility will continue to work on their fall reduction and prevention. Person assigned HR/Grant Coordinator. Completion date identified as ongoing. Follow up education and communication were ongoing with any concerns noted with UKG. Next step was plans to be advanced scheduling. New this meeting was that in March 2024, performance reviews were now in the new UKG to start using. HR was to send managers information and training video. There was no documentation to support the QAPI committee had data to analyze brought forward, no action plan as how the facility would achieve their compliance, or if revisions were needed. Review of the 7/29/24, QAPI meeting minutes identified the facility departments were submitting data to be reviewed by the committee. 2 examples of failure to document a measurable goal and/or analyze the data identified: 1) Problem, April falls: 7 of 9 falls were on a weekend in April. Tasks identified will review staffing and activities. Person assigned was managers, completion date identified as ongoing. The follow up action plan included afternoon snack cart in dining room versus room to room. Get residents out of their room for afternoon snack/socialization. Review activity staffing hours on weekends. Monitor to see if continues as a trend or pattern. The problem had been identified at May meeting, with no documentation of a measurable goal, no documentation to support the QAPI committee analyzed any data brought forward, how they were going to achieve their compliance, if further education was needed, or if the action plan required revision. 2) Problem, dementia. Tasks included education with staff on how to handle residents with dementia. No person was assigned, completion date was ongoing, and there was no follow up or action plan identified. There was no documentation of a measurable goal, no documentation to support the QAPI committee analyzed any data brought forward, how they were going to achieve their compliance, if the action plan required revision. Interview on 8/27/24 at 2:45 p.m., with administrator identified the QAPI documentation was lacking but discussions had taken place about concerns identified. She agreed that there was a lack of measurable goals, and analysis of information brought forward during the meetings. Review of the 10/8/18, Quality Plan policy identified the administrator had the responsibility and was accountable to the Regional Director/VP/CEO and governance Board of Directors of QAPI and ensuring quality of care was delivered. The administrator was to provide staff support to the QAPI program and review recommendations made through that process. The administrator was to oversee each department actively participated in the program with objectives to problem identification, implementation of corrective action, and evaluation of the effectiveness of the program through ongoing monitoring and data collection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to comprehensively assess, and create and implement interventions for ongoing undesired weight loss for 1 of 1 (R7) reviewed for significant weight loss. Findings include: R7's 9/6/23, resident face sheet identified R7 was admitted to the facility on [DATE]. R7 had the following diagnoses a history of left hip fracture, adjustment disorder with depressed mood, age-related osteoporosis, hypertension, amnesia, seizures, and dementia. R7's 8/8/23, significant Minimum Data Set (MDS) assessment identified R7 had severe cognitive deficit, was independent with eating after set up assistance. R7 had physical behaviors towards others, had behaviors that significantly affected her cares and impacted others. R7 took a daily antipsychotic medication and had no identified swallowing or chewing problems. R7's 7/10/23, Service Plan (care plan) identified R7 was independent with eating and should continue to be independent after set up assistance. The staff were to offer R7 foods and drinks per R7's preference. R7 will brush her own existing teeth with a soft brush in the morning and evening during cares. R7 had partials but did not wear them. Review of 7/27/23, certified dietary manager (CDM) 5 day nutritional assessment with the assessment reference date (ARD) of 7/17/23, the CDM identified R7's weight was 104 pounds, R7 had a regular diet and no supplements at the time. R7 was pleasantly confused. CDM identified R7 was as risk for weight loss and dehydration and would care planned R7 to increase fluid intake at meals, offer drinks after toileting program, and increase snacks and possible supplements. There was no mention of these interventions on the care plan. Review of 8/7/23, CDM Significant Change Nutritional Assessment identified R7's weight at 101 pounds. R7 remained on a regular diet and started supplement 2 ounces three times a day. R7 continued to be independent with eating after set up assistance, R7 was identified to be confused and combative at times. R7 was at risk for weight loss and dehydration, R7 slept through meals and refused meals. The assessment identified care plan changes included increase fluid intake at meals, offer drinks after toileting program, increase snacks and possible supplement. There was no change to the care plan interventions, and no mention of these intervention on the care plan. Review of R7's weights since admission on [DATE]: 7/10/23-103.9 pounds (lbs) 7/11/23-102.8 lbs. 7/12/23-103.8 lbs. 7/19/23-104 lbs. 7/25/23-101.6 lbs. 8/25/23-96.6 lbs. 8/25/23-89.2 lbs. 8/31/23-90.8 lbs. 8/31/23-90.8 lbs. Between 7/10/23 and 8/31/23, R7 had a 12.61% weight loss, with no interventions implemented. Observation on 9/6/23 at 8:33 a.m., of R7 in dining room sitting at table eating her breakfast independently. She then starts to leave wheeling herself away from the table, she had a couple bites of scrabbled eggs left, and some sausage. There was a medication staff at medication cart about 4 feet from her and a staff person charting off to the side of the dining area however, no staff attempted to stop her to encourage her to finish her breakfast. Interview on 9/6/23 at 8:51 a.m., with cook (C)-A identified she normally gave R7 small portions because if she gave her to much on her plate in the morning she would not eat as R7 seemed to get overwhelmed. So if she gave her small portions she would eat everything on her plate and not leave the table. She also reported R7 normally would not come out for lunch or eat lunch. She stated they brought her out for lunch yesterday but she would not eat anything she just sat there. Observation 9/6/23 at 11:53 a.m., R7 was sleeping in her room in her recliner, others are all in the dining area seated at the table for lunch. At 12:21 p.m., R7 continues to be in her room sleeping in her recliner during noon meal. At 12:40 p.m., R7 was seated at the table in dining room not eating, there was no staff encouraging her to eat. Interview on 9/6/23 at 1:52 p.m., with CDM identified when there was a new admission she would completed an assessment within 5 days. The Dietician then would review the admission assessment, and she would complete the annually, and significant changes assessment or assess a resident upon request. The CDM revealed that the dietician had not reviewed R7 yet related to being ill the last time she was scheduled to come to the facility and she had to work remotely. She reported that R7 had been admitted to the facility under weight and the family had reported to her that R7 did not like to drink supplements. She reported she had started the dietary assessment and nutritional risk assessment for R7 in the electronic medical record with the review date of 7/17/23, however she had not completed either of them and they both still showed in progress, she stated she did assess R7 though and just made a progress note. She monitored weights weekly and was aware R7 had been loosing weight. She stated she had been monitoring R7's intake about every other day reporting that R7 did well with drinking her fluids so she had dietary give her vanilla ensure in her milk when she ate breakfast but did not have that documented anywhere. She confirmed she had not started R7 on any type of supplement, she stated the doctor had not even referred R7 to the dietician at all. When asked if she had contacted the dietician about R7's weight loss she reported she had contacted her 2 days ago and had no record of that as she had just called the dietician. There was no indication the kitchen staff were fortifying her food for extra caloric intake. Interview on 9/6/23 on 4:36 p.m., with dietician identified she was unaware of R7's weight loss and had not been notified of R7's weight loss. She identified she would expect to be notified any time a resident was loosing weight either by a phone call or email as she could make a recommendation to the facility or she could contact the provider with a recommendation. She reported she does admission assessments, and annual assessment when she comes to the facility for her visits. For issues that arise between those times that need addressing sooner she was contacted and could complete an assessment remotely if she has access. She agreed that R7's weight loss was significant and the provider should be updated and interventions put into place. Interview on 9/7/23 at 8:25 a.m., with trained medication aide (TMA)-A identified R7 ate independently and normally ate a good breakfast but did not eat lunch unless she ate her dessert. TMA-A revealed R7 did not get any supplements that she was aware of and staff did not do anything for her to get her to eat as she eats independently when she wants to eat. Interview on 9/7/23 at 9:18 a.m., with registered nurse(RN)-B identified nursing does weights on bath days, then dietary reviews those weights. Staff can see other weights when they enter the weight into the computer system and if they note a change they should be reporting that to the charge nurse. If a resident was noted to be having a weight loss nursing would notify the provider as well as talk with the dietary manager to see what else we could be doing to help prevent additional weight loss. She was unaware that R7 had a significant weight loss. Interview on 9/7/23 at 10:26 a.m., with director of nursing identified that nursing completes weights weekly, dietary should monitoring weights weekly, and if a resident was loosing weight an assessment should have been completed to find out the root cause of the weight loss and implement interventions to prevent further weight loss. Review of 1/18/21, Weight Monitoring Program policy identified a significant weight loss was of 5% or more in 30 days or 10% in 189 days. The staff were to monitor for weights to maintain or improve a residents overall health. Staff would weight residents weekly, weights would be tracked and assessed once entered into the electronic health record. Residents with weight loss or risk of weight loss should be discussed at interdisciplinary team (IDT) and identify interventions. The registered dietician would be notified of all new admission, hospital returns with identified changes in conditions that may affect weight so interventions could be implements. The provider would be contacted for any significant weight changes and care plans should reflect interventions implemented.

Based on observation and interview the facility failed to ensure hair nets were accessible prior to entry for visitors and staff for 1 of 1 kitchenette. The facility also failed to ensure 1 of 1 walk-in freezer, 1 of 1 walk-in refridgerator, 2 of 2 stand alone refrigerators temperatures were consistently monitored and 1 of 2 stand alone refrigerator outside of the kitchen and 1 of 1 walk-in refrigerator was kept clean and free of food-like debris. In addition, the facility also failed to ensure food was not stored on the floor in 1 of 1 dry food storage area, scoops were not stored in 1 of 2 bulk containers, and 1 of 1 dishwasher temperature was consistently monitored. Findings include: Observation, interview, and document review on 9/5/23 at 10:00 a.m., with the certified dietary manager (CDM) on initial tour identified a log was hung outside of both the walk-in freezer and the walk-in refrigerator. On those logs were 2 documented temperatures (both within normal range). 3 of the 5 days had no temperatures logged. The CDM revealed that had been a known concern of getting staff to log the temperatures daily as required. Inside the walk-in refrigerator there was a spill of pink juice-like substance just below the box marked chicken, located on the bottom shelf approximately the size of a pie plate. The floor inside the walk-in refrigerator was observed to be sticky while walking on it. The CDM stated the cook should have cleaned up any spills immediately. Observation of the dry storage area identified a box of potatoes was sitting on the floor next to the storage rack. The CDM picked the box up and carried it into the walk-in refrigerator. She agreed food was not to be stored on the floor. The bulk flour container was noted to have the scoop stored in the container sitting in the flour. The CDM removed the scoop stated staff were aware they were not to leave scoops food items. In the washing machine room was a hot temperature washing machine. Staff were to log temperatures during each wash cycle. The log had 1 temperature noted for the month of September. Observation on 9/5/23 at 11:35 a.m., of the refrigerator on the Centennial wing found a temperature log hanging on the outside of the refrigerator with 4 of the 5 days documented. Inside the refrigerator there was observed to be a red juice-like substance spilled on the bottom and the sides of the refrigerator wall. There were no hairnets accessible at the Centennial kitchenette serving area. There was a yellow sign hanging on the paper towel holder above the sink to notify staff to Make sure to wear your hairnet. When asked, staff were unable to locate or recall where hairnets were stored. Observation on 9/6/23 at 11:00 a.m., of the South nurses station refrigerator identified a temperature log outside of the refrigerator. Only 1 documented temperature was recorded for month of September. Further review of the July, August, and September 2023, temperature logs for the walk-in freezer identified: 8 out of 31 days in July,no temperatures documented as having been monitored. 8 out of 31 days in August had no temperatures documented as having been monitored, and 2 out of 5 days in September had no temperatures documented as having been monitored. Further review of the July, August, and September 2023, temperature logs for the walk-in refrigerator identified: 8 out of 31 days in July had no temperatures documented as having been monitored. 8 out of 31 days in August had no temperatures documented as having been monitored, and 2 out of 5 days in September had no temperatures documented as having been monitored. Review of the July, August, and September 2023, temperature log for Centennial wing refrigerator identified 17 out of 31 days in July had no temperatures documented as having been monitored, 2 out of 31 days in August had no temperature documented as having been monitored, and 1 out of 5 days in September had no temperature documented as having been monitored. Review of the July, August, and September 2023, temperature log for South nurses station refrigerator identified 4 out of 31 days in July had no temperatures documented as having been monitored, 11 out of 31 days in August had no temperature documented as having been monitored, and 3 out of 6 days in September had no temperature documented as having been monitored. Further review of July, August, and September 2023, temperature log for the dishwasher identified: 1/31 morning shift and 31/31 PM shift in July had no temperatures documented as having been monitored, 1/31 morning shift and 31/31 PM shifts in August had no temperature documented as having been monitored, and 4/5 morning shifts and 5/5 PM shifts in September had no temperature documented as having been monitored. Review of 8/27/23 through 9/2/23, Daily Cleaning/Duty Sheet identified staff were to wipe out the refrigerator in Centennial serving area and record refrigerator and freezer temperatures. There was no mention of a cleaning task in the kitchen area. Interview on 9/6/23 at 4:36 p.m., with the registered dietician identified she would expect dietary staff would maintain a sanitary department, keeping the refrigerators clean, not leave scoops in bulk stock foods, ensure there was no food stored on the floor, log temperatures in all refrigerators and freezers daily, and log dishwasher temperature to ensure appropriate monitoring occurred with each wash. There was to be a cleaning schedule for routine cleaning, but staff were expected to maintain sanitation should a spill occur. Review of undated, Hair Covering policy identified all exposed hair, such as facial and hair on staff's head, was to be covered in order to prevent hair from contaminating food or clean dishes. There was no mention hairnets should be accessible at the entrances of the kitchen or the kitchenette serving areas.

Based on observation, interview and document review the facility failed to appropriately clean and disinfect 1 of 2 Master Care Integrity Bath with Reservoir tubs per the manufacture's guidelines using a wet contact time of 10 minutes with an approved chemical. This had the potential to effect 41 of 41 residents who used the Master Care tubs. Findings include: Observation and interview on 9/6/23 at 10:36 a.m., with nursing assistant (NA)-A as she took the attached sprayer and rinsed the tub and chair surfaces with water and allowed to drain from the tub, She then closed the tub drain, turned on the jets, filled the tub to the intake value, turned on the disinfectant switch to allow the disinfectant/cleaner to flow into the tub, and used a scrub brush to scrub all interior surfaces of the tub and bath chair. NA-A turned off the jets and drained the solution from the tub. She again closed the drain, reached to the side of the Master Care jetted tub, turned the panel button for the attached manufacturer's disinfectant located beside the tub and using the attached sprayer, sprayed the tub and bath chair surfaces, she then took the scrub brush and scrubbed the tub and chair surfaces with disinfectant and removed the chair cushion to allow cleaning of the bottom surfaces. NA-A sprayed the disinfectant over the tub and chair and reported she would wait 10 minutes and then return to rinse the tub. The surface of the tub sides and upright chair surface was observed drying and were dry at 10:51 a.m., when NA-A reported she could now open the drain and rinse the tub and chair surfaces with water to get rid of the disinfectant that was on the surface, and it was ready for the next bath. NA-A reported staff were to clean the tub after each bath and a there was an additional cleaning and disinfecting process completed after the last bath was given. She referred to the cleaning and disinfecting instructions posted on the wall beside the tub which listed to let the disinfectant sit on the tub surfaces for at least 10 minutes. She reported she followed the directions to make sure the tub was clean and disinfected and was not aware of a need to keep the tub and chair surfaces wet for disinfection, only that it needed to be on the surface for 10 minutes. Interview on 9/6/23 at 11:00 a.m., with the infection preventionist (IP)/assistant director of nursing (ADON) reported staff had been reeducated on cleaning and disinfecting the Master Care tubs, after being cited last year, but she was not aware of the manufacture's label directions on the disinfectant solution that identified the required wet time of 1 to 10 minutes for disinfection depending on the organism. The ADON agreed that the disinfectant was not being used per the manufacture's guidelines. Interview on 9/6/23 at 11:45 a.m. with the director of nursing (DON) reported staff had received education on how to clean and disinfect the Master Care tub and review of the Master Care integrity Bath with reservoir System Operation procedures listed to open the drain and after standard contact time per label directions on disinfectant container, use the Shower Wand to rinse all areas that had contact with the disinfectant cleaner. She reported she was not aware of the need for surfaces to remain wet for 1 to 10 minutes as directed on the disinfectant label. Interview on 9/07/23 at 11:01 a.m., with the environmental services supervisor reported he had contacted the Master Care company about the brand of whirlpool disinfectant and cleaner being used in the facility. He reported they did not specify a specific brand of disinfectant to be use in the Master Care jetted tubs, but the label directions should be followed to ensure disinfection was completed. Review of the manufacturer's System Operation Procedures identified the Master Care Integrity Bath with Reservoir System disinfection was to be used according to the standard contact time on the label of the disinfectant container. The Classic Whirlpool Disinfectant and Cleaner label identified after using the whirlpool unit, staff were to drain and refill with fresh water to the level of covering the intake valve. Staff were to add 2 ounces of the disinfectant for each gallon of fresh water added. Staff were to then start the pump to circulate the solution and wash down the unit sides, seat of the chair, lift and any/all related equipment with a clean swab, brush, or sponge. Treated surfaces were to remain wet for 10 minutes. After the unit had been thoroughly cleaned, staff were to drain the solution from the unit and rinse any/all cleaned surfaces with fresh water.

Based on interview and document review, the facility failed to notify the county (designated State mental health authority) when for 1 of 3 residents (R4) reviewed, who had a changes in mental health and/or had new-onset mental illness diagnoses. Findings include: R4's face sheet printed on 7/22/22, identified admission date in November 2019, with a primary diagnosis of hydrocephalus unspecified, hypertension, right and left artificial hip joint, unilateral osteoarthritis, presence of left and right artificial knee joint, type 2 diabetes mellitus, pain in right toes, and hypothyroidism. R4's diagnosis list identified that upon admission R4 had no diagnosis of MI or related condition. R4 did have diagnosis of major depression, single episode unspecified on 11/18/19. On 3/25/21, R4 was diagnosed with dementia without behavioral disturbance, then on 12/27/21, R4 was diagnosed with delusional disorders and hallucinations. R4's medical recorded lacked information that the county had been notified of the new diagnoses. R4's 11/7/19, Initial Pre-admission Screening (PASRR) Results identified R4 lived in their own home or apartment, including assisted living. R4 had a 3 day stay in hospital with discharge to long term care facility on 11/9/19. Screening identified R4 did not meet the criteria for mental illness (MI). R4's 2/28/22, quarterly Minimum Data Set (MDS) assessment identified the diagnosis of psychotic disorder, depression, and dementia. R4 had severe cognitive impairments, with inattention that fluctuates, behaviors not directed at others 1 to 3 days during the assessment period. R4's 5/2/22, Significant Change MDS did not identify any behaviors or inattention. Review of R4's physician orders identified R4 received an order on 12/27/22, for Risperdal (antipsychotic) 1 milligram (MG) every day for diagnoses of delusions and hallucinations. R4's 5/18/22, care plan identified R4 received treatment of antidepressant and antipsychotic medication related to mood disorder, delusional disorder with hallucinations. Interview on 7/20/22 at 3:20 p.m., with social service designee (SSD) revealed she had never had to update the county to come and complete a level II screening for services since she started here about a year ago. She revealed she did not think she had any training on PASARR since she had worked here and have just learned things as they have come up. Interview on 7/22/22 at 9:15 a.m. with registered nurse (RN)-A who is the MDS coordinator identified that R4 Risperdone order was on 1/28/22 for new diagnosis of hallucinations and delusional disorder that was added on 12/27/21. RN-A revealed she was unaware that the county needed to be updated with new mental disorder diagnosis to re-evaluate the need for services. Interview on 7/22/22 at 9:30 a.m., with the director of nursing revealed she was unaware that an level II screening needed to be completed after a resident received an new diagnosis related to mental illness. She revealed she did not believe the facility had ever done that before. She identified the facility normally did not have this many residents on antipsychotic medication so it most likely did not trigger to look at the PASRR. Review of 3/7/22 Pre-admission Screening (PASRR) policy identified that a pre-admission screening was to be completed by appropriate assessor to determine the need for nursing facility care center level of care and complete activities related to serous mental illness. When mental illness was identified, an additional screening, referred as PASRR Level II screening was required. The level II screening determines whether a person has a serious mental illness which may require needed mental heath services offered in the nursing facility or in the community. Level II screeners have 9 work days from the referral to the county to complete the level II screening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to appropriately clean and disinfect 1 of 1 whirlpool tub per the manufacture's guidelines using a wet contact time of 10 minutes with an approved chemical. Finding include: Observation and interview on 7/21/22 at 9:39 a.m., with nursing assistant (NA)-C who turned button for the attached manufacturer's disinfectant located beside the tub (MasterCare). NA-C sprayed the tub down with the disinfectant but failed to appropriately scrub the tub with brush to remove any debris or particles that may be on the walls of the tub. NA-C stated staff were to clean the tub after each use and then a couple times a week housekeeping also cleans the tub with Clorox bleach or another cleaner. NA-C further revealed that staff only need to spray the disinfectant on the tub and then leave it. NA-C indicated she did not have to scrub the tub, ensure a wet contact time of 10 minutes or rinse the chemical from the tub. We just leave it sit. Observation, interview, and manufacturer's instruction label review on 7/21/22 at 12:21 p.m. with assistant director of nursing (ADON)/ infection preventionist identified she reviewed the MasterCare Bath Aire System Disinfectant label that is used to fill the disinfectant hose on tub. The MasterCare disinfectant identified directions for use to disinfection of hard non-porous surfaces in whirlpool units after using the whirlpool unit. Staff were to drain and refill with fresh water to the level of covering the intake valve. Staff were to add 2 ounces of MasterCare bath Aire system disinfectant for each gallon of fresh water added. Staff were to then start the pump to circulate the solution and wash down the the unit sides, seat of the chair, lift and any/all related equipment with a clean swab, brush or sponge. Treated surfaces were to remain wet for 10 minutes. After the unit had been thoroughly cleaned, staff were to drain the solution from the unit and rinse any/all cleaned surfaces with fresh water. The ADON agreed that the disinfectant was not being used per the manufacture's guidelines. The ADON confirmed there were no instructions located in the tub room for staff to follow. She confirmed her expectation was manufacture instructions were to be followed. Interview on 7/21/22 at 2:01 p.m., with NA-E who identified staff used a spray bottle of cleaner to spray the tub. They got this cleaner from housekeeping. NA-E looked in locked cupboard for the spray bottle but the product was not there that she normally used. She then stated We spray the tub after use and leave it on for a little bit, then rinse it off. She revealed we do not use the hose thing on the side of the tub. NA-E stated the spray bottle contained a cleaner named Comet or something. She then went outside the tub room and told housekeeper (H)-B the tub was missing the spray bottle to clean the tub. H-B returned with a bottle of Comet All Purpose Cleaner. Interview on 7/21/22 at 2:08 p.m., with H-B identified that housekeeping sometimes used the comet cleaner with added bleach to clean the tub or the floor and made a copy of the Comet cleaner instructions. The bottle was Comet cleaner with bleach 3-30. Further interview on 7/12/22 at 2:12 p.m., with ADON identified she was unaware some staff were using a common household cleaner named Comet on the tub. She was unsure why housekeeping was supplying that product to use when the tub manufacturer did not recommend that cleaner. She revealed she had now posted clear instructions on the wall in tub rooms on how to clean and disinfect the tubs after use according to manufacturer's guidelines. Review of MasterCare tub manufacture's instruction for cleaning and disinfection the tub identified to spray areas thoroughly scrub, disinfect, and rinse the appropriate disinfectant from the tub after a standard wet contact time of 10 minutes. Review of the bottled, Comet cleaner label identified it was ready to use and for use on a toilet to flush toilet, spray entire area and let stand for 10 minutes and flush again. There was no directions for use in bathtubs. The product also stated if it came in contact with skin, rinse with plenty of water. Get medical attention if irritation develops and persists. The cleaner contained sulfuric acid monododecyl [NAME] sodium salt (cleaning surfactant used to remove dirt and grime) and sodium hypochlorite (bleach).

Based on interview and document review the facility failed to report to residents, representatives, and families suspected or confirmed COVID-19 within 12 hours of the occurrence of a single confirmed COVID-19 infection or of three or more residents or staff with new onset of respiratory symptoms that occurred within 72 of each other. This had the potential to affect all 35 residents and thier families. Findings include: Review of staff positive COVID-19 results identified 2 staff tested positive during the month of May and 9 staff tested positive during the month of June. Review of resident positive COVID-19 results identified no residents tested positive during the month of May and 9 residents tested positive during the month of June. Review of facility notification to families identified there were no family notifications sent out in May and there were only 4 notifications sent out in June, confirming that families had not been updated following a single occurrence of confirmed COVID-19 and at times there had been up to 5 days of individual positive cases one each day with notification not going out until day 5 with the update of the new cases. Interview on 7/25/22 at 9:20 a.m., with the assistant director of nursing (ADON) also the infection control nurse identified that the administrator was responsible for communication with family's on new COVID-19 cases. Interview on 7/25/22 at 12:39 p.m., with administrator identified she sent out weekly updates on COVID-19. She identified when there was a COVID-19 positive case she sent out a notices as soon as possible. She then revealed at the weekly COVID update call they were told they had 24 hours to update families and it was staff and they had not been in the building for 72 hours prior to testing they did not need to report that as there would have been no risk to residents. The administrator revealed some of the COVID-19 positive results happened over the weekend and she did not report until Monday and that was 'her bad that she had missed the weekend ones. Review of the 7/13/20, Communication with Residents, Families, and Staff policy identified the facility was to use an automated service to notify families and residents when a confirmed case of COVID-19 had been identified. There was no mention the facility ensured notification was to be sent by 5 p.m. the next calendar day following a confirmed infection of COVID-19.