**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure the resident representative had been notified of an elopement and change in the resident's status for one of one sampled resident (24) with cognitive impairment. The resident was identified as at risk for elopement and had eloped (left the facility grounds without staff knowledge) on 7/4/25.Findings include:1. Review of the provider's 7/24/25 SD DOH FRI regarding resident 24 revealed:*On 7/4/25 at 6:57 p.m., resident 24 was found to be at the apartment building across the street.*She [resident 24] had signed out of the facility earlier in the day, therefore the incident was not reported.*The resident had a 5/5/25 contract agreement that the resident would not leave the premises of the facility.-This contract had been signed by resident 24 and social services director (SSD) C. It had not been signed by resident 24's resident representative.*The resident had left the facility without staff awareness on 7/4/25, and that event had not been reported to resident 24's representative or SD DOH until 7/24/25. 2. Review of the facilities' sign-out log revealed on 7/4/25, resident 24 signed out at Noon and returned at 1:00 p.m. That was the only time resident 24 signed out that day. 3. Review of resident 24's Guidelines for Outside Activity contract agreement with the facility revealed:*Resident MUST sign herself out and in each time she leaves the building.*Inform Charge Nurse on duty of her going outside & [and] how long she plans to be outside.*Resident will remain on facility property when [she] goes outside: will not go up town to any place of business or location w/o [without] family or facility personnel.*Resident [24] will not go to the apartments to the East or North of the facility.*The contract was signed on 5/5/25 by resident 24 and SSD C. 4. Review of resident 24's electronic medical record revealed:*She was admitted on [DATE].*Her diagnoses included anxiety, nicotine dependence, and dementia (a group of symptoms affecting memory, thinking, and social abilities).*Her 4/19/25 Elopement Risk Evaluation indicated that she was an elopement risk; her wandering placed her at significant risk of getting [in] to an unsafe situation, had a history of leaving the center without notifying staff members, and on 4/19/25 she left [a] supervised area to walk around outsid[e].*Her 5/19/25 Brief Interview of Mental Status (BIMS) assessment score was 10, which indicated she was moderately cognitively impaired.*A 2/14/25 Durable Power of Attorney (POA) for Health Care was signed by resident 24, designating her daughter and son as her POAs.-Her POAs had been involved in assisting the resident with making decisions and with signing documents since that time.*Resident 24's POAs were listed as her emergency contact persons. 5. Interview on 7/24/25 at 9:25 a.m. and again at 4:38 p.m. with resident 24's son revealed:*His mother was admitted to the facility after a hospitalization and illness several months ago because she required more assistance and supervision than he or his sister could provide to her at home.*He had been notified in April 2025 when his mother had walked away from an outside group activity at the facility, but he had not been notified when she left the faciity on 7/4/25.*On 7/5/25, while at the facility, he was informed that the board had decided that his mother could come and go from the facility, including on overnight visits, if she signed herself out, that the facility did not need to notify him or his sister when she left the facility, and that the facility was not responsible if something happened after she signed herself out of the facility.*He was unsure who the board members were who had made those decisions.*SSD C made a phone call to her supervisor while he was present in the facility on 7/5/25, to confirm the above information he was told, because he was questioning the decision to change her status at that moment, and he continued to be worried for her safety. 6. Interviews on 7/24/25 between 9:45 a.m. and 10:45 a.m. with staff members S and T, who requested anonymity, revealed:*On 7/4/25, around 7:00 p.m., staff members identified they had not seen resident 24 for some time that day and began looking for her.*Resident 24 was allowed to sign herself out to go outside and smoke, but she was not allowed to leave the facility property.*Resident 24 had not signed out that evening and was not found within the facility or outside the facility in the designated smoking area.*Staff were worried about resident 24's safety because she had not indicated that she was leaving, and it was raining that day.*Resident 24 was found at the apartments next door. Staff encouraged her to return to the facility; however, resident 24 refused to return to the facility.*Resident 24 then went to the shed, behind the facility, and took out her trike [a three-wheeled bicycle] and took off down the street, which was when staff members reported they lost sight of resident 24.*Resident 24 was then seen by one of those staff members about a block away from the facility on that trike.*Charge nurse U had called the supervisors on call that evening while staff members searched for resident 24 and tried to convince the resident to return to the facility.*Staff members S and T were told, Just let her go, not to report the incident, not to document the incident, and not to mention or talk about the incident again by charge nurse U.*Resident 24's son and daughter were her POAs and had not been notified of the resident's elopement.*Resident 24's son had been angry about the incident that had occurred on 7/4/25 and he came to the facility on 7/5/25 to talk to the facility staff about his concerns of his mother's safety. 7. Interview on 7/24/25 at 2:00 p.m. and again at 2:50 p.m. with director of nursing (DON) B, administrator A, and SSD C revealed:*DON B confirmed that resident 24's son and daughter had not been notified of the 7/4/25 incident because it had not been considered an elopement.*Administrator A stated that after reviewing additional documentation, it was determined that the incident on 7/4/25 should have been considered an elopement.*Administrator A expected that resident 24's POA or resident representative would be notified of all elopements or changes in her status. 8. A resident representative rights and notification policy was requested from DON B on 7/24/25 at 12:10 p.m. with referral to the Facility admission Agreement. 9. Review of the provider's June 2020 Facility admission Agreement packet revealed:*A November 2016 Notice of Resident Rights Under Federal Law document indicated:- The resident has the right to formulate an Advance Directive.- The resident has the right to be informed, in advance, of the care furnished.-The resident has the right to be informed of, and participate in his/her treatment, including: The right to be fully informed.participate in the planning process.to be informed I advance of any changes in the plan of care.*The provider's December 2023 Resident Handbook indicated:-The center will abide by any instructions provided in your Advance directive.Health Care Power of Attorney.*There was no information specific regarding notification to a resident's representative of a change in status or of an elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, record review, and policy review, the provider failed to report an elopement in the required timeframe to the SD DOH for one of one sampled resident (24) with cognitive impairment and identified at risk for elopement, who had eloped (left the facility grounds without staff knowledge).Findings include:1. Review of the provider's 7/24/25 SD DOH FRI regarding resident 24 revealed:*On 7/4/25 at 6:57 p.m., resident 24 was found to be at the apartment building across the street.*She [resident 24] had signed out of the facility earlier in the day, therefore the incident was not reported.*The resident had a 5/5/25 contract agreement that the resident would not leave the premises of the facility.*The resident had left the facility without staff awareness on 7/4/25, and that event had not been reported to resident 24's representative or SD DOH until 7/24/25.-That was 20 days later. 2. Review of the facilities' sign-out log revealed on 7/4/25, resident 24 signed out at Noon and returned at 1:00 p.m. That was the only time resident 24 signed out that day. 3. Review of resident 24's Guidelines for Outside Activity contract agreement with the facility revealed:*Resident MUST sign herself out and in each time she leaves the building.*Inform Charge Nurse on duty of her going outside & [and] how long she plans to be outside.*Resident will remain on facility property when [she] goes outside: will not go up town to any place of business or location w/o [without] family or facility personnel.*Resident [24] will not go to the apartments to the East or North of the facility.*The contract was signed on 5/5/25 by resident 24 and social services director D. 4. Interviews on 7/24/25 between 9:45 a.m. and 10:45 a.m. with staff members S and T, who requested anonymity, revealed:*On 7/4/25, around 7:00 p.m., staff members identified that they had not seen resident 24 for some time and began looking for her.*Resident 24 was allowed to sign herself out to go outside and smoke, but she was not allowed to leave the facility property.*Resident 24 had not signed out that evening on 7/4/25 and was not found within the facility or outside in the designated smoking area.*Staff were worried about resident 24's safety because she had not indicated that she was leaving, and it was raining that day.*Resident 24 was found at the apartments next door. Staff encouraged her to return to the facility; however, resident 24 refused to return to the facility.*Resident 24 then went to the shed and took out her trike [a three-wheeled bicycle] and took off down the street, which was when staff members reported they lost sight of resident 24.*Resident 24 was then seen by a staff member about a block away from the facility on that trike.*Registered nurse (RN) U had called the supervisors on call that evening while staff members searched for resident 24 and tried to convince resident 24 to return to the facility.*Staff members S and T were told by LPN U that she had been instructed by the supervisors to just let her go, not to report the incident, not to document the incident, and not to mention or talk about the incident again. 5. Interview on 7/24/25 at 2:00 p.m. and again at 2:50 p.m. with director of nursing (DON) B, administrator A, and social services director (SSD) C revealed:*DON B stated that there was no investigation into resident 24's 7/4/25 incident because it had not been considered an elopement at that time.*Administrator A stated that after reviewing additional documentation, it was determined that the incident on 7/4/25 should have been considered an elopement.*Administrator A expected that all elopements would be reported to the state agency immediately and investigated. She expected the results of any investigation related to a resident's elopement to have been documented and reported to the state agency within five working days.*DON B and Administrator A confirmed that there was no documentation of resident 24's 7/4/25 elopement in her electronic medical record, and there was no investigation documentation from that 7/4/25 elopement. 6. Review of resident 24's electronic medical record revealed:*She was admitted on [DATE].*Her diagnoses included anxiety, nicotine dependence, and dementia (a group of symptoms affecting memory, thinking, and social abilities).*Her 4/19/25 Elopement Risk Evaluation indicated that she was an elopement risk; her wandering placed her at significant risk of getting [in] to an unsafe situation, had a history of leaving the center without notifying staff members, and on 4/19/25 she left [a] supervised area to walk around outsid[e].*Her 5/19/25 Brief Interview of Mental Status (BIMS) assessment score was 10, which indicated she was moderately cognitively impaired. 7. Attempts made to contact RN U by phone were unsuccessful, and she was not available for an interview during the survey. 8. Review of the provider's February 2025 Elopement/Wandering policy revealed:*The resident/patient exits the Center without staff knowledge OR the resident/Patient enters an unsafe area without staff knowledge or presence.*A resident is found in the parking lot of the Center by a staff [member] or visitor without staff knowledge or presence. This is elopement.*A resident exits the front door without staff knowledge or presence. This is elopement.*If [the] resident exhibits exit seeking behavior, the episodes are documented in the resident medical record. Documentation includes interventions used and their effectiveness. Review of the provider's September 2017 Abuse Reporting and Response policy revealed:*The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents.in accordance with state and federal laws.*Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director.*The Executive Director or designee reports alleged violations to the state's survey agency and other officials in accordance with state law.*The Center reports the results of all investigations to the Executive Director and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident.*It had been Updated October 202. It was unknown what year, as the last digit of the date was not present.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to:*Provide adequate supervision for one of one sampled resident (24) during an outside activity by one of one activities assistant L.*Ensure the safety of one of one sampled resident (24) with cognitive impairment, identified at risk for elopement, who had eloped (left the facility grounds without staff knowledge) on 7/4/25. Findings include:1. Review of the 4/19/25 SD DOH FRI regarding resident 24 revealed: *On 4/19/25 at 5:32 p.m. the report had been submitted that indicated resident 24 had eloped from the facility at 2:50 p.m. on 4/19/25. *The resident had told activities assistant L she wanted to see the kids at the easter egg hunt on the other side of the facility. *Resident 24 had walked around to the other side of the facility and was out of staff’s sight. *The resident was found by activities director (AD) V walking around the back side of the facility towards an entrance to the facility. *The resident refused to be assessed or to have her vitals (blood pressure, temperature, pulse, respirations, and oxygen level) taken after returning to the facility. -The resident was assessed an hour later by nursing staff and her vitals were stable. *The on-call physician, family, and the local sheriff were notified of the resident’s elopement. *Resident 24's care plan indicated she needed to be accompanied by family, a responsible party, or a staff member when leaving the facility. 2. Review of resident 24's electronic medical record (EMR) revealed she: *She was admitted on [DATE]. *Her diagnoses included anxiety, nicotine dependence, depression, sepsis (serious condition in which the body responds improperly to an infection), dementia (decline in mental ability that interferes with daily life), and behavioral disturbance (disruptive behaviors). -A Brief Interview for Mental Status assessment (BIMS) completed on 2/12/25 with a score of 10, indicated she was moderately cognitively impaired. *On 2/12/25 she had been assessed and was determined not at risk for elopement. *On admission she had a smoking safety evaluation, and determined she could smoke independently. *She was instructed to only smoke outside in the designated area. - When she would go outside to smoke, she was to sign in a book with her name, date, time of leaving and time of returning. *Prior to 4/19/25, she did not have a history of wandering, exit-seeking, or elopement. 3. Interview on 7/22/25 at 10:00 a.m. with resident 24 revealed: *She reported on 4/19/25 she had walked around to the other side of the building during an outside activity. *She had indicated, she told activities assistant L that she was going to walk around the building. *At that time, she was allowed to be outside with staff supervision. *After she had returned to the facility, she had indicated to staff that she went for a “walkabout” when she had walked around the building. 4. Interview on 7/22/25 at 10:12 a.m. with director of nursing (DON) B, regarding resident 24's 4/19/25 elopement revealed: *The resident had walked around the facility on 4/19/25 at 2:50 p.m. and she was out of sight of staff for only a short amount of time, about 45 seconds. *The resident had returned on her own to the facility without harm. * On 4/19/25 resident 24’s care plan had been updated to reflect she was an elopement risk. *Resident 24’s care plan indicated all exit seeking behaviors must be documented in resident 24’s EMR. *The resident’s care plan indicates an elopement risk will be completed quarterly on her and this was initiated on 4/19/25. 5. Interview on 7/24/25 at 9:30 a.m. with certified medication aide (CMA) Q revealed: *She referred to a pocket care plan staff used to care for the residents. Those included resident cares and information about them. *She had indicated resident 24 was only to be outside with supervision of staff or a responsible person. *She had indicated that on 4/19/25 resident 24 had a BIMS score of 10 and needed staff supervision. 6. Interview on 7/24/25 at 12:24 p.m. with activities director (AD) V revealed: *On 4/19/25 at 2:50 p.m. resident 24 was outside being supervised by activities assistant L. *That day the resident had walked around to the other side of the facility and was out of sight of the staff for only a couple minutes . *A code white (missing resident) was called to inform all staff of a missing resident for them to start looking for her. *Staff then found the resident had been seen by staff walking up the sidewalk next to the building and had come from the opposite side of the facility. 7. Review of the provider's 7/24/25 SD DOH FRI regarding resident 24 revealed: *On 7/4/25 at 6:57 p.m., resident 24 “was found to be at the apartment building across the street.” *”She [resident 24] had signed out of the facility earlier in the day, therefore the incident was not reported.” *The resident had a 5/5/25 contract agreement “that the resident would not leave the premises of the facility.” *The resident had left the facility without staff awareness on 7/4/25, and that event had not been reported to resident 24’s representative or SD DOH until 7/24/25. 8. Review of the facilities’ sign-out log revealed on 7/4/25, resident 24 signed out at “Noon” and returned at 1:00 p.m. That was the only time resident 24 signed out that day. 9. Additional review of resident 24’s electronic medical record revealed: *Her 4/19/25 Elopement Risk Evaluation indicated that she was an elopement risk; her wandering placed her at “significant risk of getting [in] to an unsafe situation, had a history of leaving the center without notifying staff members, and on 4/19/25 she “left [a] supervised area to walk around outsid[e].” *Her 5/19/25 BIMS assessment score was 10, which indicated she was moderately cognitively impaired. *There was no documentation of resident 24’s elopement on 7/4/25 as indicated in the 7/24/25 SD DOH FRI. *There was no documentation of the resident’s exit-seeking or other behaviors or incidents on 7/4/25. *A 7/5/25 BIMS assessment score of 13, which indicated she was cognitively intact. -That BIMS assessment was completed the day after resident 24 left the facility without staff knowledge on 7/4/25. *A 7/20/25 Elopement Risk Evaluation indicated a score of “NA [not applicable]”: -Her cognition was impaired with poor decision-making skills. -She had a history of wandering. -She had a diagnosis of dementia/cognitive impairment. -She had a history of leaving the facility without notifying staff. -She had a substance use disorder. -She had “no reported episodes of wandering in the past 3 months.” -Risks included: “Hospitalization, Fall/Injury/Bone Fracture, Being reported as a missing person/elopement.” -The resident had been educated on signing out and telling a staff member that she was leaving before she left, and the risks associated with leaving the facility.She acknowledged the risks and understood the process of leaving the facility. -She was determined not to be an elopement risk and “allowed to leave facility is signed out/policy [It was unclear what this indicated].” 10. Review of resident 24’s “5/5/25 Guidelines for Outside Activity” contract agreement with the facility revealed: *”Resident MUST sign herself out and in each time she leaves the building.” *”Inform Charge Nurse on duty of her going outside & [and] how long she plans to be outside.” *”Resident will remain on facility property when [she] goes outside: will not go up town to any place of business or location w/o [without] family or facility personnel.” *”Resident [24] will not go to the apartments to the East or North of the facility.” *The contract was signed on 5/5/25 by resident 24 and social services director C. 11. Review of resident 24’s care plan revealed: *A 5/28/25 problem area indicated “[Resident 24] is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] Cognitive deficits, Depression, Mood/Behaviors, [and] Physical Limitations.” *A 6/16/25 problem area indicated “[Resident 24] has an alteration in safety r/t: cognitive impairment and being a risk for elopement off the [facility name] Campus.” That was deleted and revised on 7/5/25 to indicate “Resident [24] is her own responsible party.” *A 6/16/25 goal for the above problem area was to “Prevent [resident 24] from risk, including exposure to dangerous environmental factors, increased risk of falls or accidents, and potential for exploitation or abuse.” *A 6/6/25 intervention indicated “[Resident 24] will be accompanied by family, responsible party, or center staff member when leaving the center. Or approved outings by daughter POA [Power of Attorney].” That was deleted and revised on 7/5/25 to indicate “[Resident 24 will be compliant with facility sign [sign] out/sign in process. These are approved outings by [her] daughter POA.” *A 6/16/25 intervention indicated ”If [resident 24] exhibits behavior leaving campus, the episodes are documented in [resident 24’s] medical record. Documentation includes interventions used and their effectiveness.” That was deleted and revised on 7/5/25 to indicate “If [resident 24] exhibits behaviors of not signing B/4 [before] leaving then [the] facility & [and] signing in after returning, the episodes are documented in [resident 24’s] medical record. Documentation includes interventions used and their effectiveness.” *Resident 24’s care plan had been revised on 7/5/25 the day after she left the facility without staff knowledge. 12. Review of resident 24’s “7/6/25 Guidelines for Outside Activity” contract agreement with the facility revealed: *”Resident MUST sign herself out and in each time she leaves the building.” *”Inform Charge Nurse on duty of her going outside & [and] how long she plans to be outside.” *”Resident will notify staff on duty, sign out & [and] back in when [she] goes uptown to any place of business or location on her three wheeled bicycle.” *The contract was signed on 7/5/25 by resident 24 and social services director C. *The contract was signed two days after resident 24 had left the facility without staff knowledge on 7/4/25. 13. Interviews on 7/24/25 between 9:45 a.m. and 10:45 a.m. with staff members S and T, who requested anonymity, revealed: *On Friday, 7/4/25, around 7:00 p.m., staff members identified they had not seen resident 24 for some time that day and began looking for her. *Resident 24 was allowed to sign herself out to go outside and smoke, but she was not allowed to leave the facility property. *Resident 24 had not signed out that evening and was not found within the facility or outside in the designated smoking area. *Staff were worried about resident 24’s safety because she had not indicated that she was leaving, and it was raining that day. *Resident 24 was found at the apartments next door to the facility. Staff encouraged her to return to the facility; however, resident 24 refused to return to the facility. *Resident 24 then went to the shed behind the facility and took out her “trike” [a three-wheeled bicycle] and “took off down the street,” which was when staff members reported they lost sight of resident 24. *Resident 24 was then seen by one of those staff members about a block away from the facility on that trike. *The charge nurse had called the supervisors on call that evening while they searched for resident 24 and tried to convince the resident to return to the facility. *Staff members S and T were told by the charge nurse, “Just let her go,” not to report the incident, not to document the incident, and not to mention or talk about the incident again. *Staff members S and T knew resident 24 was allowed to “sign out” to smoke independently in the designated smoking area, but she was not to leave the facility property that day unsupervised because it was part of a posted outside activity agreement for resident 24, and the resident had not been care planned to leave the facility independently. 14. Interview on 7/24/25 at 9:25 a.m. and again at 4:38 p.m. with resident 24’s son revealed: *His mother was admitted to the facility after a hospitalization and illness several months ago because she required more assistance and supervision than he or his sister could provide for her at home. *He had been notified in April 2025 when his mother had walked away from an outside group activity at the facility, but he had not been notified when she left the faciity on 7/4/25. *On 7/5/25, while at the facility, he was informed that the “board” had decided that his mother could “come and go” from the facility, including on overnight visits, if she signed herself out, that the facility did not need to notify him or his sister when she left the facility, and that the facility was not responsible if something happened after she signed herself out of the *He was unsure who the “board” members were who had made those decisions. *Social services director (SSD) C made a phone call to her supervisor while he was present at the facility on 7/5/25, to confirm the above information he was told, because he was questioning the decision to “change her status at that moment,” and he continued to be worried for her safety. 15. Interview and review of resident 24’s occupational therapy records on 7/24/25 at 3:58 p.m. with director of rehabilitation R regarding resident 24’s participation in therapy revealed: *Resident 24 received occupational therapy services from 6/5/25 through 7/23/25. *Her occupational therapy evaluation included assessing her safety with the use of an adult tricycle on facility grounds and in the community. *On 7/23/25, resident 24 was discharged from occupational therapy with the recommendation “not realistic for off campus due to safety concerns of use with traffic. Can use on campus.” *The occupational therapy assistant who completed the safety assessment was on leave and unavailable for interview. 16. Interview on 7/24/25 at 2:00 p.m. and again at 2:50 p.m. with director of nursing (DON) B, administrator A, and social services director (SSD) C revealed: *DON B stated there was no documentation or investigation of resident 24’s 7/4/25 “incident” because it had not been considered an elopement. *Administrator A stated after reviewing additional documentation, it was determined that the “incident” on 7/4/25 should have been considered an elopement as the resident had left the facility without the staff’s knowledge or supervision. *Administrator A had not been aware of the ”Guidelines for Outside Activity” contracts that had been made with resident 24 on 5/5/25 before the incident on 7/4/25 and again on 7/6/25 after the incident occurred on 7/4/25. *Administrator A was surprised that resident 24 had a BIMS assessment score of 10 before the incident on 7/4/25 and had been reassessed to have a BIMS of 13 “magically” on 7/5/25. *SSD C confirmed she had completed resident 24’s 7/5/25 BIMS assessment, had updated the outside activity contract, and updated resident 24’s care plan to reflect the new agreement. *SSD C stated that resident 24’s family had not been involved in the development of the contract but had agreed with it on 7/5/25. -Those documents had been updated after the incident on 7/4/25. *Administrator A expected that all elopements would be reported to the state agency and investigated for potential abuse, neglect, or additional interventions. She expected the results of any investigation related to a resident's elopement to have been documented and reported to the state agency. *DON B and Administrator A confirmed there was no documentation of resident 24’s 7/4/25 elopement in her electronic medical record, and there was no investigation documentation from that 7/4/25 elopement. *DON B was unaware of occupational therapy’s 7/23/25 discharge recommendation that resident 24 was assessed as unsafe for off-campus use of her trike due to safety concerns. 17. Review of the provider’s February 2025 Elopement/Wandering policy revealed: *”The Center evaluates residents for wandering and/or exit seeking behavior and implements appropriate interventions as indicated via the evaluation process.” *”The resident/patient exits the Center without staff knowledge OR the resident/Patient enters an unsafe area without staff knowledge or presence.” *”A resident is found in the parking lot of the Center by a staff [member] or visitor without staff knowledge or presence. This is elopement.” *”A resident exits the front door without staff knowledge or presence. This is elopement.” “Residents deemed at risk to elope…are accompanied by family, responsible party, or a center staff member when leaving the center for appointments… are ai eyesight when on center sponsored outings. If staff are unable to keep the resident in line of sight, the resident is accompanied by a staff member assuring resident safety.” *” Recurrent evaluations are completed quarterly for those at risk to elope… with [a] change in condition and following elopement events. The care plan is reviewed and updated as appropriate.” *”If [a] resident exhibits exit seeking behavior, the episodes are documented in the resident's medical record. Documentation includes interventions used and their effectiveness.” Review of the provider’s June 2020 Facility admission Agreement packet revealed: “Your stay begins with a complete assessment of cognitive and physical health so that your care team may provide you with comprehensive attention specific to the care you need.” *”Care plans are individualized for every patient based on their diagnosis and needs. The goal is to maximize each patient’s functional abilities…your needs and the risks associated with them change over time, and we review your plan of care regularly to make sure it continues to meet your needs.”

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure proper infection control practices had been followed for the cleaning and storage of oxygen equipment for two of two sampled residents (21 and 22) who required the use of a Continuous Positive Airway Pressure (CPAP) machine (a device that uses air pressure to keep breathing airways open).Findings Include:1. Observation and interview on 7/22/25 at 9:59 a.m. with residents 21 and 22 in their shared room revealed:*There were two CPAP machines on the nightstand between the residents' beds.*Resident 21's CPAP mask was attached to the machine by a hose and was on the top of his CPAP machine.*Resident 22's CPAP mask was attached to the machine by a hose and was on her pillow.*They both indicated they had brought their CPAP machines when they were admitted to the facility a couple of weeks ago.*Resident 22 stated prior to moving in she had cleaned their CPAP masks, hoses, and water tanks every day at home with hot water and dish soap and allowed them to air dry.*She had been unable to clean their CPAP masks, hoses, and water tanks at the facility because she could not stand at the sink long enough and did not have any dish soap.*The staff members had assisted her with adding distilled water to the tanks, if they spot that it is low.*She thought the staff did not know that the CPAP machines and masks needed to be cleaned or how to clean them.*She stated she would have known if the staff had cleaned their CPAP masks because she felt they are getting smelly. 2. Review of resident 21's electronic medical record (EMR) revealed:*He was admitted on [DATE].*His diagnoses included obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked) and dementia (a group of symptoms affecting memory, thinking, and social abilities).*His 7/5/25 Brief Interview of Mental Status (BIMS) assessment score was 3, which indicated he was severely cognitively impaired.*A 7/1/25 physicians order APAP (automatic CPap) with settings of 5-20 cm [centimeters of] H2O [water] every night.*There was no documentation in his EMR that indicated his CPAP mask and tubing were being cleaned. 3. Review of resident 22's EMR revealed:*She was admitted on [DATE].*Her diagnoses included obstructive sleep apnea and fracture of the right lower leg.*Her 7/5/25 BIMS assessment score was 14, which indicated she was cognitively intact.*A 7/1/25 physicians order CPap with 8 cm of water nightly every night shift for OSA [obstructive sleep apnea].*There was no documentation in her EMR that indicated her CPAP mask and tubing were being cleaned. 4. Interview on 7/24/25 at 12:10 p.m. with director of nursing (DON) B and administrator A regarding residents 21 and 22's CPAPs revealed:*DON B was aware that residents 21 and 22 had brought their CPAPs with them when they were admitted and that they were using them every night.*DON B expected there would be a nursing order on the residents' treatment administration record (TAR) to ensure that the CPAPs were cleaned daily between uses.*Administrator A and DON B confirmed that residents 21 and 22 did not have that nursing order on their TARs.*Administrator A confirmed that the provider's oxygen use policies did not address the use of CPAPs and that they would follow the manufacturer's instructions for the cleaning of the CPAP machines and masks. 5. Review of the undated ResMed CPAP manufacturer's instructions revealed:*Regularly clean your tubing assembly, water tub and mask to receive optimal therapy and to prevent the growth of germs that can adversely affect your health.*You should clean your device weekly as described. Refer to the mask user guide for detailed instructions on cleaning your mask.*Wash the water tub and air tubing in warm water using only mild detergent.*Rinse the water tub and air tubing thoroughly and allow to dry.*Wipe the exterior of the device with a dry cloth. 6. The provider had not provided cleaning instructions for the CPAP masks. 7. Review of the provider's November 2018 Respiratory Care: Equipment Care and Handling policy revealed it did not address the use or cleaning of CPAP machines or CPAP masks. 8. Review of the provider's December 2017 Guidelines for Administration of Aerosolized Care policy revealed it did not address the use or cleaning of CPAP machines or CPAP masks.

Based on observation, interview, record review, and policy review, the provider failed to:*Follow standard food safety practices to ensure one of one kitchen had been cleaned to maintain a sanitary environment to store, prepare, and serve food to residents related to the cleanliness of the food preparation areas.*Follow acceptable food safety practices by not having ensured that food packages were dated when opened and outdated food items were discarded from inventory in one of one observed kitchen related to food items requiring refrigeration.*Properly temp foods to prevent the spread of cross-contamination by one of one observed cook M during one of one meal services.*Ensure the use of a beard net by one of one food and nutrition service (FANS) manager (F).Findings include:1. Observation and interview on 7/21/25 at 3:30 p.m. with FANS manager F in the kitchen revealed:*He was cooking food in a pot on the stove.*He had a short beard and was not wearing a beard net.*He was the acting FANS manager.*FANS manager N had been on leave since June 2025. 2. Observation on 7/21/25 at 3:55 p.m. in the main kitchen revealed:*There were uncovered containers of whipped margarine labeled Keep Refrigerated and peanut butter on the counter near the food serving area.*Two unopened and one partially used one-pound blocks of margarine labeled Refrigerate for best quality, were on a shelf in the rear of the kitchen.-The partially used margarine had an orangish-pink discoloration on two sides. It had not been labeled when it had been opened or with a use-by date.*Four cereal dispensers containing dry cereal, on the shelf near the three-compartment sink, were not labeled with the contents or the date they had been opened, or their use-by date.*Two open bags of dry cereal that were not labeled with the contents or the date they had been opened, or their use-by date.*The food preparation sink contained unidentifiable orange and brown pieces of food and a significant amount of coffee splatter.*A coffee machine with two plastic trays beneath it.-The trays contained at least four wet, stained, crumpled rags and a significant amount of pooled cold coffee that was not absorbed by the rags.*The counters, a white plastic scoop, and other utensils in the utensil tray adjacent to the coffee machine contained coffee splatter.*An approximately eight-inch by four-inch coffee spill was noted on the floor to the left of the coffee machine.*The walk-in refrigerator contained:-At least nine uncovered cups with an orange puree dessert.-At least 20 uncovered cups of a white creamy dessert with what appeared to be chunks of fruit.-Peas dated 7/18 that did not contain a use-by date.-Carrots dated 7/17 that did not contain a use-by date.-Baked beans dated 5/21/25 use by 5/22/25.- BBQ chicken dated 5/21/25 use by 5/23/25.-A cart contained nine plastic pitchers of juice dated 7/16 use by 7/19 and ten open boxes of juice that had not been labeled with their open date, which indicated use within seven days.*On the floor, under the metal shelf, in the walk-in freezer, were two individual frozen waffles and two ice cream cups. 3. Observation on 7/21/25 at 5:05 p.m. in the main dining room revealed:*FANS aide P poured juice from the plastic pitchers dated 7/16 use by 7/19 and the ten open boxes of juice that had not been labeled with their open date, which indicated use within seven days during the meal service.*He served the creamy white and orange desserts to resident at their tables. 4. Observation on 7/21/25 at 5:25 p.m. of FANS manager F in the kitchen serving area revealed he did not wear a beard net while he plated resident meals and placed them on the window ledge to be served. 5. Observation and interview on 7/22/25 at 11:27 a.m. with dietitian O and FANS manager F revealed:*Dietitian O was at the facility once a week.*Dietitian O expected that FANS manager F or any dietary staff with facial hair would wear a beard net during food preparation and serving.-She confirmed that FANS manager F had not been wearing a beard net and she provided him with one.*Dietitian O expected that boxed juice containers would be dated with the date they were opened and discarded within seven days after that.*FANS manager F confirmed that the opened boxed juice on the cart in the walk-in refrigerator had not been dated when opened.*The juice pitchers on the top shelf that appeared to be the same pitchers observed above, contained new labels dated 7/21 use by 7/24.*Dietitian O stated that she followed the food code and that juice prepared from a powdered mix was to be discarded after seven days.*FANS manager F confirmed that the carrots and peas observed in the refrigerator had been discarded, but she thought that the baked beans and BBQ chicken had been prepared and served yesterday (7/21/25) and had been mislabeled with May dates.*There had been no meal substitutions documented in June or July. 6. Observation on 7/23/25 at 11:00 a.m. with cook M and dietician O of the food temperature monitoring of food to be served at the lunch meal revealed:*Cook M took the thermometer from its protective sleeve and, without cleaning the thermometer probe, placed it into a piece of fish.*Cook M took a second thermometer from its protective sleeve and, without cleaning the thermometer probe, placed it into a second piece of fish.*Cook M removed both thermometers from the fish and placed them on the counter with the probes touching the counter. He then placed the first probe back into another piece of fish from the same tray.*Dietician O then assisted cook M with monitoring the temperatures of the vegetables and cleaning the thermometer with an alcohol wipe before and after she used it.*Cook M then removed a thermometer from its protective sleeve, cleaned that probe with an alcohol wipe, and temped the rice. Without cleaning the thermometer probe he temped the potatoes. 7. Interview on 7/23/25 at 2:25 p.m. with dietitian O revealed she:*Expected that cook M would have cleaned the food thermometer before using it, when it became soiled or touched a potentially contaminated surface like the counter, between food items, and when he was finished.*Expected that foods would be labeled to identify the item, when they were opened, and when they needed to be discarded to ensure food safety.*Expected food to be discarded by the use-by date or by the date indicated on the item.*Had been unaware that the margarine items had been left out on the counter and expected them to have been stored as the package indicated.*Confirmed there had been no menu items substituted, and therefore it was unknown if the items in the refrigerator had been mislabeled for May 2025.*She completed weekly walk-throughs of the kitchen and felt that the kitchen had been maintained in a sanitary manner. 8. Review of the provider's 7/21/25 menu revealed:*Oven-fried chicken and mashed potatoes had been served.* BBQ chicken and baked beans had not been on the menu that day or within the past three days. Review of the providers' FANS DAILY INSPECTION logs revealed:*The logs were completed approximately once a week.*On 5/21/25, Food is within use by date guidelines was marked No.*On 6/4/25, Food is within use by date guidelines was marked No.*On 6/11/25, EVERYTHING: Covered, labeled, dated;. (date made/opened and use-by date)? was marked No.*On 6/25/25, EVERYTHING: Covered, labeled, dated;. (date made/opened and use-by date)? was marked No. Review of the Orange Juice Blend Base manufacturer's product label revealed there was no recommendation for a use-by date. Review of the Classic Lemonade Drink Mix manufacturer's product label revealed there was no recommendation for a use-by date. 9. Review of the provider's May 2017 Food Safety and Temperatures policy revealed:*Label, date, cool, and store any left-over food in compliance with the Food Code.*Dispose of all food items according to the time team frames noted in the Food Code.*Dispose of any questionable food items.*Prior to preparing or serving food to residents the food is inspected by the Dietary Supervisor or designate to guarantee that the food is fresh and without any evidence of contamination or spoilage.*The policy did not address the cleaning of the thermometer when temping food items. Review of the provider's March 2018 Food Labeling Reference Guide for Opened Foods policy revealed:*Area, Refrigerator.margarine.*Cooked leftovers.use by date 3 days after original cooking date.*Dry items such as bulk cereal.use by 3 months after opened.*Fruit juice.use by date 7 days after open. Review of the provider's June 2021 Personal Hygiene Standards policy revealed:*For all employees with beards, beer guards are worn. Review of the provider's October 2017 Menus policy revealed:*If any meal served varies from the planned menu the change is posted for the residence and on the posted menu in the kitchen and/or in the substitution log used solely for recording such changes. Review of the provider's March 2025 Food and Nutrition Service Managers job description revealed:*Verifies compliance with both State and Federal standards of participation for long-term care facilities.*Supervises food preparation and service; Verifies high level of food quality and compliance with food service regulations.*Verifies high sanitation standards, Maintains current cleaning schedules.

Based on observation, interview, and record review, the provider failed to ensure staff interactions and services were provided in a manner that maintained a resident's sense of dignity and respect by failing to: *Knock and ask permission to enter one of one sampled resident's (5) room. *Refer to one of one sampled resident (27) by a preferred nickname. *Follow two of two sampled resident (24 and 25) care plans for transfers in a dignified manner from their wheelchairs to their dining room chairs. *Provide incontinence care to one of one sampled resident (25) prior to being transferred into a dining room chair. *Maintain a homelike dining atmosphere by speaking loudly across the dining room to coworkers and other residents, and speaking about a resident (31) in front of that resident and others during two of two mealtime observations. Findings include: 1. Observation and interview on 6/3/24 at 3:27 p.m. with resident 5 in his room revealed: *He stated that workers bust in the door without knocking. *During the interview, certified nurse aide (CNA) E walked into the resident's room without knocking and interrupted the conversation. -The door was all the way open. 2. Observation on 6/3/24 at 5:39 p.m. in the dining room revealed: *CNA E sat down at one of the assisted dining tables and yelled across the room to another staff member. -Did [resident 36] eat? Did he eat? *CNA E and two other unidentified female staff members were also talking loudly to each other across the dining room, attempting to plan when they should take their respective breaks and where they were going to go. -CNA E said, Can you feed so these two can go on break? *CNA E was overheard asking a resident at the assisted dining table, Is it too hot for you, baby? *He was speaking with resident 16 in a child-like manner, exclaiming Good job! when she took a bite of food. 3. Observation on 6/4/24 from 11:13 a.m. to 11:51 a.m. in the dining room during the noon meal revealed: *CNA E transferred resident 25 from her wheelchair to a dining chair by grabbing her under her arm and the waistband of her pants and hoisted her up. *As resident 25 stood, her bottom was noticeably wet and soaked through, potentially with urine. -CNA E touched the soiled portion of her pants with his ungloved left hand and did not wash his hands. *CNA E sat resident 25 back down in her dining chair and walked away without assisting her out of the dining room to attend to her visibly wet pants. *He proceeded to touch other residents' wheelchairs and walkers, to place clothing protectors on residents, and to help other residents to transfer to their dining chairs with his unclean hands. *CNA E assisted resident 24 from his wheelchair to a dining room chair without first having locked his wheelchair brakes, grabbed his waistband to hoist him up and pivoted him into a chair. *CNA E then used hand sanitizer at 11:27 a.m. *CNA E was seated at one of the assisted dining tables and observed resident 34 walking out of the dining room. -CNA E yelled out the resident's name four times. -He then walked over to resident 34, and loudly said, You need to go sit back down because you haven't eaten yet! -Resident 34 walked back over to his table, appeared to have seen his food had not been served, and walked out of the dining room. *Resident 139 had propelled herself into the middle of the dining room as her oxygen cord dragged on the floor. CNA E yelled across the room, [Resident 139], you okay? *CNAs E and F were seated at an assisted dining table and had been helping residents eat their lunch. -CNA E asked CNA F, Have you seen her [resident 31] eat by herself? in front of that resident, other residents, and a guest. -CNA F responded, No she doesn't feed herself. I've never seen her feed herself. 4. Observation on 6/4/24 at 2:50 p.m. with CNA G and resident 27 while in her room revealed: *CNA G was by resident 27's bedside and had been preparing to obtain her vitals. *CNA G stated, Hey grandma, I'm going to take your vitals. *Resident 27 did not say any comments about having been called grandma. 5. Interview on 6/5/24 at 10:33 a.m. with CNA H regarding how she would have properly transferred a resident from their wheelchair to a dining room chair revealed: *She stated she would have first informed the resident that she would be helping them from their wheelchair to the dining room chair. *She would have then locked the wheelchair brakes and used a gait belt to have assisted the resident to stand and pivot to their chair. 6. Interview on 6/5/24 at 10:50 a.m. with nurse aide I regarding how to properly transfer a resident from their wheelchair to a dining room chair revealed: *She indicated she was in CNA training. *She stated she would have locked the resident's wheelchair breaks, used a gait belt, assisted the resident to stand, pivot, and sit in their dining chair, and then removed the gait belt. *She would have also explained to the resident what she would be doing before she did it. 7. Interview on 6/5/24 at 12:41 p.m. with social services designee/registered nurse (RN) J regarding resident dignity and privacy revealed: *She would have expected staff to knock, introduce themselves, and ask for permission before entering a resident's room. *She had provided staff with education and had reminded them to treat the residents with respect even if the staff were busy. 8. Interview on 6/5/24 at 1:58 p.m. with administrator A regarding resident dignity and privacy revealed: *She would have expected staff to knock on resident's doors before entering their rooms and introducing themselves before providing care to residents. *She would have expected staff to take residents back to their rooms if they need continence care before entering the dining room. 9. Interview on 6/6/24 at 11:14 a.m. with licensed practical nurse (LPN) K regarding resident dignity in the dining room revealed: *When she assisted in the dining room, she would have expected staff to offer a clothing protector to the residents. *Staff should have made sure residents' hands and faces were clean. *Transfer belts and slings should have been removed. *She indicated it was not acceptable for staff to have yelled across the dining room at other staff members or residents. *She also indicated it was unacceptable for staff members to have spoken about a particular resident in front of that resident, or in front of other residents. 10. Interview on 6/6/24 at 11:25 a.m. with CNA H regarding resident dignity in the dining room revealed: *Staff should have covered the residents with a clothing protector so their clothes would stay clean. *She said, When they are a 'feeder' keep them clean. *She indicated it was not appropriate for staff to have talked about a resident when that resident is present. *She said when communicating with other staff members, staff should not have been yelling at each other across the dining room. 11. On 6/4/24 at 3:08 p.m., a policy on resident dignity was requested. The provider indicated they did not have a policy for resident dignity. 12. Review of resident 27's current care plan revealed: *There was an intervention which read, Prefers to be called: [resident's nickname]. Date initiated and revised on 6/3/22. *There was no mention of the word grandma in her care plan. 13. Review of resident 25's current care plan revealed: *Intervention of TRANSFER/AMBULATION: Assist x 2 and FWW for short distances. Wheelchair for long distance mobility as needed. Date initiated 9/26/22, revised on 5/28/24. *Intervention of Gait belt while ambulating, standing, transferring. Date initiated 11/9/22, revised on 2/23/24. 14. Review of resident 24's current care plan revealed there was an intervention of TRANSFER: assist x2 staff for transfers. Assist x2 staff due to behaviors. Date initiated 2/24/22, revised on 5/22/24. 15. Interview on 6/6/24 at 11:35 a.m. with director of nursing services B regarding maintaining resident dignity and respect revealed: *Staff should have engaged with the residents to foster a homelike environment. *It was inappropriate for staff to have spoken loudly across the dining room at other staff members or to other residents. *It was not appropriate for staff to have talked about the residents in front of that resident. *Staff should not have used pet names such as baby or grandma for residents unless that resident provided consent to do so. -She confirmed that resident 27 was not CNA G's grandma and he should not have been calling her that. -She indicated that some of their travel staff was from the southern region of the country, and it was a cultural thing for them to call each other by those pet names, but that was not necessarily the culture of the Midwest. *She had previously spoken to CNA E about his interactions with residents and other staff members but had not seen any improvement. *She confirmed residents 24 and 25 should have been transferred using a gait belt rather than by their waistband. *She confirmed CNA E should have performed hand hygiene after he had touched resident 25's soiled pants with his bare hand.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure necessary food safety guidelines were implemented and followed for appropriate storage and labeling of food items and for cleaning and sanitary maintenance of one of one kitchen and one of two kitchenettes. Findings include: 1. Observation on 6/3/24 from 2:43 p.m. to 3:38 p.m. during the initial kitchen tour revealed: *The water dispenser and ice machine in the dining room had a buildup of limescale in and around the machine, the metal grate was visibly rusty, and there was an unidentified black substance buildup in the catch tray. The machine was dripping water. *There were wooden storage cabinets in the dining room which contained the following outdated food items: -One bottle of caramel sauce with a Best if used by date of 15 May 2024, and an opened date of 2/8. -A jar of instant coffee with a Sell by [DATE] . The year on the jar was smudged and appeared to have been either 2021 or 2024. -A shaker of Mrs. Dash brand seasoning with a Best by date of 3/10/23. *In the service window area of the kitchen: -There was dust, food crumbs, and hair visible in the plate warmer drawers. -The storage area beneath the sink was stained with visible white and yellow residue. -There was a buildup of dust, garbage, and food crumbs beneath the serving equipment. -There was a visible burnt substance, food crumbs, and dust in the napkin dispenser. -The storage area beneath the cold holding table was scattered with food crumbs and garbage wrappers. *The ceiling vents had a visible buildup of dust. One of the vents was directly above the food prep area. *Regarding the gas range and flattop grill equipment: -The metal splash guard in between the flattop grill and the gas range was visibly soiled with layers of burnt food. -The grease trap drawer was not able to have been opened due to the amount of solidified grease and other food items in the drawer. -The backsplash on the gas range was visibly soiled with splashes of burnt food. -The catch tray beneath the gas range was soiled with layers of burnt food. *The top convection oven was soiled with splatters of burnt food and other food crumbs. The glass door was difficult to see through due to the amount of burnt particles. *There were several outdated and improperly stored food ingredient items in the baker's prep area in the kitchen: -A bottle of lemon juice concentrate was sitting at room temperature. The manufacturer's label indicated to Refrigerate after opening. The bottle was labeled as opened on 5/7. -A bottle of imitation vanilla flavor with an opened date of 6/30/23 and an Best by date of [DATE]. -There was a brick of margarine sitting at room temperature and was not cool to the touch. The manufacturer's label indicated Perishable keep refrigerated. -A bottle of ground ginger with a label indicating Best by [DATE]. *Regarding the walk-in cooler: -There was at least two containers of sour cream with a manufacturer's label indicating Best By 05/31/2024. Those containers had a handwritten date of 4/24. -There was at least one container of cottage cheese with a manufacturer's label indicating Best If Used By May 22 24. -There were several pitchers of various juices. Some of the labels did not match up with what was in the pitcher, and all the pitchers were past the handwritten Best By 5/20 date. --There was a pitcher of an amber liquid that appeared to have been apple juice that was labeled as water. --Some of the labels were missing from the pitchers and it was difficult to determine what the liquid was. *Regarding the dishwasher room: -It was a low-temperature chemical dishwasher. -There was significant grime buildup on the floor beneath the dishwasher. -The dishwasher was coated with limescale and food particle buildup. -The inside of the dishwasher appeared to be covered in limescale and food particle buildup. -The top of the dishwasher was covered in soap scum, limescale, and food particles. 2. Observation on 6/3/24 at 4:33 p.m. in the 200-hallway day room kitchenette cabinets revealed: *There was an opened package of candy that was sealed with a rubber band. -The rubber band was no longer elastic and crumbled when removed from the package. -There was a best by date from 2016. *A shaker of pepper had a printed date of 2015. *There was a package of individual pancake syrup that had turned rock solid. There was no manufacturer's date on the package. 3. Interview and observation on 6/5/24 at 3:20 p.m. with cook D in the kitchen revealed: *They did not use the flattop grill to cook food. -It was used as a prep table. -To clean the surface, he would sometimes scrape the food scraps into the grease trap drawer. -He had difficulties opening the grease trap drawer due to the amount of solidified grease. -He did not know when the drawer was last cleaned. *He confirmed the drip tray beneath the gas range should have been cleaned monthly and after each food spill. He confirmed it was unacceptable to have that much burnt food in the tray. *He indicated the convection ovens were deep cleaned with oven cleaner and a degreaser on a weekly basis. *There was a cleaning checklist binder and staff were supposed to initial when task items were completed. -He indicated the checklists might not have been filled out lately due to staffing shortages and their busy working schedules. -Observation of the cleaning checklist binder at that time revealed there had not been any cleaning checklists filled out since January 2024. *He indicated they delimed the dishwasher weekly. 4. Interview on 6/5/24 at 4:20 p.m. with dietary manager C about food storage and kitchen cleanliness revealed: *Daily, he expected his staff to clean the trayline work area, wipe down the inside and outside of the steamer, sweep and mop, and clean the outside surfaces of the food preparation equipment. *The gas range grates were supposed to have been cleaned weekly. *He indicated he recently completed a deep clean of the kitchen which included cleaning the walls and ceiling pipes. -He was not able to clean all the burnt food particles on the gas range backsplash. He indicated the tin metal might have been discolored from use. *He expected staff to clean their work areas as they worked. *The ceiling vents and grease trap drawer probably should have been cleaned monthly. *He confirmed the dishwasher was delimed once per month as recommended by their dishwasher maintenance representative. *He was not aware of the state of the dishwasher with the buildup of limescale, soap scum, and food particles. *He was not aware of the expired foods in the cooler or the baker's prep area. -He indicated he reused the same bottle of vanilla extract and refilled the bottle from the larger jug of vanilla. -He did not indicate whether the reused bottle was washed in between refills. -He was not aware of the relabeling requirements when using refillable bottles. 5. Review of the provider's October 2017 Food Storage policy revealed: *Policy statement: Food storage areas are maintained in a clean, safe, and sanitary environment. *Procedure: -1. Food storage areas are kept clean at all times. - .4.Empty food cans are not reused. Only food grade reusable containers are used for food storage. - .11. The manufacturer's expiration date, when available is the use by date for unopened items. Review of the provider's April 2018 Food Labeling Reference Guide for Opened Items document revealed: *The manufacturer's expiration date, when available, is the 'use by' for unopened items. Use by dates should not exceed the manufacturer's expiration date. *Under the Refrigerator section: -Thickened milks, thickened juices, thickened water: use by date 7 days after opened. -Potentially hazardous cold foods, including but not limited to: milk, cottage cheese, hard cooked eggs, bacon: use by date 7 days after opened. -Fruit juice, canned fruit: use by date 7 days after opened. -Sour cream, buttermilk, yogurt, cream cheese: use by date 14 days after opened. -Bulk, non-potentially hazardous foods, including but not limited to .lemon juice . use by date 6 months after opened. *Under the Dry Storage section: -Spices, rice, sugar: use by date 1 year after opened. Review of the provider's December 2009 Cleaning and Sanitizing Work Surfaces policy revealed: *All surfaces must be cleaned and rinsed. This includes walls, storage shelves, and garbage containers. *All surfaces that are in contact with food must be cleaned rinsed and sanitized. This includes counter tops and work surfaces. *Process to Clean / Sanitize Work Surfaces. Work surfaces are cleaned: -1. After they are used. -2. Before handling a different type of food. Review of the provider's December 2009 Cleaning and Sanitizing Fixed Equipment policy revealed: *All surfaces must be cleaned and rinsed. This includes walls, storage shelves, and garbage containers. *All surfaces that are in contact with food must be cleaned, rinsed and sanitized. This includes, but not limited to, blender base, food processor base, slicer, mixer, can opener base, and microwave. *Process to Clean / Sanitize Work Surfaces. Work surfaces are cleaned: -1. After they are used. -2. Before handling a different type of food. Review of the provider's September 2019 Sanitation policy revealed: *Policy Statement: The food service area is maintained in a clean and sanitary manner. *Procedure: -1. Kitchens, kitchen areas, and dining areas are kept clean, free from litter and rubbish . -2. Utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks, corrosions, open seams, cracks, and chipped areas. - .4. Ice used in connection with food or drink is from a sanitary source and is handled and dispensed in a sanitary manner. - .7. Cleaning schedules are developed by the FANS [food and nutrition services] Manager or Person in Charge. -8. The FANS Manager or Person in Charge monitors compliance to the cleaning schedule. - .10. The FANS Manager maintains completed cleaning schedules for a minimum of 60 days. A policy and procedure for cleaning the dishwasher was requested on 6/5/24. The provider indicated they did not have such a policy. 6. Review of the provider's daily, weekly, and monthly cleaning schedules for the past three months revealed that it appeared as though a base copy was drafted and photocopied for the past three months, with the different dates handwritten at the top of each page. The validity of the checklists could not be confirmed.

Based on observation, interview, cleaning log review, and policy review, the provider failed to ensure: *One of one flattop grease trap drawer was maintained in a clean manner free from food and grease buildup. *One of three ceiling vent fans were free from dust. *Food items such as dill relish, tomatoes, apple cider vinegar, and red wine vinegar were discarded after the item was spoiled or expired. *One of one hand soap dispenser was functional. Findings include: 1. Observation on 6/12/23 from 3:37 p.m. to 3:58 p.m. in the kitchen revealed: *The grease trap drawer under the flattop grill had burnt bits of food, noodles, and burnt grease in it. -The grease trap hole that connected the flattop grill to the drawer was caked with a thick layer of black grease. -The drawer was difficult to open due to the amount of grease. *The ceiling vent fan near the food preparation area and the cooking equipment had a layer of dust on the vent grates, and streaks of dust spreading out on the ceiling from the vent. *In the walk-in cooler, there was: -A gallon jug of dill relish that had an unknown black slimy substance growing near the opening rim. --There was a label which read 3-31-23 opened. -A plastic tub of tomatoes. Several tomatoes had unknown white fuzzy and white slimy substances growing on them. --There was a label which read Tom 5-3. *In the dry storage room, there was: -An opened gallon jug of apple cider vinegar with a handwritten date of 2-26. --There was no year to indicate what year the product was opened. --The manufacturer's Best if used by date was 11/18/20. -An opened gallon jug of red wine vinegar with a handwritten date of 9-3. --There was no year to indicate what year the product was opened. --The manufacturer's Best if used by date was 7/18/21. -There were two additional unopened gallon jugs of red wine vinegar with the same Best if used by date of 7/18/21. *There was a handwashing sink near the coffee and juice machine. The hand soap dispenser was not functional. -The antibacterial foaming hand soap that was in the dispenser had an expiration date of EXP 7/17. Observation on 6/13/23 at 11:23 a.m. revealed the kitchen equipment was still in the same condition as above and the spoiled/expired products were still there. Observation on 6/14/23 at 1:00 p.m. revealed the same as above. Interview on 6/14/23 at 1:03 p.m. with food and nutrition services (FANS) manager E about the above observations revealed: *She was not aware the ceiling fan was as dusty as it was. *She was aware of the grease trap drawer and agreed it needed to be deep cleaned more often. *Their process for discarding expired food was as follows: -The night cook was responsible to review the cooler and discard foods that were past its expiration date. -She was not aware there was a black slimy substance growing on the pickle relish jar. *She indicated they did not use tomatoes that often in their recipes. -She was not aware the tomatoes were starting to spoil. -They bought the tomatoes over one month ago. *She was not aware of the several jugs of vinegar in the dry storage room that had been there for years. -She indicated they did not use red wine vinegar or apple cider vinegar in their recipes. Review of the provider's 2018 Daily Cleaning Schedule template revealed the following items were included: *Range - Catch Pan *Grill *Handsink/Soap/Paper Towels *There were blank spaces to provide hand-written additions to the task list. Review of the provider's Daily Cleaning Schedule for 6/1/23 through 6/13/23 revealed: *The Range - Catch Pan and Grill were marked as completed on 6/1/23, 6/2/23, 6/3/23, 6/4/23, 6/10/23, 6/11/23, and 6/12/23. *The Handsink/Soap/Paper Towels were marked as completed on 6/4/23, 6/10/23, 6/11/23, and 6/12/23. Review of the provider's 2018 Weekly Cleaning Schedule template revealed the following items were included: *Refrigerator - Clean/Organize *Store Room - Clean/Organize *Fans *There were blank spaces to provide hand-written additions to the task list. Review of the provider's Weekly Cleaning Schedule for May 2023 revealed: *The Refrigerator - Clean/Organize and Fans items were marked as being completed for Week 5. *The Store Room - Clean/Organize item was not marked as being completed that month. Review of the provider's 2018 Monthly Cleaning Schedule template revealed the following items were included: *Ceiling *Ceiling Lights and Covers - Clean *Drains - Clean *There were blank spaces to provide hand-written additions to the task list. Review of the provider's Monthly Cleaning Schedule for 2023 revealed: *Each task item on the list was initialed as being completed for Month 1 and Month 5. *The only items that were initialed for Month 2 and Month 3 were Ice Machine and FANS Manager Office - Clean. *For Month 4, the following items had initialed as being completed: -Ice Machine -Lowerator/Plate Warmers (Heavy Clean) -Fire Extinguishers - Wipe/Clean -Drains - Clean -FANS Manager Office - Clean. Review of the provider's 2017 Food Storage policy revealed: *Policy Statement: Food storage areas are maintained in a clean, safe, and sanitary environment. *Procedure: -1. Food storage areas are kept clean at all times. -5. Foods are dated with month and year of delivery to the Center. EXCEPTION: Food items with used by dates of less than 30 days (e.g. milk, cottage cheese, fresh bread, and produce) do not require labeling with the moth and year of delivery. -6. Food products are used within one year unless the manufacturer's expiration date is different. -10. Opened items have 'use by' dates indicated on them . May indicate date opened or date prepared if required by your survey agency. -11. The manufacturer's expiration date, when available, is the use by date for unopened items. Review of the provider's 2019 Sanitation policy revealed: *Policy Statement: The food service area is maintained in a clean and sanitary manner. *Procedure: -1. Kitchens, kitchen areas, and dining areas are kept clean, free from litter and rubbish, and protected from rodents, roaches, flies and other insects. -2. Utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks, corrosions, open seams, cracks, and chipped areas. -7. Cleaning schedules are developed by the FANS Manager or Person in Charge. -8. The FANS Manager or Person in Charge monitors compliance to the cleaning schedule.