**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to discard expired food items, and label and date food available for resident use in 1 of 1 walk-in cooler and 1 of 4 reach-in coolers in the main kitchen, in 1 of 1 walk-in cooler and in 2 of 3 reach-in coolers in building 4 kitchen, and in 2 of 4 nourishment room refrigerators ([NAME] and blue bird pods' refrigerators) in the 3rd floor of building 4 where the nursing home residents resided. These practices had the potential to affect food and beverages served to the residents. Findings included: a. An initial tour of the kitchen on 6/3/24 at 11:05 am was made with the Dining Services Director, Master Chef and building 4 Kitchen Manager. An initial observation of the walk-in cooler on 6/3/24 at 11:10 am revealed an opened bag of large flour tortillas dated 4/23/24, a large tray of mushrooms labeled Discard 5/28/24, a half block of white cheese wrapped in plastic dated 4/30/24, an opened jar of blue cheese dressing without any date, an opened jar labeled with a marker salad dressing 5/27/24 discard 5/30/24, an opened jar of cheese vinaigrette dressing labeled 5/16/24. b. An initial observation of the reach-in cooler in the main kitchen on 6/3/24 at 11:15 am revealed a medium tray labeled egg salad with a sticker date showing 5/24/24 and discard 5/27/24, and olives in a large tray with a sticker date of 5/24/24 and discard 5/27/24. The Dining Services Director stated they were mislabeled but should have been discarded after 7 days. The Master Chef stated the items in the main kitchen were used in preparation of food for residents in all buildings. c. An initial observation of the building 4 kitchen where the nursing home residents resided on 6/3/24 at 11:45 am revealed the walk-in cooler had an open carton of fat free milk dated 5/20/24, reach-in cooler #1 had a small tray of shredded cheese without any date, reach-in cooler #2 had a small tray of lettuce without any date and an opened bag of turkey slices dated 5/24/24. d. An initial observation of the nourishment refrigerators on 6/5/24 at 2:30 pm revealed an opened lemonade bottle without a date in the [NAME] pod's refrigerator. The blue bird pod's refrigerator had 6 small cups of cottage cheese dated 3/17/24 with a marker and a small, opened bag of loaf bread dated 4/20/24. During an interview on 6/5/24 at 1:51 pm, the Dining Services Director stated the Master, and the Sous Chefs were responsible for checking labels and expiration dates in the main kitchen twice daily. He stated one of them was off during the initial tour and the checks were not done yet. He stated there were a lot of new staff that needed to be trained in food storage. He stated the Kitchen Manager was responsible for checking food items in building 4 and she was new. The nourishment refrigerators were also checked by the Kitchen Manager and her staff. He stated they should be checked twice daily. During an interview on 6/5/24 at 3:24 pm, the Administrator stated she was aware of unlabeled and misdated food items found in the kitchen. She stated they will work on correcting the problem. During a follow up interview on 6/6/24 at 9:59 am, the Administrator stated she expected staff to follow their policy on labeling and storing food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interviews the facility failed to follow their policy on pneumococcal vaccine and offer up to date pneumonia vaccines to 5 of 5 residents reviewed for immunization status (Resident #3, Resident #8, Resident #9, Resident #12, and Resident #123). The findings included: The facility's policy on pneumococcal vaccine last reviewed in July 2023 stated, the administration of the pneumococcal vaccines are made in accordance with current Centers for Disease Control and Prevention (CDC) recommendation at the time of the vaccination. a. Resident #3 was admitted to the facility on [DATE]. Her diagnoses included rheumatic heart disease, hypertension and atrial fibrillation. Review of Resident #3's immunization record revealed she received PPSV23 on 10/16/14 and PCV13 on 2/1/16. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact, and her pneumococcal immunization was up to date. Review of Resident #3's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of the 20-valent pneumococcal conjugate vaccine (PCV20). During an interview on 6/5/24 at 10:30 am, Resident #3 stated she did not know about pneumonia vaccine. She could not remember if a staff member talked to her about it. b. Resident #8 was admitted to the facility on [DATE]. Her diagnoses included atherosclerotic heart disease, cholecystitis and hypertension. Review of Resident #8's immunization record revealed she received PPSV23 on 4/15/10 and a PCV13 on 10/4/16. Review of the quarterly MDS dated [DATE] revealed that Resident #8 was cognitively intact, and her pneumococcal immunization was up to date. Review of Resident #8's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of PCV20 vaccine. During an interview on 6/5/24 at 10:40 am, Resident denied being offered a pneumonia shot and denied receiving one. c. Resident #9 was admitted to the facility on [DATE]. His diagnoses included chronic kidney disease, heart attack and stroke. Review of Resident #9's immunization record revealed he received PPSV23 on 1/1/94 and a PCV13 on 4/22/16. Review of the comprehensive MDS dated [DATE] revealed that Resident #9 was cognitively intact, and his pneumococcal immunization was up to date. Review of Resident #12's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of PCV20 vaccine. Resident #9 was not available for interview. d. Resident #12 was admitted to the facility on [DATE]. His diagnoses included diabetes mellitus, hypertension and vascular dementia. Review of Resident #12's immunization record revealed he received PPSV23 on 7/13/10 and a PCV13 on 2/26/16. Review of the quarterly MDS dated [DATE] revealed that Resident #12 was severely cognitively impaired, and his pneumococcal immunization was up to date. Review of Resident #12's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of PCV20 vaccine. The resident's representative was not available for interview by telephone during the survey. e. Resident #123 was admitted to the facility on [DATE]. His diagnoses included hypertension, atherosclerotic heart disease and vascular dementia. Review of Resident #123's immunization record revealed he received PPSV23 on 7/7/10 and a PCV13 on 4/3/15. Review of the quarterly MDS dated [DATE] revealed that Resident #123 was cognitively intact, and his pneumococcal immunization was up to date. Review of Resident #123's medical record revealed no information that the Resident or their legal representative was provided education regarding the benefits and potential side effects of PCV20 vaccine. Resident #123 preferred not to be interviewed during the survey. During an interview on 6/5/23 at 3:50 pm, his representative stated she did not get any information on the update pneumonia vaccine for the resident. During an interview on 6/5/24 at 2:24 pm, the Infection Preventionist stated she thought the residents did not need any more pneumococcal vaccines after they received the PPSV23. She stated she would check the current guidelines. During a follow up interview on 6/6/24 at 8:46 am, the Infection Preventionist stated she would discuss the current guidelines for the pneumococcal vaccine with the Medical Director. During an interview on 6/6/24 at 10:03 am, the Director of Nursing stated she expected staff to follow the facility's policy, current guidelines and immunization best practices for the residents.

Based on staff interview and record review the facility failed to submit accurate payroll data, regarding 24-hour licenses nurse coverage, for 9 of 9 days reviewed (10/14/23, 10/28,23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, 12/31/23) of the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) for the 1st quarter in fiscal year 2024. Findings included: The CMS submission report, PBJ Final File Validation Report for Fiscal Year 2024 (October 1 to December 31) showed the facility failed to have Licensed Nursing Coverage, 24 hours out of 24 hours for the days of 10/14/23, 10/28/23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, and 12/31/23. Posted Nurse Staffing, nurse schedules, and the nursing staff's timecards for 10/14/23, 10/28,23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, and 12/31/23 were reviewed and revealed there was 24-hour licensed nursing coverage for the 1st quarter of Fiscal Year 2024. During an interview with the Administrator on 6/6/24 at 11:35am she revealed that there was 24-hour licensed nursing staff working on 10/14/23, 10/28,23, 11/25/23, 11/26/23, 12/9/23, 12/16/23, 12/17/23, 12/23/23, and 12/31/23 but that the office must have not submitted the information incorrectly.

Basedonrecordreviewandstaffinterviews thefacilityfailedtoprovidetheCentersforMedicare& MedicaidServices(CMS NoticeofMedicareNonCoverageLetter(NOMNC CMS10123 form for1 of3 sampledresidentsreviewedforbeneficiaryprotectionnotificationreview(Resident# 73). Findingsincluded Resident# 73 wasadmitted tothefacilityon8/10/22 withdiagnosesthatincludedcerebralinfarctionduetothrombosisofleftvertebralartery Type2 diabetesmellituswithhyperglycemia andmuscleweaknessandabnormalitiesofgait Theresidentwasdischarged on10/31/22. AreviewoftheSkilledNursingBeneficiaryProtectionNotificationReviewformrevealedResident#73'sMedicarePartAservicesstartedon8/10/22 andthelastcovereddaywas10/31/22. TheformfurtherrevealedthatthefacilityinitiatedthedischargefromMedicarePartAserviceswhenbenefitdayswerenotyetexhausted Thedischargewasplannedbetweenthecareteamandtheresident ThemedicalrecordreviewfurtherrevealedthattheNOMNCletterwhichexplainedtheMedicareAcoverageforskilledserviceswasnotissuedtotheResident#47 ortheresidentsrepresentative Duringaninterviewon2/9/23 at10.08 AM theAccountingmanagerstatedtheresidentsbenefitshadnotbeenexhaustedandtheresidentwasnotprovidedtheNOMNCformasitwasanoversightduetostaffissue Theaccountingmanagerfurtherstatedshewasnotintheofficethatweekandthestaffresponsiblejustquittheorganizationandhenceitwasnotcompleted On2/8/23 at2:39 PManinterviewwasconductedwiththeAdministratorandDirectorofNursing(DON. TheDONstatedtheresidentpriortoherdischargewenthomeonaLeaveofAbsence(LOA. TheDONfurtherstateduponreturntothefacilitytheresidenthadinitiatedthedischargeprocess Careteamandtherapyagreedtheresidenthadmethergoalsandsafedischargeprocesswasputinplace TheAdministratorstateditwasmoreresidentinitiateddischargeversusbenefitexhaustionorreductionintheresidentsservices TheAdministratorstatedastheresidentinitiatedthedischarge theNOMNCwasnotprovidedtotheresident Itwasoverlookedbystaff

Based on staff interviews and record review, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification surveys dated 10/7/21 in order to achieve and sustain compliance. This was for recited deficiency on a recertification survey on 2/9/23. The deficiency was in the area of Medicaid/Medicare Coverage/Liability Notice. The continued failure during one federal survey of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: This tag is cross-referenced to: F582 - Based on record review and staff interviews, the facility failed to provide the Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage Letter (NOMNC, CMS-10123 form) for 1 of 3 sampled residents reviewed for beneficiary protection notification review (Resident # 73). During the previous recertification survey on 10/7/21, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) letter for discharge from Medicare Part A services for 2 of 3 residents reviewed for beneficiary protection notification review. An interview with the Administrator was conducted on 2/09/23 at 2:54 PM. The Administrator stated the Quality Assurance (QA) committee does 1) identifies areas of concern, 2) does a root cause analysis, 3) develops a plan, audits, and monitors that plan and 4) discusses the outcome. System change and addition task would put in place as needed to resolve the issue. The Administrator further stated that for the last citation the performance improvement plan was in place. The old plan would be revisited and analyzed to see where the failures, and where the breakdown happened. The root cause would be revisited and new interventions, monitoring tools would be put in place. Audit / education would be completed as needed. The new process will be put in place as a plan of correction to ensure compliance. The team would continuously monitor until the deficient area concerns have been resolved. The Administrator indicated that all citations were discussed in the QAA meeting including any repeat citation.