**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with residents and staff, the facility failed to protect the resident's right to be free from misappropriation of controlled narcotic pain medications for 3 of 4 residents reviewed for misappropriation of property (Resident #46, #1, and #18). Findings included: The facility's Abuse, Neglect, and Exploitation policy, last revised 7/11/24 revealed the facility would not tolerate misappropriation of resident property defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of resident's belongings without consent. a. Resident #46 was admitted to the facility on [DATE]. Resident #46's diagnoses included osteoarthritis and right hip pain. A physician's order dated 4/9/24 revealed Resident #46 received hydrocodone-acetaminophen (a combination of a narcotic opioid analgesic and a non-narcotic medication used to relieve pain) 5-325 milligram (mg) tablet before meals and at bedtime for right hip pain. The significant change in status Minimum Data Set (MDS) dated [DATE] revealed Resident #46's cognition was intact. Resident #46 received scheduled and as needed pain medication, had no presence of pain, and was taking an opioid medication. A review of the controlled narcotic medication declining records for Resident #46 revealed on 4/21/24 at 8:00 AM Nurse #1 signed she removed one tablet of hydrocodone-acetaminophen 5-325 mg and used her signature as the second nurse witness to indicate the medication was wasted. On 4/21/24 at 11:30 AM Nurse #1 signed she removed two tablets of hydrocodone-acetaminophen 5-325 mg and administered both. The wasted and extra dose of hydrocodone-acetaminophen 5-325 mg were subtracted from the amount of medication remaining. A review of the Medication Administration Record (MAR) for Resident #46 revealed on 4/21/24 at 8:00 AM and 4/21/24 at 11:30 AM Nurse #1 initialed she administered one tablet of hydrocodone-acetaminophen 5-325 mg. During an observation and interview on 02/11/25 at 9:51 AM Resident #46 revealed he received scheduled and as needed pain medication. Resident #46 did not recall a time he did not receive his pain medication and stated nurses were good administering his pain medication on time and shared no concerns of uncontrolled pain. Resident #46 showed no signs of pain during the interview. b. Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses included vascular dementia, spinal stenosis, osteoarthritis, and chronic pain. The annual MDS assessment dated [DATE] revealed Resident #1's cognition was severely impaired. Resident #1 received scheduled pain medication, had no presence of pain, and was taking an opioid medication. A physician's order dated 4/24/24 revealed Resident #1 received oxycodone/acetaminophen (a combination of a narcotic opioid analgesic and a non-narcotic medication used to relieve pain) 5-325 mg give one tablet before meals and at bedtime for chronic pain. A review of the controlled narcotic medication declining record for Resident #1 revealed on 5/17/24 at 8:00 AM Nurse #1 signed she removed two tablets of oxycodone/acetaminophen 5-325 mg and wasted one and administered one. Nurse #1 used her signature as the second nurse witness to indicate the medication was wasted. On 5/24/24 at 8:00 AM Nurse #1 signed she removed two tablets of oxycodone/acetaminophen 5-325 mg and wasted one and administered one. A second nurse signature was included to indicate a witness observed Nurse #1 waste the medication. The two wasted doses of oxycodone/acetaminophen were subtracted from the amount remaining. A review of the MAR for Resident #1 revealed Nurse #1 initialed on 5/17/24 at 8:00 AM and 5/24/24 at 8:00 AM to indicate she administered one tablet of oxycodone/acetaminophen 5-325 mg. During an observation and interview on 02/11/25 at 1:51 PM Resident #1 had no visible signs of pain and stated she was doing good. Resident #1 was unable to confirm she received pain medication. c. Resident #18 was admitted to the facility on [DATE]. Resident #18's diagnoses included chronic pain and left knee pain. A review of the physician order dated 5/8/24 revealed Resident #18 received oxycodone (a narcotic opioid analgesic) extended release 10 mg tablet every twelve hours. The quarterly MDS assessment dated [DATE] revealed Resident #18's cognition was intact. He had received scheduled pain medication, occasionally had pain rated 4 out of 10, and was taking an opioid medication. A review of the controlled narcotic medication declining record for Resident #18 revealed on 5/26/24 at 8:00 AM Nurse #1 signed she removed two tablets of oxycodone 10 mg extended release. Nurse #1 signed she wasted one tablet and administered the other. There was a second nurse signature to indicate a witness verified Nurse #1 wasted the medication. The wasted dose of oxycodone 10 mg extended release was subtracted from the remaining amount. A review of the MAR for Resident #18 revealed on 5/26/24 at 8:00 AM Nurse #1 initialed she administered one oxycodone 10 mg extended release tablet. During an interview and observation on 02/12/25 at 8:48 AM Resident #18 revealed he had chronic back pain back and nerve damage in his leg. Resident #18 stated he received scheduled and as needed pain medication, and it was effective, and he did not recall a time he had not received his pain medication. Resident #18 showed no signs of pain during the interview. A review of the initial 24-hour report revealed on 5/27/24 at 1:00 PM the facility became aware of an alleged diversion of resident drugs when staff noticed double signatures for the same date and time for the administration of residents' narcotic medications with unknown witness signatures for medications being wasted. The report named Resident #1, Resident #18, and Resident #46 and Nurse #1 as the accused employee. Law enforcement was notified on 5/27/24 at 1:15 PM and the State Agency on 5/27/24 at 2:59 PM. A review of the facility's 5-day investigation revealed law enforcement filed criminal charges against Nurse #1 who refused to write a statement and a complete a drug screen test. The investigation revealed audits were completed of residents with narcotic medications, drug diversion education was provided to nurses including agency staff, and medication administration nurse skill checks were done. Resident pain assessments determined there was no harm. The allegation was substantiated and identified the Director of Nursing (DON) as the investigator and included written statements from staff. On 2/13/25 at 11:08 AM an attempt to interview Nurse #1 was unsuccessful. A review of the statement written by Nurse #2 revealed narcotic medication declining records signed by Nurse #1 indicated possible drug diversion and Unit Manager #1 was notified. During a phone interview on 2/13/25 at 5:04 PM Nurse #2 revealed she identified a pattern when Nurse #1 signed the controlled narcotic medication declining records, and she made copies of those records and notified Unit Manager #1. Nurse #2 revealed that when a controlled narcotic medication was wasted a second nurse needed to observe and co-sign the declining record as a witness it was wasted and put in a dissolving solution kept on the med cart. A review of the statement written by Unit Manager #1 revealed on 5/27/24 she was asked to review the narcotic controlled medication records on the days Nurse #1 worked. Her review identified concerns with Resident #46, #1, and #18 records and noted medications were removed and signed twice for the same time and date and she notified the DON. During an interview on 2/14/25 at 11:24 AM Unit Manager #1 revealed on 5/27/24 she reviewed the controlled narcotic medication declining records signed by Nurse #1. She identified controlled narcotic medications were wasted and then administered for the same date and time and she did not recognize the second nurse signature used as a witness. Unit Manager #1 revealed Nurse #1 was removed from the medication cart and the Administrator and DON were notified. After questioned, Nurse #1 was unable to provide an explanation and escorted out of the facility. Unit Manager #1 revealed after drug diversion was identified education was provided to nurse staff on what to look for on the controlled medication declining records and included to check signatures. Unit Manager #1 stated she completed random observations of nurse staff during medication administration, interviewed alert and oriented residents about their pain, and completed pain assessment using the facial pain scale for residents that were unable to make their needs known and voice they were in pain. A review of the DON statement revealed on 5/27/24 she was notified of possible drug diversion and frequent wasting for controlled narcotic medications signed by Nurse #1 with a co-signature that was not familiar. Nurse #1 was interviewed and admitted she had co-signed and there was no second nurse witness to verify narcotic medications were wasted. Nurse #1 did not remember where she wasted the narcotic medications and thought it was either the trash or sharps container. The Unit Manager was instructed to check all sharp containers, and no controlled narcotic medications were found. Nurse #1 was asked to write a statement and provide a urine sample for a drug screen test that she refused and was escorted out of the facility. Interviews were conducted on 2/13/25 at 1:20 PM and 2/14/25 at 10:24 AM with the DON. The DON revealed the investigation focused on reviewing residents controlled narcotic medications records signed by Nurse #1 on the dates she worked and the medication cart she was assigned. The DON stated in all five narcotic medications were diverted. She revealed Resident #46 records identified on 4/21/24 at 8:00 AM Nurse #1 signed she removed one tablet of hydrocodone/acetaminophen 5-325 mg and wasted it without a second nurse witness signature and on 4/21/24 at 11:30 PM signed she removed two tablets of hydrocodone/acetaminophen 5-325 mg. Her review of Resident #1 records identified on 5/17/24 at 8:00 AM Nurse #1 signed she removed two tablets of oxycodone 5-325 mg and wasted one without a witness second nurse signature and on 5/24/24 at 8:00 AM signed she removed two tablets of oxycodone 5-325mg and wasted one with an unknown second nurse signature. Her review of Resident #18 records identified on 5/26/24 at 8:00 AM Nurse #1 signed she removed 2 tablets of oxycodone 10 mg extended release and wasted one with an unknown second nurse signature. The DON revealed Nurse #1 was interviewed and asked to write a statement and take a drug screen test and initially agreed but then declined and stated she needed legal counsel. The Administrator statement revealed on 5/27/24 he conducted an interview with Nurse #1 to discuss the second nurse signature was not recognized. Nurse #1 initially stated she did not remember who the second nurse was then admitted the other signatures were hers and no other nurse witnessed her waste the controlled narcotic medications. Nurse #1 stated she wasted three narcotics in the sharps container then changed her story to she threw them in the trash. No narcotics were found in the sharps container and Nurse #1 was asked to write a statement and she agreed. Nurse #1 was asked to complete a drug screen test and initially agreed then stated she took pain medication for a previous accident then refused to write a statement and complete a drug screen test stating she needed representation. Unit Manager #2 was asked to escort Nurse #1 from building. During an interview on 2/14/25 at 3:35 PM the Administrator revealed he was notified by Unit Manager #1 on 5/27/24 that there was a problem with drug diversion and asked to review the controlled narcotic medication records signed by Nurse #1. The Administrator revealed he noticed something was off with signatures and interviewed Nurse #1 with other Department Head staff present. He revealed Nurse #1 was asked to provide the name of the second nurse signature that witnessed her waste controlled narcotic medication and was unable to provide that information. Nurse #1 was asked to write a statement and take a drug screen test and when she refused was asked to leave the building. The Administrator revealed they started their investigation, and he called the police and reported concerns of drug diversion, and the Police Officer came to facility and a report was made. The Administrator revealed family members or if cognitively intact the resident were notified of the diversion and the DON reported Nurse #1 to the North Carolina Board of Nursing (NCBON). He revealed on 5/27/24 members of Quality Assurance and Performance Improvement (QAPI) put a plan of correction in place and the audit tools were reviewed at following meeting. The Administrator revealed Nurse #2 recognized drug diversion and knew what to look for when reviewing the controlled medication declining records. Review of statement written by Unit Manager #2 revealed controlled narcotic medication declining records signed by Nurse #1 had several instances of the same medication being wasted with an unrecognizable second nurse signature as the witness then removed same medication again. After an interview with Administrator, DON, and Unit Managers, Nurse #1 admitted the second nurse signature was hers and stated she gave the medication. Nurse #1 was informed that the incident would be reported and asked to write a statement and offered a drug screen test. Nurse #1 refused to complete a written statement and declined the drug screen and stated she needed legal representation. Unit Manger #2 escorted Nurse #1 out of the building. During an interview on 2/14/25 at 12:43 PM Unit Manager #2 revealed controlled narcotic medication declining records signed by Nurse #1 identified concerns medications were wasted with an unknown second nurse signature as a witness. Unit Manager #2 revealed Department Heads interviewed Nurse #1 about the unknown second nurse's signature and she admitted it was hers. Unit Manager #2 revealed Nurse #1 was asked to take a drug screen test and stated she was taking pain medication and when asked to provide the prescription she did not and refused a drug screen test. Unit Manager #2 revealed Nurse #1 was asked to write a statement and refused stating she needed lawyer and on 5/27/24 was escorted out of the facility. The facility provided the following corrective action plan with the correction date of 5/30/24: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Upon Discovery on 5/27/24 Nurse #2 observed discrepancies on facility narcotic count sheets Nurse #1 was unable to account for. The facility, in accordance with our Quality Assurance Performance Improvement (QAPI) program, leadership implemented the following corrective action measures: 5/27/24 Facility staff notified Unit Manager of the discrepancies on the narc count sheet. Unit Manager notified Director of Nursing and Nursing Home Administrator. 5/27/24 Director of Nursing immediately replaced Nurse #1 in question with facility Unit Manager. Nurse #1, in question left the facility prior to face to face interview. 5/27/24 Director of Nursing (via phone), Nursing Home Administrator, and Unit Managers interviewed Nurse #1 on discrepancies. Nurse #1 in question refused a drug screen and to write a comprehensive statement. 5/27/24 Director of Nursing and Nursing Home Administrator notified Regional [NAME] President of Operations, Regional Director of Clinical Services, Police Department, Pharmacy Representative, Medical Director, Nurse Practitioner, and families of Resident #1, Resident #46, and Resident #18. During the facility investigation, it was determined there were 5 pills unaccounted for pertaining to Resident #1, Resident #46, and Resident #18. Any missing narcotics would have been obtained from the facility Omni cell (facility dispensing unit for medications, including narcotics) which is owned by the facility and pulled under house stock and not billed to the resident. 5/27/24 Quality Assurance Performance Improvement meeting was completed. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents receiving controlled pain medication have the potential of being affected. The Director of Nursing/Designee completed pain audits on all residents receiving narcotics. 5/27/24 Director of Nursing/Designee completed full narcotic counts on all medication carts. 5/27/24 Director of Nursing/Designee initiated education on medication administration, wasting narcotics, receiving narcotics, administration and wasting of fentanyl patches, notification of narcotic discrepancies. 5/27/24 Director of Nursing/Designee completed a complete pain assessment audit on all residents for anyone that receives narcotics. Interviews completed on all alert and oriented residents with a Brief Interview for Mental Status of 12 or above. A [NAME] Scale was completed on all residents with a Brief Interview for Mental Status below 12 to determine if there was any pain. No negative findings were noted. These audits were completed on 5/28/24. Audits completed on all narcotic sheets to determine if there was any diversion. Five areas were identified for Resident #1, Resident #46, and Resident #18. The Unit Managers completed medication pass observations that was completed on all facility nurses. This audit was started on 5/27/24 and completed on 5/30/24. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not reoccur. The Director of Nursing/Designee educated all licensed nurses including agency on drug diversion and medication rights. This education was completed on 5/27/2024, nurses who were not working that day were educated via phone. On 5/27/2024 notification was sent to all agencies that the facility utilized in regard to facility expectation and accountability. Any licensed nurses on PTO/Vacation will be educated prior to working. All newly hired licensed nurses will be educated on said process during orientation. All agency licensed nurses will receive training prior to the start of their next shift. Indicate how the facility plans to monitor its performance and make sure that solutions are sustained. The Director of Nursing/Designee will audit five random narcotic sheets weekly, to ensure that there is no signs of drug diversion. This audit will be completed weekly for 12 weeks then monthly for 2 months. The Director of Nursing/Designee will audit five random residents to ensure that they have no issues with care and services weekly for 12 weeks then monthly for 2 months. The Director of Nursing/Designee will complete medication pass observation on five nurses weekly to ensure meds are passed appropriately and that no diversion is noted. This audit will be completed weekly for 12 weeks and monthly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. The facility completed and accepted an ad hoc QAPI meeting 5/27/24 Root cause analysis: The facility completed a thorough investigation to determine the root cause of the diversion. It is the facility's conclusion that Nurse #1 was addicted to pain medication due to her refusal to take a drug screen and her behavior when questioned regarding the narcotics. Alleged date of compliance: 5/30/24 The facility's corrective action plan with a completion date of 5/30/24 was validated on 2/14/24 by record review, observations, residents, and staff interviews. A review of the QAPI meeting agenda dated 5/27/24 revealed attendees included the Medical Director, Administrator, DON, and Unit Managers for review and approval of their corrective action plan. A review of police report revealed a warrant was issued on 5/27/24 for the arrest of Nurse #1 for embezzlement/diversion of controlled substances by fraud/forgery. The facility census on 5/27/24 was 82 residents. Forty-seven resident interviews were completed on 5/28/24 by the Social Worker. Residents were asked do you have any concern about not getting your medications and any concerns about narcotic medication. A facial pain scale rating system completed on 5/27/24 by Unit Manager #1 who observed 35 residents. A total of 82 residents were reviewed for concerns related to medications and pain with no negative findings. Resident pain evaluations were completed on 5/27/24 that included a numeric pain level, description, and frequency. The pain evaluation for Resident #46 indicated no pain was present. The pain evaluation for Resident #1 indicated no pain was present. The pain evaluation for Resident #18 revealed he was satisfied with his current level of pain rated 7 out 10 and indicated pain was chronic and persistent/daily. A review of the note signed by the Nurse Practitioner on 5/29/24 revealed Resident #46, #1, and #18 were seen and their pain status assessed. The NP noted Resident #46, #1, and #18 pain was at baseline and well controlled on their current medications. Urine drug screen test results were completed on resident who received controlled medications to ensure their medications were received. Results for Resident #46 revealed opiates were present. Results for Resident #1 revealed oxycodone was present. Results for Resident #18 revealed oxycodone was present. A review of the education provided on 5/27/24 revealed the topics reviewed included the process for wasting narcotics with the objective if resident refused or medication was removed by mistake it must be wasted in the dissolving fluid and witnessed and cosigned by a second nurse. Twenty-one nurses signed they had received the education. A review of nurses' skills checkoff for medication administration started on 5/27/24 and completed on 5/30/24 revealed no concerns were identified. Medication administration skill checks continued weekly from 6/6/24 through 8/25/24 then monthly on 09/2024 and 10/2024 with no concerns identified. A review of the notification to the NCBON dated 6/6/24 revealed the DON provided the nurse license number of Nurse #1 and other information obtained from their investigation of drug diversion. A review of controlled narcotic declining records revealed audits continued weekly from 6/7/24 through 8/25/24 then monthly on 09/2024 and 10/2024 with no concerns identified. A review of resident audit tool revealed 5 random residents were asked if needs were met and if they had any concerns with medications continued weekly on 6/5/24 through 8/25/24 then monthly on 09/2024 and 10/2024 with no concerns identified. Observation of medication administration revealed nurses reviewed the physician orders, the medication label, and MAR prior to administering resident medication. Controlled medications were kept locked in a separate storage area on the med cart. Residents with controlled narcotic medications had a declining record that matched the remaining amounts. Declining records were signed by the administering nurses with no controlled narcotic medications wasted. Interviews with nurses including agency nurses revealed they were observed during medication administration. Nurses were able to explain the facility's process for wasting controlled medications in a fluid dissolving liquid and ensure a second nurse observed and signed as the witness. Nurses revealed they review the count of controlled medications with the off-going nurse to ensure the declining records matched the remaining amount of medication and both nurses signed the count was correct before accepting the keys to the medication cart. An interview with Medical Director revealed he attended the QAPI meeting on 5/27/24 and agreed with corrective action plan put in place and reviewed the audits during the next QAPI meeting. Interviews with alert and oriented residents revealed no concerns were identified with uncontrolled pain or medication administration. Interviews with family members of residents unable to make their needs known revealed no concerns were identified related to medication or uncontrolled pain. The completion date of 5/30/24 was validated.

Based on observations and staff interviews, the facility failed to discard potentially hazardous food with signs of spoilage in 1 of 1 walk-in refrigerators, date food items available for residents in 1 of 1 kitchen refrigerators and discard damaged canned goods available for use. This practice had the potential to affect food served to residents. Findings included: a. An observation of the walk-in refrigerator on 02/26/24 at 08:56 AM revealed the following: - A box containing cucumbers with a received date of 12/31/24 that was shriveled with white on the surface. - A box of green bell peppers with a received date of 1/14/25 that was shriveled with black on the surface. b. An observation of the kitchen refrigerator on 02/26/24 at 08:56 AM revealed the following: - 1 ham and cheese sandwich and 1 peanut butter and jelly sandwich that were not dated. c. An observation of the canned goods rack on 02/11/25 at 10:00 AM revealed the following: - An unopened can of catsup with a dent approximately 3 inches wide across the front of it available for use. An interview on 02/11/25 at 10:01 AM with the Certified Dietary Manager (CDM) revealed that the box of cucumbers and the bell peppers should have been thrown away. He further revealed that vegetables should have been held for 7 days only. He stated that both sandwiches should have been dated, and it must have been an oversite. He stated that it was the staff's responsibility to date the sandwiches when they were made. The CDM indicated that the can of catsup must have fallen on the shelf last night and staff must have just placed the can back on the shelf. He further indicated that the can of catsup should have been placed in the damaged canned goods return area. An interview with the Administrator on 02/14/25 at 12:39 PM revealed that his expectation was that food be stored and dated according to regulatory standards, and vegetables that were showing signs of spoilage be thrown away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Nurse Practitioner (NP), Director of Nursing (DON) and Administrator, the facility failed to protect the resident's right (Resident #1) to be free of abuse when Resident #2's family member (facility Housekeeper) pulled Resident #2's TV remote from Resident #1's hands. Resident #1 sustained a fracture of his left index finger that required no surgical intervention. This deficient practice occurred for 1 of 1 resident reviewed for abuse. Findings Included: Resident #1 was admitted to the facility on [DATE] with diagnoses including stroke, paralysis of the right side and legal blindness. Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] coded Resident #1 as severely cognitively impaired with no behaviors noted. Resident #1 was care planned (2/7/23) for altered or at risk for altered behaviors and/ or mood with a history of yelling, cursing, paranoid, history of cycling through roommates, history of many room changes due to anger, and behavior. Resident non-compliant with care. Resident with a history of suddenly becoming angry and verbally aggressive with roommates and history of hoarding objects. Interventions included to allow the resident to vent his thoughts and feelings. Use reorientation, validation. Approach in a calm, relaxed manner. Identify what helps calm the resident down when upsent such as snacking, talking, reminiscing, walking, and reapproaching. The Activities Assistant was interviewed on 12/12/23 at 10:06 AM and stated that she was working on 11/12/23 but was unable to remember what time the interaction with Resident #1 had occurred. The Activities Assistant said she walked into Resident #1's room to take him to an activity. She noticed Resident #1 had a TV remote laying in his lap. The Activities Assistant asked Resident #1 to leave the TV remote for his roommate (Resident #2) to use while he was in the activity. Resident #1 then stated to the activities assistant he was not leaving the TV remote with that f--- retard. The activities assistant told Resident #1 he should not talk to Resident #2 that way and then took Resident #1 to the nursing station to calm down. She saw Resident #2's family member/housekeeper who was working in housekeeping at the facility on 11/12/23. She asked the family member if the TV and TV remote belonged to Resident #2, and he stated yes, and Resident #1 does not share it. The Activities Assistant stated she did not witness or hear any altercation with Resident #2's family member and Resident #1. Resident #2's family member/housekeeper's statement dated 11/12/23 was reviewed and read in part as follows. On 11/12/23, the Family Member had an altercation with Resident #1. The Family Member spoke with Resident #1 when his shift as a housekeeper had ended. The Family Member told Resident #1 the TV remote and TV was Resident # 2's, and he needed to share it. The Family Member said to Resident #1, I heard you are having a bad day and I hope it gets better for you. Resident #1 replied to the Family Member that he was not having a bad day; it was the retard that was having a bad day as Resident #1 pointed towards Resident #2. The Family Member wrote he reached for the TV remote the Resident #1 was holding, and Resident #1 pulled the remote up to his chest and grabbed the remote with both hands. The Family Member pulled the bottom of the remote down from Resident #1. The Family Member wrote he did not grab Resident #1's finger or attempt to break it. After freeing the TV remote, the Family Member rolled Resident #1 to the nurses' station and told Nurse #2 Resident #1 needed to stay in a different room as Resident #1 was calling Resident #2 a F----retard. The Family Member wrote he was not mad at Resident #1 and he wished the best for Resident #1. Resident #2's family member was not available for interview. Resident #1's assigned Nurse #2 on 11/12/23 was interviewed on 12/12/23 at 9: 23 AM. Nurse #2 stated Nurse Aide (NA) #1 notified her that Resident #1 had been speaking ugly to his roommate. Nurse #2 was going back towards the nursing station, when she saw Resident #2 and his family member/housekeeper leaving the room. The family member told Nurse #2 that Resident #1 had said to Resident #2 he was retarded, and the family member did not want Resident #1 to remain in the room with Resident #2. The family member did not mention there had been an incident with Resident #1. Nurse #2 then notified the Unit Manager about Resident #1's language toward Resident #2, and the Unit Manager instructed Nurse #2 to move Resident #1 to a different room. Nurse #2 stated she moved Resident #1 to another room, and Resident #1 did not mention an altercation with Resident #2's family member or complain of any pain or discomfort to his hand or finger. Nurse #1 stated in an interview on 12/11/23 at 3:40 PM on 11/13/23 sometime after breakfast, she was notified by Nurse #2= that Resident #1's hand was swollen and bruised. Nurse #1 stated she asked Resident #1 what had happened to his hand. Resident #1 told her Resident #2's family member tried to break his fingers. Nurse #1 said she notified the Director of Nursing (DON), and the DON told her to get an order for an x-ray of his hand. NA #1 was interviewed on 12/12/23 at 9:12 AM and stated she was working on 11/13/23 as a Medication Aide and noticed Resident #1's left hand and finger was bruised and swollen. NA #1 stated she notified Nurse #1 about Resident #1's hand. The Unit Manager wrote a progress note dated 11/13/23 at 4:31 PM that read in part Resident #1 was brought to Nurse #1 with discoloration of left index finger. Resident #1 was asked what happened and the resident stated his roommates' family member tried to break his finger. Resident #1's left index finger was noted to be purple/red with edema noted into hand. The Nurse Practitioner (NP) was notified, and an order was received for a left-hand x-ray. Resident #1's pain level was 2 out of 10. A review of Resident #1's radiological report dated 11/14/23 found a fracture on the second finger of the left hand. The fractured finger was not displaced. A review of Resident #1's orthopedic progress noted dated 11/15/23 confirmed a fractured left index finger. The treatment plan was to buddy tape the bases of the middle finger and index finger for 1 month and change the tape as needed. The NP progress note dated 11/14/23 was reviewed. The progress note read in part Resident #1 was being seen for left hand and index finger bruising and swellings. An urgent orthopedic referral was placed. Therapy will screen and provide stabilization until the appointment with orthopedics. On exam, Resident #1's pain appears mild and had prn Tylenol available. A request for a psychiatry consult to see the resident and evaluate for any post-traumatic stress concerns. The NP who assessed Resident #1 was interviewed on 12/12/23 at 1: 06 PM. The NP stated she assessed Resident #1 on 11/13/23. The NP stated the resident had obvious bruising on his middle-left finger along the side and on the palm of his left hand and Resident #1 was able to make a fist with his hand. The NP stated Resident #1 told her his roommates family member tried to break his finger. The NP said the x-ray came back positive for a fracture, and the following day (11/15/23) the Resident went to see orthopedics who gave orders to buddy tape his affected finger. The NP stated Resident #1 did to go to the hospital, had mild pain and a standing order for Tylenol and was not sure how often he was taking it. A review of Resident #1's Medication Administration Record (MAR) for November and December 2023 revealed Resident #1 received Tylenol on 11/16/23 and 11/19/23. On 12/11/23 at 10:45 AM Resident #1's left middle and index fingers were observed to be tapped together. Resident #1 did not appear in any pain or distress. Resident #1 was not able to recall the incident. Resident #2 was interviewed on 12/11/23 at 3:12 PM and was not able to recall the incident. A review of nursing progress notes dated 11/14/23 written by the DON read on 11/12/23 the Unit Manager was notified Resident #1 was not getting along with his roommate. The Unit Manager instructed Nurse #2 to move Resident #1 to another room for the night. On 11/13/23 at approximately 3:30 PM NA #1 brought the resident to the Unit Manager with concern of bruising and swelling noted on the left index finger as well as the left palm of the hand. The DON was notified and instructed the Unit Manager to notify the NP and obtain an order for an X-ray. DON notified Administrator and an immediate investigation began. When speaking to Resident #1 he stated, his roommate's family member tried to break his finger. Resident #1 had not verbalized anything prior to this. Resident #1 had no complaints of pain. The Administrator notified Resident #2's family member (also employed by housekeeping) of suspension pending investigation. The completed X-ray noted an acute fracture involving the medial corner of the proximal phalanx of the left second finger. Resident #1 was ensured to be safe. A head-to-toe assessment completed on Resident #1 with no other concerns noted. The initial state report was completed. The Saluda police notified with a police investigation initiated. A message was left for Resident #1's adult protective services guardian to call the facility. Resident/Staff interviews initiated. Psych services notified. Head to toe skin assessments completed on residents with a BIMS score less than 12 with no issues or concerns for further abuse noted. Abuse policy education-initiated facility wide and completed. Resident #2's family member/housekeeper was interviewed by Administrator and DON and currently remains suspended. The Administrator and DON were interviewed together on 12/12/23 at 2:37 PM. The DON stated the nursing Unit Manager called her on 11/12/23 in midafternoon to report Resident #1 and his roommate were not getting along. The DON stated she instructed the Unit Manager to move Resident #1 to another room for the night. The next day, on 11/13/23 an NA noticed Resident #1's finger and hand was swollen and bruised. The Unit Manager looked at Resident #1's hand and notified the DON. Resident #1 told the Unit Manager that Resident #2's family member/housekeeper tried to break his finger. The DON said the NP was then called to get an x-ray order and to assess Resident #1. The DON stated the Administrator was notified about the incident, and Resident #2's family member/housekeeper was suspended immediately after being interviewed and pending an investigation, and was terminated on 11/17/23. Resident #1 was interviewed by multiple facility staff and his story was consistent. Resident #1 told DON and other staff that his roommates family member who worked as a housekeeper had tried to break his finger. The DON stated Resident #1 had a complete head to toe assessment completed on 11/13/23 that did not find anything additional. The Administrator stated he notified the police of the incident that the investigation included interviewing staff who might have seen or heard anything. The Administrator stated that the investigation revealed the incident occurred on 11/12/23 and was witnessed by Resident #1's roommate and the family member/housekeeper. The Administrator stated the family member told him he went to Resident #1's room to tell Resident #1 that the TV remote belonged to Resident #2, and he needed to share it. Resident #1 told the family member he was not giving the TV remote to that F----retard. The family member went to take the TV remote from Resident #1, and Resident #1 held on to the remote with both hands while the family member pulled the TV remote from Resident #1. Resident #2's family member/housekeeper stated he did not intend to hurt the resident and the resident did not complain of any pain. The facility provided the following corrective action plan with a completion date of 11/17/23. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 11/12/23, Unit Manager was notified Resident #1 and his roommate (Resident #2) were not getting along by Charge Nurse, Resident #1 was immediately moved to another room. On 11/13/23 Unit Manager was notified Medication Aide of swelling and bruising of Resident #1's Left Index Finger. Head to toe assessment completed of Resident #1 on 11/13/23 and no other injuries were noted. Resident #1 stated dead head tried to break my finger, who Resident #1 identified as the Resident #2's family member/housekeeper. With bruising noted we also had an allegation of abuse on Resident #1, staff member was immediately notified and suspended on 11/13/23 and told not to come to the building until interviewed by Administrator and Director of Nursing. Police and Adult Protective Services notified on 11/13/23 due to bruising on left hand of Resident #1 and residents' #1's statement regarding the incident. Two View X-Ray completed of Resident #1's left hand on 11/13/23 and noted an acute fracture of the left second finger. Nurse Practitioner ordered Urinary Analysis for Resident #1 on 11/14/23, also ordered therapy consult and sent order for therapy referral. Resident #1 went to an orthopedic appointment on 11/15/23 with new orders to buddy tape fingers. Psych referral initiated on 11/14/23 via tele-visit, medication changes initiated for Resident #1. Staff member was terminated on 11/17/23 following investigation. An initial report for the allegation of abuse was reported on 11/13/23 and our investigative report was reported on 11/17/23, which substantiated the allegation. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Social Worker conducted interviews and educated all alert and oriented residents on November 14, 2023 on abuse and neglect and how to report abuse and neglect with no concerns noted. Director of Nursing completed skin checks on all residents with a BIMs score of 12 or less (impaired cognition) on November 13, 2023, with no concerns noted. Staff interviews initiated regarding the incident on 11/13/23. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. Director of Nursing/Designee educated all staff including agency staff and as needed staff on 11/13/23 on abuse and neglect policy and reporting. This education was completed in person or via phone for those not working or on leave of absence, these individuals were required to sign the attendance sheet when they returned to work. Two Educational programs were added to Relias program (Staff Education On-Line) on 11/14/23, Abuse, Neglect and Exploitation in the Elder Care Setting and Recognizing Abuse, Neglect and Exploitation. These programs include a final exam that staff member must score an 80 or above to pass the course. This training included recognizing abuse, neglect and exploitation as well as reporting abuse, neglect and exploitation. It also included training on care giver burnout, risk factors for committing abuse, preventing abuse. The course titled Abuse, Neglect, and Exploitation in the Elder Care Setting also included education on person centered care and providing care to residents regarding approaching those residents with behaviors. This education was completed by all staff by 11/17/23. New hires will be educated upon hire. During Concierge rounds, which are rounds completed by facility managers Monday through Friday, of assigned rooms and residents, managers will monitor for abuse and care concerns and report immediately to their supervisor, this will be added to their round sheets for monitoring. The Supervising Nurse or Manager on Duty will complete these rounds on the weekends. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Administrator/Designee will complete three staff interviews weekly for 4 weeks and monthly for two months on what to do if they see or hear abuse and who to report it to and how to deal with difficult or agitated residents. Director of Nursing/Designee will interview 5 residents weekly for 8 weeks then monthly for three months to ensure there are no issues with abuse/neglect with the residents. Director of Nursing/Designee will conduct observations of 3 residents weekly for four weeks then monthly for two months of Certified Nursing Assistants interactions with residents to ensure no issues with abuse/neglect. Results of the interviews/audits will be presented monthly to the QAPI committee meeting by the Director of Nursing/Designee for review/revision as needed for three months. 5. Include dates when corrective action will be completed. November 17, 2023 The facilities action plan was validated on 12/12/23 and confirmed the compliance date of 11/17/23. concluded the facility had implemented an acceptable corrective action plan effective on 11/17/23. The corrective action plan was validated by the following: 1.On 12/11/23 a review of the initial report for the allegation was verified reported on 11/13/23 and concluded on 11/17/23. 2. Every resident had a head-to-toe assessment completed and was verified. 3. On 12/11/23 and 12/12/23 interviews with facility staff and agency staff verified they had received education on abuse and neglect. 4.On 12/11/23 and 12/12/23 interviews with alert and oriented residents verified they had been provided with education on abuse and neglect. 5.A review of the facilities monitoring book verified three staff interviews had been conducted weekly for 4 weeks. Further review found 5 residents had been interviewed weekly and ongoing for 8 weeks to ensure no concerns with abuse and neglect. The DON or designee had conducted observations of 3 residents with NAs for 4 weeks with no concerns of abuse or neglect. 6.Resident #2's family member was verified to be terminated from the facility on 11/17/23. 7. A review of the November QAPI verified the audits were included in the meeting. The compliance date of 11/17/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to assess the ability of a resident to self-administer medications for 1 of 4 sampled residents observed with medications at bedside (Resident #64). Findings included: Resident #64 was admitted to the facility on [DATE]. His diagnoses included congestive heart failure, diabetes, and left shoulder pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #64 had intact cognition. Review of the medical record revealed no documentation that Resident #64 was assessed for self-administration of medications. During an observation and interview on 10/31/23 at 1:05 PM, Resident #64 was sitting up on the side of his bed with the overbed table pulled directly in front of him and placed on top of the overbed table was his lunch tray and a medicine cup containing 2 round white pills. Resident #64 explained earlier that morning he had 3 teeth pulled and the pills in the medicine cup were the Tylenol he requested for pain that Nurse #1 had left for him to take. Resident #64 stated he was capable of taking his medications on his own but the nurse usually stayed in the room with him while he took his medications. During an interview on 10/31/23 at 1:11 PM, Nurse #1 revealed she usually stayed in the room with Resident #64 as he took his oral medications; however, when she brought Resident #64 his PRN (as needed) Tylenol for pain, she got distracted when staff brought him his lunch tray. Nurse #1 explained she left the medications with Resident #64 and returned to her medication cart to continue with her medication pass. Nurse #1 stated Resident #64 had not been assessed to self-administer medications and she should have remained in the room with Resident #64 while he took his oral medications. During interviews on 10/31/23 at 2:40 PM and 11/01/23 at 5:45 PM, the Director of Nursing (DON) stated nurses were expected to wait at bedside for the resident to take their oral medications prior to leaving the room and not leave medications unattended at the resident's bedside. The DON confirmed Resident #64 had not been assessed to self-administer his medications and stated Nurse #1 should have stayed in the room with Resident #64 while he took his oral medications. During an interview on 11/01/23 at 6:16 PM, the Administrator stated nursing staff knew to stay in the room with the resident while they took their oral medications. He further stated nursing staff should never leave medications unattended in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #26 was admitted to the facility 02/08/19 with multiple diagnoses including anxiety disorder and depression. Review of an undated North Carolina Medicaid Screening Tool (NC MUST) inquiry document revealed Resident #26 had a time-limited Level II Preadmission Screening and Resident Review (PASRR) with an effective date of 09/09/20 and expiration date of 06/27/21. Review of an undated NC MUST inquiry document revealed Resident #26 was re-evaluated due to a change in condition and issued a new Level II PASRR effective 06/28/21 with no expiration date. The annual Minimum Data Set (MDS) dated [DATE] indicated Resident #26 was not considered by the state Level II Preadmission Screening and Resident Review (PASRR) process to have serious mental illness and/or intellectual disability or a related condition. During an interview 11/01/23 at 2:59 PM, the MDS Coordinator revealed she completed the section related to Level II PASRR on MDS assessments and confirmed that Resident #26 had a Level II PASRR. The MDS Coordinator stated it was an oversight on her part that Resident #26's MDS assessment dated [DATE] did not accurately reflect she had a Level II PASRR. During an interview on 11/01/23 at 6:16 PM, the Administrator stated it was his expectation for MDS assessments to be completed accurately. 3. Resident #83 was admitted to the facility 08/28/23 with multiple diagnoses including non-Alzheimer's dementia and heart failure. Review of Resident #83's behavior care plan last updated 09/11/23 revealed she wandered and at risk for elopement. Interventions included placing Resident #83 in a room close to the nurse's station and utilizing distractions to decrease wandering. The quarterly Minimum Data Set (MDS) dated [DATE] did not reflect Resident #83 had wandering behavior during the lookback period. In an interview with the Social Worker (SW) on 11/01/23 at 3:13 PM she confirmed she coded Section E on Resident #83's quarterly MDS dated [DATE]. She stated it was her understanding if a behavior was care-planned, it did not have to be coded on the MDS. In a follow-up interview with the SW on 11/01/23 at 4:12 PM she confirmed Resident #83 had wandering behavior during the lookback period. She stated she misunderstood coding guidelines for behavior and the MDS dated [DATE] should have reflected that Resident #83 had wandering behaviors. In an interview with the Administrator on 11/01/23 at 6:16 PM he stated it was his expectation MDS assessments be completed accurately. Based on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of Preadmission Screening and Resident Review (PASRR) and wandering behavior for 3 of 22 sampled residents reviewed (Residents #10, #26 and #83). Findings included: 1. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses that included anxiety disorder and depression. a. Review of an undated North Carolina Medicaid Uniform Screening Tool (NC MUST) inquiry document revealed Resident #10 had a time-limited Level II PASRR with an effective date of 09/02/22 and expiration date of 10/02/22. The admission MDS assessment dated [DATE] indicated Resident #10 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. b. Review of an undated NC MUST inquiry document revealed Resident #10 was re-evaluated on 02/06/23 by PASRR due to a change of condition and issued a new Level II PASRR effective 02/09/23 with no expiration date. The significant change MDS assessment dated [DATE] indicated Resident #10 was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or other related conditions. During an interview 11/01/23 at 2:59 PM, the MDS Coordinator revealed she completed the section related to Level II PASRR on MDS assessments and confirmed that Resident #10 had a Level II PASRR. The MDS Coordinator stated it was an oversight on her part that Resident #10's MDS assessments dated 09/09/22 and 03/20/23 did not accurately reflect she had a Level II PASRR and modifications would be submitted. During an interview on 11/01/23 at 6:16 PM, the Administrator stated it was his expectation for MDS assessments to be completed accurately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #9 was admitted to the facility 02/11/20 with diagnoses including heart failure and quadriplegia (paralysis that affects all four limbs). The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #9 was cognitively intact. Review of Resident #9's physician orders revealed no current order for the use of zinc oxide cream. During observations on 10/29/23 at 12:42 PM, 10/20/23 at 8:27 AM, 10/31/23 at 8:46 AM, and 11/01/23 at 8:14 AM, in clear view on top of a shelf in Resident #9's room was a 15-ounce container of medicated cream with the active ingredient 25% zinc oxide. An interview with Resident #9 on 10/29/23 at 12:43 PM revealed the zinc cream was applied by staff but had not been applied for a while. An observation and interview were conducted on 11/01/23 at 4:22 PM with the Director of Nursing (DON). The DON observed the medicated cream on the shelf and explained it could not be kept in Resident #9's room. She stated a physician order would need to be in place for the use of zinc oxide cream and the cream should be applied by the nurse and kept on the treatment cart. In a follow-up interview with the DON on 11/01/23 at 5:43 PM she stated it was ultimately her responsibility to follow up on medications by doing random spot checks of resident rooms. She also stated nurses should check resident rooms for medications left at the bedside. 3. Resident #57 was admitted to the facility 12/28/21 with diagnoses including diabetes and muscle weakness. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #57 was cognitively intact. Review of Resident #57's physician orders revealed no current order for the use of antifungal cream. Observations on 11/01/23 at 8:14 AM and 11/01/23 at 3:55 PM in clear view on top of Resident #57's dresser was a tube of antifungal cream with the active ingredient 2% miconazole nitrate. An interview with Resident #57 on 11/01/23 at 8:15 AM revealed staff applied the antifungal cream after he used the bathroom. An observation and interview conducted on 11/01/23 at 4:22 PM with the Director of Nursing (DON). The DON observed the medicated cream on the shelf and explained it could not be kept in Resident #57's room. She stated a physician order would need to be in place for the use of antifungal cream and the cream should be applied by the nurse and kept on the treatment cart. In a follow-up interview with the DON on 11/01/23 at 5:43 PM she stated it was ultimately her responsibility to follow up on medications by doing random spot checks of resident rooms. She also stated nurses should check resident rooms for medications left at the bedside. Based on record review, observations, and interviews with staff, the facility failed to secure medicated creams that were in clear view at the bedside for 3 of 4 residents reviewed for medication storage (Resident #37, Resident #9, and Resident #57). Findings included: 1. Resident #37 was admitted to the facility on [DATE]. Her current diagnoses included dementia and arthritis. The annual Minimum Data Set, dated [DATE] revealed Resident #37's cognition was assessed as severely impaired. Review of Resident #37's physician orders revealed no current order for the use of a triad hydrophilic wound dressing cream. A standing physician's order was in place for the use of a moisture barrier cream and included directions to apply for 7 days. During observations on 10/29/23 at 1:58 PM and 10/31/23 at 11:03 AM in the room of Resident #37, in clear view on top of the nightstand were two tubes of medicated cream. One 2.5-ounce tube labeled triad hydrophilic wound dressing cream that included the active ingredient zinc oxide and one 5-ounce tube labeled moisture barrier cream with the active ingredient 12% zinc oxide. An observation and interview were conducted on 11/01/23 at 4:49 PM with the Director of Nursing (DON). The DON observed both tubes of the medicated cream on the top of the nightstand and explained those could not be kept in the room of Resident #37. She revealed standing orders were in place for the use of the moisture barrier cream and it was kept on the treatment cart and applied by the nurse and for the use of triad hydrophilic wound dressing cream a physician order would need to be in place and the cream applied by the nurse and kept on the treatment cart. During an interview on 11/01/23 at 5:43 PM the DON stated it was ultimately her responsibility to follow up on medications by doing random spot checks of resident rooms. She further stated the nurses should check resident rooms for medications at the bedside.

Based on record review, resident and staff interviews, the facility failed to resolve and communicate the facility's efforts to address repeated dietary and staffing concerns voiced by residents during Resident Council meetings for 7 of 9 months reviewed (February 2023, April 2023, May 2023, June 2023, July 2023, September 2023, and October 2023). Findings included: The Resident Council minutes for the period January 2023 through October 2023 were reviewed and revealed the following: • Resident Council minutes dated 02/22/23 noted in part, residents voiced staffing concerns that third shift agency staff talked loudly in the halls, did not answer call lights, and wore ear buds to talk on their cellphones. In addition, food on the meal trays were served cold and ice cream was not kept cold. • Resident Council minutes dated 03/29/23 noted the staffing and dietary concerns voiced during the previous month's meeting were reviewed and reported as resolved. There were no new staffing or dietary concerns noted as voiced during the meeting. • Resident Council minutes dated 04/26/23 noted in part, residents voiced dietary concerns related to menu inconsistency and meals being served late. In addition, residents voiced staffing concerns with third shift staff being too loud and Nurse Aides (NAs) taking too long to answer call lights. • Resident Council minutes dated 05/31/23 noted in part, the Administrator and Director of Nursing (DON) addressed the previous month's concerns related to staffing and dietary and all were noted as resolved. Under New Business it was noted residents voiced concerns that NAs took too long to provide assistance when requested. • Resident Council minutes dated 06/28/23 noted the staffing concerns voiced during the previous month's meeting were reviewed and noted as resolved. Under New Business it was noted residents voiced concerns with NAs talking on their cellphones. • Resident Council minutes dated 07/26/23 noted the staffing concerns voiced during the previous month's meeting were reviewed and noted as resolved. Under New Business it was noted residents voiced continued concerns with NAs cellphone use. • Resident Council minutes dated 08/30/23 revealed no indication that the concerns voiced during the previous month's meeting regarding cellphone use were reviewed, resolved or remained ongoing. There were no new staffing or dietary concerns noted as voiced during the meeting. • Resident Council minutes dated 09/27/23 noted in part, there was no old business to review from the previous month's meeting. Under New Business it was noted residents voiced concerns that staff were eating resident snacks from the snack cart and requested dietary use plate warmers on meal trays to keep food warm. • Resident Council minutes dated 10/25/23 noted the dietary and staffing concerns voiced from the previous month's meeting were reviewed and noted as resolved. Under new business it was noted residents voiced concerns with being served cold food, cold coffee, and melted ice cream. The facility's grievance logs for the period January 2023 through September 2023 were reviewed. Grievances filed on behalf of the Resident Council related to the concerns voiced during the monthly meetings were all noted as resolved. During an interview on 10/29/23 at 2:05 PM, the Dietary Manager revealed she attended Resident Council Meetings and was aware of the food concerns voiced by residents. The Dietary Manager did not provide any explanation as to what was or had been done to address the food concerns. A Resident Council group interview was conducted on 11/01/23 at 10:01 AM with Resident #14, Resident #16, Resident #19, Resident #33, Resident #47, Resident #65, Resident #74, Resident #75, Resident #78 and Resident #80 in attendance. The residents all reported ongoing dietary concerns, specifically with meals being served cold. The residents were in agreement that when meals were served not everyone received a bottom plate warmer just a cover over the plate and the food was usually cold and ice cream melted by the time they were served their meal tray. In addition, residents stated there was inconsistency in what they had ordered for lunch or dinner and what they actually received. The residents also reported ongoing staffing concerns regarding agency staff at night taking too long to answer their call lights and staying on their cellphones. The residents all stated they had voiced these concerns during previous meetings and the usual follow-up they received from staff was we are working on it. The residents stated while they felt facility staff tried to address the concerns voiced during the Resident Council meetings, they hadn't noticed much improvement and they really didn't receive feedback from administration on the efforts that had been made or attempted to resolve the concerns. During an interview on 11/01/23 at 3:17 PM, the Social Worker (SW) revealed she attended the Resident Council meetings to transcribe the minutes and any concerns voiced, she documented them on a grievance form and turned them into the appropriate Department Manager to address. The SW confirmed residents did bring up repetitive concerns during the monthly meetings, mainly related to dietary and staffing. She explained typically, the resolution was discussed individually with the person voicing the concern. During the next Resident Council meeting, they reviewed the general concern under old business to see if the concern was resolved or remained ongoing but did not have an in-depth group discussion on the attempts being made to address the repeated concerns. During an interview on 11/01/23 at 3:47 PM, the Activity Director revealed while she facilitated the Resident Council meeting, the SW, who also attended, documented the minutes and concerns voiced by the residents. The Activity Director stated for the past year and a half, the residents attending the Resident Council meetings brought up the same concerns month-to-month related to food, dietary and staffing. The Activity Director explained that when concerns were voiced during the meeting, they were addressed and usually discussed with the individual who voiced the concern. She stated during the next Resident Council meeting, they reviewed the general concern under old business to see if it was resolved or remained ongoing but didn't necessarily discuss in detail the efforts being made to address the repeated concerns. During an interview on 11/01/23 at 6:16 PM, the Administrator stated he was aware there had been repeated dietary and staffing concerns voiced during Resident Council meetings. The Administrator explained he did try to discuss resolution efforts with the Resident Council group regarding the concerns they voiced but realized he could definitely improve on his communication to them so they felt more part of the solution and better informed.

Based on a lunch meal tray line observation, record review, and staff interviews the facility failed to serve correct portions of food according to the planned menus. This failure had the potential to affect 61 residents receiving a regular diet texture and 6 residents receiving a pureed diet texture. Findings included: 1. The menu for the lunch meal on 10/31/23 for residents receiving a regular texture diet was 2 ounces of baked chicken, a half-cup of au-gratin potatoes, and a half-cup of mixed vegetables. A continuous observation of the lunch meal tray line on 10/31/23 from 12:00 PM through 12:55 PM revealed [NAME] #2 began plating food and used tongs to place a mixture of bone-in and boneless chicken thighs for residents receiving a regular diet texture. There was no consistent size to the pieces of chicken thighs being served. In an interview with the Dietary Manager on 10/31/23 at 12:05 PM she confirmed the chicken being served at the lunch meal was a mixture of boneless and bone-in chicken thighs. When the surveyor asked her how she could verify residents were receiving the correct portion size, she stated she could not because she did not have a working scale. In an interview with the Registered Dietician (RD) on 10/31/23 at 1:20 PM she confirmed there was no way to accurately ensure residents receiving a regular diet texture were getting the correct portion size according to the menu without weighing the chicken, but the plates looked like they contained at least two ounces of chicken. She stated she expected menu portion sizes to be followed. An interview with [NAME] #2 on 10/31/23 at 2:08 PM revealed the diet spreadsheet contained information on portion size and residents receiving a regular diet should have received two ounces of chicken. She stated she was instructed by the Dietary Manager to mix boneless and bone-in chicken thighs for the lunch meal and without a scale she was not able to ensure residents received the correct portion size. [NAME] #2 stated she tried to look through the pieces of chicken and if a piece appeared small, she plated 2 pieces of chicken. A follow-up interview with the Dietary Manager on 11/01/23 at 9:02 AM revealed she expected dietary staff to follow portion sizes as directed by the menu. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected dietary staff to follow menu portion sizes. 2. The menu for the lunch meal on 10/31/23 for residents receiving a regular texture diet was 2 ounces of baked chicken, a half-cup of au-gratin potatoes, and a half-cup of mixed vegetables. A continuous observation of the lunch meal tray line on 10/31/23 from 12:00 PM through 12:55 PM revealed [NAME] #2 began plating au-gratin potatoes for residents receiving a regular diet using a number 12 scoop. In an interview with the Dietary Manager on 10/31/23 at 12:05 PM she confirmed the au-gratin potatoes were to be served in a half-cup portion and was not sure if [NAME] #2 was using the correct sized scoop because she could not locate the diet spreadsheet. In an interview with the Registered Dietician (RD) on 10/31/23 at 1:20 PM she confirmed residents receiving a regular diet texture were to receive half-cup portions of au-gratin potatoes. She stated [NAME] #2 used a number 12 scoop which contained one-third of a cup of au-gratin potatoes and she should have used a number 8 scoop, which contained a half-cup portion. She stated she expected menu portion sizes to be followed. An interview with [NAME] #2 on 10/31/23 at 2:08 PM revealed the diet spreadsheet contained information on portion size and residents receiving a regular diet should have received a half-cup portion of au-gratin potatoes. She stated she was instructed by the Dietary Manager to use the number 12 scoop instead of the number 8 scoop for au-gratin potatoes served at the lunch meal. A follow-up interview with the Dietary Manager on 11/01/23 at 9:02 AM revealed she expected dietary staff to follow portion sizes as directed by the menu. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected dietary staff to follow menu portion sizes. 3. The lunch menu for residents receiving a pureed diet texture on 10/31/23 was 3.25-ounces of chicken, a half-cup portion of au-gratin potatoes, and a 3.25-ounce portion of green beans. A continuous observation of the lunch meal tray line on 10/31/23 from 12:00 PM through 12:55 PM revealed [NAME] #2 began plating chicken and mixed vegetables for residents receiving a pureed diet using a number 12 scoop for both food items. In an interview with the Dietary Manager on 10/31/23 at 12:05 PM she stated mixed vegetables were substituted for green beans for residents receiving a pureed diet. She stated she was not sure if [NAME] #2 was using the correct sized scoop to serve pureed chicken and mixed vegetables because she could not locate the diet spreadsheet. In an interview with the Registered Dietician (RD) on 10/31/23 at 1:20 PM she confirmed residents receiving a pureed diet texture were to receive a 3.25-ounce portion of chicken and a 3.25-ounce portion of mixed vegetables. She stated [NAME] #2 used a number 12 scoop which contained 2.8-ounces of chicken and 2.8-ounces of mixed vegetables and she should have used a number 10 scoop for the chicken and a number 10 scoop for the mixed vegetables. She stated she expected menu portion sizes to be followed. An interview with [NAME] #2 on 10/31/23 at 2:08 PM revealed the diet spreadsheet contained information on portion size and residents receiving a pureed diet should have received a 3.25-ounces of chicken and 3.25-ounces of mixed vegetables. She stated she was instructed by the Dietary Manager to use the number 12 scoop instead of a number 10 scoop to plate the chicken and mixed vegetables served at the lunch meal. A follow-up interview with the Dietary Manager on 11/01/23 at 9:02 AM revealed she expected dietary staff to follow portion sizes as directed by the menu. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected dietary staff to follow menu portion sizes.

Based on observations and staff interviews the facility failed to maintain a clean floor and walls and label and date food and beverage items in 1 of 1 walk-in cooler; maintain a clean floor, cover food, and store food items off the floor for 1 of 1 walk-in freezer; date food items, store food off the floor, and remove expired food in 1 of 1 dry goods storage room; maintain clean stove, oven, shelves, and floor in 1 of 1 kitchen; cover, label, and date open beverage and food items, discard food with signs of spoilage, and maintain a clean reach-in cooler for 1 of 1 reach-in cooler; cover, label, and date food items and maintain a clean reach-in freezer for 1 of 1 reach-in freezer; restrain facial hair during food preparation; maintain 1 of 1 garbage disposal in working order; and ensure food items were labeled and dated in 1 of 2 nourishment rooms (A/B hall). Findings included: 1. An initial tour of the walk-in cooler on 10/29/23 at 10:27 AM revealed the following: (a). multiple dried brown stains were observed on the floor and multiple areas of a black/brown substance to all walls of the cooler (b). an opened and undated 46-ounce bottle of vegetable juice sitting on a shelf in the cooler (c). a tray containing 11 bowls of undated dessert sitting on a shelf An interview with the Dietary Manager on 10/29/23 at 2:05 PM revealed all food and beverage items should be labeled and dated when opened and it was everyone's job to label and date items when placing them in the cooler. She stated she was short a staff member in a prep position and that person would normally be responsible for ensuring all food and beverages were labeled and dated. The Dietary Manager stated there was not a regular cleaning schedule for cleaning the cooler, but it was cleaner than it was when she began employment at the end of June 2023. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected the cooler to be clean and free of debris and for all food and beverage items to be labeled and dated. 2. An initial tour of the walk-in freezer on 10/29/23 at 10:31 AM revealed the following: (a). scattered debris on the floor of the freezer (b). a 5-pound tube of ground beef was sitting on the floor of the freezer under a shelf. (c). an undated 10-pound box of sausage was partially open to air and the exposed sausage was dried out (d). a box of sweet potatoes, ground beef patties, potato portions, and french fries was sitting on the floor of the freezer An interview with the Dietary Manager on 10/29/23 at 2:05 PM revealed all food items should be labeled, dated, and covered when opened and it was everyone's job to label and date items when placing them in the freezer and discard food items that showed signs of spoilage. She stated she was short a staff member in a prep position and that person would normally be responsible for ensuring all food items were labeled, dated, and covered. The Dietary Manager stated there was not a regular cleaning schedule for cleaning the freezer, but it was cleaner than it was when she began employment at the end of June 2023. She stated the last food delivery was on 10/27/23 and she was not sure why there were food items on the floor. The Dietary Manager confirmed that no food items should be stored on the floor. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected the freezer to be clean and free of debris, all food items should be covered or discarded if they showed signs of spoilage, and no food items should be stored on the floor. 3. An initial tour of the dry storage room on 10/29/23 at 10:34 AM revealed the following: (a). 2 boxes of salad dressing, 2 boxes of vegetable oil, a box of instant potatoes, peanut butter, hot cocoa, and grits were sitting directly on the floor (b). 3 bags of opened but undated pasta (c). 2 packs of 24 count flour tortillas with a best by date of 10/24/23 (d). 8 packs of 12 count flour tortillas with a best by date of 09/05/23 An interview with the Dietary Manager on 10/29/23 at 2:05 PM revealed all food items should be dated when opened and it was everyone's responsibility to date food when it was opened. She stated the last food delivery was 10/27/23 and she was not sure why food items were stored on the floor. The Dietary Manager confirmed that no food items should be stored on the floor. She confirmed food should be used or discarded on or before the best by date and all staff should be checking for expired food. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected all opened food items to be dated, expired food to be used or discarded on or before the best by date, and no food items should be stored on the floor. 4. An observation of the kitchen on 10/29/23 at 10:40 AM revealed scattered debris and multiple areas of dried black substance to the floor, a thick dried layer of black debris to the stove, multiple dried splatters to the bottom shelf of a table, and multiple areas of dried debris to the oven door. An interview with the Dietary Manager on 10/29/23 at 2:05 PM revealed the kitchen floor, stove, shelf, and oven should be clean and free of debris but it was cleaner than it was when she began employment at the end of June 2023. She stated there was not a cleaning schedule and she had not been able to do as much cleaning as she would like due to having to frequently work as a cook or a dietary aide. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected the kitchen floors, stove, oven, and shelf to be clean and free of debris. 5. An observation of the reach-in cooler on 10/29/23 at 11:00 AM revealed the following: (a). an undated packet of sliced turkey that was open to air (b). an opened and undated container of butter (c). an undated container of chopped lettuce with multiple brown areas to the lettuce (d). an opened and undated 33.8-ounce bottle of water (e). multiple scattered areas of dried debris to cooler doors An interview with the Dietary Manager on 10/29/23 at 2:05 PM revealed all food and beverage items should be labeled and dated when opened and it was everyone's job to label and date items when placing them in the cooler and discard food items that showed signs of spoilage. She stated she was short a staff member in a prep position and that person would normally be responsible for ensuring all food and beverages were labeled, dated, and covered. The Dietary Manager stated there was not a regular cleaning schedule for wiping down the outside of the cooler, but it was cleaner than it was when she began employment at the end of June 2023. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected all food items to be labeled and dated, no food items should be left open to air, food should be used or discarded before showing signs of spoilage, and the cooler should be clean and free of debris. 6. An observation of the reach-in freezer on 10/29/23 at 11:05 AM revealed the following: (a). an undated bag of hashbrowns open to air that were dried out (b). an undated box of biscuits open to air (c). 2 bags of english muffins with ice crystals (d). an open and undated bag of omelets (e). multiple scattered areas of dried debris to freezer doors An interview with the Dietary Manager on 10/29/23 at 2:05 PM revealed all food and beverage items should be labeled and dated when opened and it was everyone's job to label and date items when placing them in the cooler and discard food items that showed signs of spoilage. She confirmed food should not be left open to air and the english muffins should have been discarded due to being freezer-burned. She stated she was short a staff member in a prep position and that person would normally be responsible for ensuring all food and beverages were labeled, dated, and covered. The Dietary Manager stated there was not a regular cleaning schedule for wiping down the outside of the freezer, but it was cleaner than it was when she began employment at the end of June 2023. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected food to be dated when opened, food should not be left open to air, food with freezer-burn should be discarded, and the freezer should be clean and free of debris. 7. An observation of [NAME] #1 on 10/29/23 at 11:10 AM revealed he was slicing tomatoes and did not have a restraint in place to cover his facial hair. In an interview with [NAME] #1 on 10/29/23 at 11:10 AM he confirmed he was not wearing a restraint for his facial hair and stated he was not sure if the kitchen stocked restraints for facial hair. An interview with the Dietary Manager on 10/29/23 at 2:05 PM revealed the kitchen did have facial hair restraints and they were in her office, but staff probably did not know where they were. She stated facial hair should be restrained any time food was being prepared or served. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected staff to restrain facial hair when in the kitchen. 8. An observation of the garbage disposal on 10/29/23 at 11:15 AM revealed a dish pan sitting beneath the disposal filled approximately three fourths of the way with brown water. An interview with the Dietary Manager on 10/29/23 at 2:05 PM revealed the garbage disposal was leaking and the dish pan was in place to collect drainage. She stated the garbage disposal had been leaking since she began employment at the end of June 2023 and maintenance was waiting for a part to arrive to fix the disposal. An interview with the Maintenance Director on 11/01/23 at 3:50 PM revealed he had fixed the garbage disposal periodically in the past, but he was not aware of the garbage disposal currently having a leak. He stated he relied on dietary staff to notify him of any equipment that was in need of repair. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected dietary staff to notify maintenance if there were any kitchen items that needed repair. 8. An observation of the A/B hall nourishment room refrigerator on 10/29/23 at 2:30 PM revealed there was an opened and undated bowl of soup and an undated and unlabeled bowl of unidentifiable leftover food. An interview with the Dietary Manager on 10/29/23 at 2:30 PM revealed she was not sure who was responsible for checking the refrigerator for unlabeled and undated food or discarding food that wasn't labeled or dated. An interview with the Administrator on 11/01/23 at 6:16 PM revealed he expected dietary staff to check nourishment rooms daily for unlabeled and undated food items.

Based on observations, record review, and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey completed on 05/12/22. This was for one repeat deficiency originally cited in the area of food procurement-store/prepare/serve that was subsequently recited on the current recertification and complaint investigation survey of 11/01/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program. The findings included: This tag is cross referenced to: F 812: Based on observations and staff interviews the facility failed to maintain a clean floor and walls and label and date food and beverage items in 1 of 1 walk-in cooler; maintain a clean floor, cover food, and store food items off the floor for 1 of 1 walk-in freezer; date food items, store food off the floor, and remove expired food in 1 of 1 dry goods storage room; maintain clean stove, oven, shelves, and floor in 1 of 1 kitchen; cover, label, and date open beverage and food items, discard food with signs of spoilage, and maintain a clean reach-in cooler for 1 of 1 reach-in cooler; cover, label, and date food items and maintain a clean reach-in freezer for 1 of 1 reach-in freezer; restrain facial hair during food preparation; maintain 1 of 1 garbage disposal in working order; and ensure food items were labeled and dated in 1 of 2 nourishment rooms (A/B hall). During the recertification and complaint investigation survey of 05/12/22, the facility failed to label or date food items stored in the refrigerator, discard expired food items, ensure frozen food was kept solid, and store food items away from soiled surfaces. An interview with the Administrator on 11/01/23 at 6:41 PM revealed that the breakdown with the kitchen was the turnover with the Certified Dietary Manager (CDM). The Administrator further revealed that steady leadership was the key to a successful kitchen and dining experience. He stated the facility had a plan in place that included rebuilding the entire department from scratch. He stated that that this is an issue they will continue to discuss in their monthly Quality Assurance and Performance Improvement (QAPI) meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with the Registered Dietician and staff the facility failed to provide a diet that consisted of ground textured foods for 1 of 5 residents reviewed for nutrition (Resident #68). The findings included: Resident #68 was admitted to the facility on [DATE] with diagnoses including dementia and protein/calorie malnutrition. A physician's order written on 01/27/22 revealed Resident #68's received a regular/ground texture diet. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #68 as being moderately impaired cognitively and needing supervision and setup with eating. The MDS assessment of Resident #68's nutritional status identified weight loss with a recorded weight of 105 pounds and a mechanically altered diet. A Registered Dietician (RD) note written on 04/21/22 reveiwed Resident #68 for weight loss. The note indicated Resident #68 was able to verbalize needs and feed herself. Resident #68's intake was poor, eating approximately 25 percent of meals and received a regular/ground texture diet. The care plan last revised on 04/25/22 identified Resident #68's nutrition was at risk due to complications related to diagnoses, poor appetite, refusal of supplements, and age. Interventions in place included provide diet per physician's order. During an observation of the lunch meal on 05/09/22 at 12:36 PM Resident #68 was served a plate of food that consisted of meat cut into cube like shapes approximately a quarter to half inch in size and broccoli that was chopped into bite size pieces. The meal ticket on the tray revealed the diet order was for regular/ground texture. An interview was conducted on 05/12/22 at 11:34 AM with the RD. The RD revealed the appearance of ground textured food would look like ground hamburger and not be in the shape of a cube or cut in pieces. An interview was conducted with Dietary Manager (DM) on 05/12/22 at 1:36 PM. The DM revealed food chopped into cube like pieces was not consider a ground texture. The DM revealed the last person in the kitchen to handle the meal tray should check the ticket for the diet order and ensure the food on the plate was the right consistency before leaving the kitchen. The DM revealed it was the Cook's responsibility to prepare ground food based on the recipe provided and guidance was also posted in kitchen to help dietary staff identify the difference in the consistency of chopped and ground food. During an interview on 05/12/22 at 6:00 PM the Director of Nursing (DON) stated the consistency of the food should corollate with diet order on the meal ticket. An interview with the Administrator was conducted on 05/12/22 at 6:27 PM. The Administrator stated staff serving the meal should follow the order on the meal ticket.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interviews, and facility Nurse Practioner (NP) interviews the facility failed to provide a low concentrated sweets diet as ordered for 1 of 5 residents reviewed for therapeutic diets (Resident #37). The findings included: Resident #37 was admitted to the facility on [DATE] with diagnoses that included diabetes. Review of the active physician orders included a diet order for a low concentrated sweets diet dated 3/11/21. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was on a therapeutic diet and her cognition was moderately impaired. In an observation on 5/10/22 at 8:34 am Resident #37 was in her room and her breakfast tray had been delivered and set up. Observation of the tray revealed she was served a full-sized glazed doughnut and her printed tray card indicated she was on a low concentrated sweets diet. In an interview on 5/11/22 at 3:35pm the facility Nurse Practioner (NP) stated, A doughnut should not have been on her tray. An interview was conducted with the Dietary Manager on 5/12/22 at 1:38 PM. He indicated a doughnut was not part of a low concentrated sweets diet. He stated Resident # 37 should not have been sent a doughnut on her tray. He further revealed the person at the end of the tray line should have checked the tray for accuracy before it was sent to the resident. On 5/12/22 at 4:49PM the Director of Nursing was interviewed. She stated that a resident should not be served a sweet item like a doughnut if she had an order for a low concentrated sweets diet. The Administrator was interviewed on 5/12/22 at 6:28pm. He stated he expected diet orders to be followed.

Based on observations and staff interviews the facility failed to label or date food items stored in the refrigerator; failed to discard expired food items; failed to ensure frozen food was kept solid; and failed to store food items away from soiled surfaces for 2 of 2 refrigerators located in 2 of 2 nourishment rooms (side one and side two). This practice had the potential to affect food served to residents. The findings included: 1. An observation of the side two nourishment room was made on 05/11/22 at 1:40 PM with the Director of Nursing (DON). The refrigerator in the nourishment room contained a half used, 59-ounce opened container of peach flavored punch with an expiration date of 03/21/22. A 4-ounce container of cottage cheese with an expiration date of 04/20/22 labeled with a resident's name that no longer resided at the facility. A thawed, frozen dinner, single entrée of spaghetti with meat sauce with an expiration date of 5/10/22 with no name. Two containers of leftover food with no name or date. An interview was conducted with the DON on 05/11/22 at 1:54 PM. The DON revealed food stored in the nourishment room should be labeled with the resident's name and date when placed in refrigerator or freezer and expired foods should be discarded. The DON revealed it was the staff member who placed the food item in the refrigerator or freezer responsibility to label with the name of the resident it was for and date when they placed the food item. The DON revealed dietary staff were responsible for keeping the nourishment room refrigerators and freezers clean but indicated it was a team effort and would expect staff to be aware of unlabeled and expired food items. An interview was conducted on 05/12/22 at 6:36 PM with the Administrator. The Administrator stated the issues of cleanliness, non-labeled, and expired food items was unfortunate, and the facility had done a lot of training and he expected the nourishment room refrigerators to be clean. 2. An observation of the side one nourishment room was conducted on 05/11/22 at 1:54 PM with the DON. The refrigerator was located in the designated staff breakroom. The freezer section contained approximately 10 frozen and unwrapped corn dogs placed in a plastic grocery bag with no name or date. The freezer section also contained an individual serving of frozen macaroni and cheese with no name. The refrigerator section contained the following: three containers of leftover food with no name or date, half of a large pizza in a box with no name or date, a quartered watermelon dated 04/30/22 with no name, one 12-inch and one 6-inch submarine sandwich with no name or date, a 16-ounce of organic tofu with an expiration date of 04/02/22 labeled with the name of a resident, a 8-ounce container of goat cheese with an expiration date of 03/13/22 labeled with a resident's name, a opened 8-fluid ounce supplement drink with no name or open date, five half-pint cartons of whole milk with an expiration date of 04/26/22, four half-pint cartons of whole milk with an expiration date of 04/29/22, and one carton with an expiration date of 05/02/22. All the items above were discarded by the DON. The inside of the refrigerator appeared unclean with dried, brown colored debris on the shelves of the door, pieces of cardboard stuck to the shelves on the inside of the refrigerator, and a buildup of dried debris in both storage bins. An interview was conducted with the DON on 05/11/22 at 1:54 PM. The DON revealed food stored in the nourishment room should be labeled with the resident's name and date when placed in refrigerator or freezer and expired foods should be discarded. The DON revealed it was the staff member who placed the food item in the refrigerator or freezer responsibility to label with the name of the resident it was for and date when they placed the food item. The DON revealed dietary staff were responsible for keeping the nourishment room refrigerators and freezers clean but indicated it was a team effort and would expect staff to be aware of unlabeled and expired food items. An observation and interview were conducted on 05/11/22 from 2:22 PM through 2:42 PM with the Dietary Manager (DM). The DM observed the refrigerator was not clean and all the items removed by the DON. The DM stated it was the responsibility of dietary staff to clean the refrigerators in the nourishment rooms which included to discard food items with no name or date and expired items. The DM revealed nourishment room refrigerators were to be cleaned weekly and stated it had not been done. An interview was conducted on 05/12/22 at 6:36 PM with the Administrator. The Administrator stated the issues of cleanliness, non-labeled, and expired food items was unfortunate, and the facility had done a lot of training, and he expected the nourishment room refrigerators to be clean. The Administrator revealed having a refrigerator designated for residents in the staff break room was not a good idea.

Based on observations, record review, and staff interviews the facility failed to prevent mouse activity as evidence by droppings found on the floor in the designated area used to store food for 1 of 1 kitchen dry storage areas reviewed for pest control. The findings included: Review of the most recent contracted pest exterminator document dated 04/18/22 revealed mice baits were placed by the dumpster. The document did not indicate there was evidence of mice inside the facility. On 05/09/22 at 9:59 AM an initial tour of the kitchen revealed mouse droppings were observed on the floor in the dry food storage area. The food products were being stored on a shelf off the floor. The floor had debris including a bread crouton and appeared it had not been cleaned. During an interview and observation on 05/09/22 at 10:00 AM the Dietary Manager (DM) revealed the kitchen floor was swept and mopped at least daily. The DM observed the mouse droppings on the floor of the dry food storage area and stated he was not aware of mice activity in the kitchen. During an interview on 05/11/22 at 4:03 PM the DM revealed the cleaning schedule of the kitchen did not include to sweep and mop the dry food storage area but was expected to be done at the end of the day before dietary staff left. The DM stated he should have checked before he left on 05/08/22 to ensure the dry food storage area was swept and mopped but didn't. An interview was conducted with the Administrator on 05/12/22 at 6:36 PM. The Administrator revealed the facility had a contract with a pest control company who came monthly and when needed. The Administrator revealed he was not aware of mouse activity in the kitchen, and it was his expectation dietary staff kept the kitchen clean and if there were issues those would be addressed.