Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen, which had the potential to affect 95 of 98 residents in the facility. The findings include: Review of the facility policy titled, Cleaning & Sanitation, dated 9/2/2020, showed .The Director of Food and Nutrition Services will develop, implement, and monitor schedules for cleaning, sanitizing, and maintenance .To ensure the food service department is maintained according to state and federal regulations as well as a clean, sanitary, and safe environment .The Director of Food and Nutrition Services monitors the completion of a cleaning schedule including all areas of the kitchen . During an observation on 7/23/2023 at with the Lead [NAME] (LC) at 10:40 AM, a tour of the kitchen was conducted and the following was observed: 1. The convection oven had brown dried food debris splatter present on the top and inside of both doors which occluded the view of both glass windows of the oven doors. The bottom ledge of the convection oven doors was also covered with the brown dried food debris. 2. The deep fryer was found with a large amount of food debris on the drain ledge which was present from the previous evenings use. 3. 1 Scoop was observed stored in each of the sugar and thickener (powered substance used to thicken liquids) storage bins. During an interview on 7/23/2023 at 11:10 AM, the LC confirmed the kitchen equipment was not in sanitary condition, and the scoops were in the sugar and thickener storage bins.The LC confirmed she was responsible for maintaining the cleanliness and oversight of the kitchen. During an interview on 7/23/2023 at 11:58 AM, the Certified Dietary Manager (CDM) confirmed the kitchen staff did ensure the cleaning and sanitization of kitchen equipment to include the convection oven and the deep fryer. The CDM confirmed the facility did not follow their policy and procedure for cleaning and sanitation of the facility kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Center for Medicare and Medicaid (CMS's) Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review, observation and interview the facility failed to develop a care plan for pain for 1 resident (#5) of 20 residents reviewed. The findings include: Review of CMS's RAI Version 3.0 Manual, dated 10/2018 revealed, .Identify and collect information that is needed to identify an individual's conditions that enables proper definition of their conditions, strengths, needs, risks, problems, and prognosis .Identify the individual's response to interventions and treatments . Medical record review revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes with Diabetic Neuropathy, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, and Spinal Stenosis. Medical record review of a Physician's order dated 7/4/19 revealed .PAIN: Monitor AND RECORD Q [every] SHIFT . Medical record review of a Physician's Order dated 7/18/19 revealed Oxycodone-Acetaminophen (medication to treat pain) 10-325 milligrams (mg). Give 1 tablet every 6 hours as needed for pain with a discontinue date of 7/25/19. Medical record review of a admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicated the resident was cognitively intact and received a scheduled pain medication regimen. Medical record review of a Physician's Order dated 10/9/19 revealed Oxycodone-Acetaminophen 10-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain with a discontinue date of 10/14/19. Medical record review of a Physician's Order dated 10/14/19 revealed Percocet Tablet (pain medication) 10-325 mg. Give 1 tablet by mouth every 6 hours for pain with a discontinue date of 10/31/19. Medical record review of a Physician's Order dated 10/31/19 revealed Percocet Tablet 10-325 mg. Give 1 tablet by mouth every 6 hours as needed for pain and a discontinue date of 11/2/19. Medical record review of the care plan dated 10/31/19 revealed Resident #5 was not care planned for pain. Medical record review of the Electronic Medication Administration record dated 7/18/19-11/2/19 revealed Resident #5 received pain medication as ordered. Observation of Resident #5 on 11/3/19 at 12:30 PM revealed the resident seated in the dining room eating his lunch meal independently. Continued observation revealed the resident exhibited no signs of pain or discomfort. Observation of the Resident #5 on 11/4/19 at 9:30 AM revealed the resident propelling himself in a wheelchair in the hallway. Continued observation revealed the resident exhibited no signs of pain or discomfort. Interview with the Director of Nursing on 11/4/19 at 3:30 PM, in the conference room, confirmed Resident #5 was administered regular scheduled pain medication and the facility had not developed a care plan for pain. Interview with the MDS/Care Plan Nurse on 11/4/19 at 3:45 PM, in the conference room, confirmed it was her responsibility to complete and revise care plans. Further interview confirmed Resident #5 was administered regular scheduled pain medication and the facility failed to develope a care plan for pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure a fall intervention was properly maintained for 1 resident (#64) of 3 residents reviewed for falls. The findings include: Review of the Facility's Incidents/Accidents/Falls Policy, undated, revealed .All falls will have a site investigation .to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence . Medical record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, End Stage Renal Disease, Dependence on Renal Dialysis, History of Falling, Hypertension, Chronic Respiratory Failure, and Abnormalities of Gait and Mobility. Medical record review of the facility's fall investigation dated 6/11/19 revealed .resident observed to be laying in floor next to the bed .Immediate action taken .low bed with mats . Medical record review of the Comprehensive Care Plan dated 6/11/19 revealed .bed in low position with mats at bedside . Observation on 11/4/19 at 8:20 AM, in resident's room, revealed Resident #64 lying in bed with the safety mat rolled up, lying in the floor, at the head of the bed. Observation on 11/5/19 at 8:27 AM, in resident's room, revealed the resident's safety mat was rolled up, lying in the floor, at the head of the bed. Interview with the Director of Nursing on 11/5/19 at 8:45 AM, in the resident's room, confirmed the safety mat should be extended at the resident's beside for the resident's safety.

Based on facility policies review, observation, and interview, the facility failed to maintain a sanitary kitchen in 1 of 1 walk in freezer observed, and failed to maintain resident foods in a sanitary manner in 1 of 2 nourishment rooms observed, potentially affecting 88 of 88 residents. The findings include: Review of the facility policy, Cold Storage Areas, dated 3/26/12 revealed .store cold food under safe and sanitary conditions .Date, label and properly secure all products . Review of the facility policy, Food Brought into Facility, dated 12/6/16 revealed .while maintaining the safety and sanitation requirements .set forth by local, federal and state regulations .Outside foods requiring storage .must be dated, labeled and stored per facility and state guidelines . Observation and interview with the head cook on 11/3/19 at 9:56 AM, in the kitchen main walk in freezer revealed: A). 1 box of 46 - 3.6 ounce frozen breaded fish fillets, approximately ¾ full, undated, open to air, and available for resident consumption. B). 1 box of 69 - 3.5 ounce frozen hamburger patties, approximately ½ full, undated, open to air, and available for resident consumption. C). 1 box of 159 frozen sausage links, approximately 1/3 full, undated, open to air, and available for resident consumption. Continued interview with the Certified Dietary Manager (CDM) in the CDM's office, on 11/4/19 at 8:20 AM, confirmed it is her expectation .when food is opened it is to be dated, labeled and sealed .we have zip lock baggies .to seal unused foods . Observation and interview with the CDM on 11/4/19 at 1:22 PM, in the Station 2 Nourishment Room revealed: A). 1 - half gallon container of strawberry and vanilla ice cream that was ½ full, opened, unlabeled, and undated in the freezer. B). 1 - pint container of vanilla ice cream that was ¾ full, opened, unlabeled, and undated in the freezer. Continued interview with the CDM on 11/4/19 at 1:22 PM, in the Station 2 Nourishment Room , confirmed the unlabeled and undated ice creams were brought in from the outside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to obtain a physician's order for the use of a Continuous Positive Airway Pressure (CPAP) machine (a continuous pressure machine to improve oxygen delivery in residents with sleep apnea) for 1 resident (#94) of 23 residents reviewed for respiratory treatments of 25 residents sampled. The findings include: Medical record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including Morbid Obesity, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Hypertension, and Sleep Apnea. Medical record review of the Physician's Recapitulation Orders dated 10/22/18 revealed .02 [oxygen] at 2L[liters] to maintain sats [oxygen saturation] over 90% [percent] . Continued review revealed no documentation of a physician's order for the use of a CPAP device. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident's health conditions included shortness of breath while lying, sitting, and on exertion. Continued review revealed the resident's respiratory treatments included the use of a CPAP machine. Observation of Resident #94 on 11/5/18 at 10:15 AM, in the resident's room, revealed a CPAP machine was located in the open top drawer of the resident's bedside table. Interview with the Director of Nursing (DON) on 11/7/18 at 8:23 AM, in the DON's office, confirmed the facility failed to obtain a physician's order for the use of a CPAP machine for Resident #94.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of manufacturer's recommendations, medical record review, observation, and interview, the facility failed to ensure a Continuous Positive Airway Pressure (CPAP) device (a continuous pressure machine to improve oxygen delivery in residents with sleep apnea) was cleaned for 1 resident (#94) of 23 residents reviewed for the use of respiratory equipment of 25 sampled residents. The findings include: Review of the CPAP manufacturer's user guide, undated, reveals .clean the device weekly .wash the water tub and air tubing in warm water using mild detergent .rinse and allow to dry .wipe with a dry cloth .Facemask cleaning .daily-after each use-disassemble the mask components .hand wash mask .use soft bristle brush to clean the vent .rinse with drinking quality water and allow to air dry .weekly-hand wash the headgear and soft sleeves . Medical record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including Morbid Obesity, Chronic Kidney Disease, Chronic Obstructive Pulmonary Disease, Hypertension, and Sleep Apnea. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident's health conditions included shortness of breath while lying, sitting, and on exertion. Continued review revealed the resident's respiratory treatments included the use of a CPAP machine. Observation of Resident #94 on 11/5/18 at 10:15 AM, in the resident's room, revealed a CPAP machine with the tubing connected to the facemask and headgear located in the open top drawer of the resident's bedside table. Interview with Licensed Practical Nurse #1 on 11/7/18 at 8:21 AM, at the 200 hallway nurse's station, confirmed .nursing don't document any type of cleaning of the machine that I am aware of . Interview with the Director of Nursing (DON) on 11/7/18 at 2:04 PM, in the DON's office, confirmed the facility failed to clean and sanitize the CPAP per the manufacturer's guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review of Resident #49's Plan of Care dated 7/27/18 revealed .Goal .Resident will have a regular bowel elimination pattern as evidenced by soft/formed bowel movements at least once every three days . Medical record review of the resident's BM Report dated 9/2018, revealed the resident did not have a BM from 9/12/18 to 9/18/18 (7 days). Continued review of the BM Report dated 10/2018, revealed the resident did not have a BM from 10/4/18 to 10/10/18 (7 days). Medical record review of Resident #49's MAR for 9/2018 and 10/2018 revealed no documentation the resident received a laxative or an enema. Telephone interview with Resident #49's physician on 11/7/18 at 12:50 PM, confirmed he would have expected the facility to implement the physician's standing order for acute constipation for Resident #49. Interview with the DON on 11/7/18 at 1:03 PM, in the conference room, confirmed the facility failed to follow a physician's order for Resident #49. Based on review of the physician's standing orders, medical record review, and interview, the facility failed to implement a bowel protocol for 2 residents (#30 and #49) of 3 residents reviewed for constipation of 25 sampled residents. The findings include: Review of a Physician's Standing Orders, undated, revealed .MEDICATION PROTOCOL .5. Acute Constipation: Check for hard stool, remove if present. LOC [laxative of choice] .or soapsuds enema if no BM [bowel movement] > [greater than] 3 days. 6. Chronic Constipation: Check for hard stool; remove if present. Colace 100 mg [milligrams] po [by mouth] bid [twice a day] . Medical record review revealed Resident #30 was admitted to the facility on [DATE] with diagnoses including Hemiplegia, Cerebral Infarction, and Drug Induced Constipation. Medical record review of the resident's Plan of Care dated 8/30/18 revealed .has an alteration in elimination due to bowel incontinence .Goal .resident will have a regular bowel movements at least once every three days . Medical record review of the resident's BM report dated 9/2018, revealed the resident did not have a BM from 9/21/18 to 9/24/18 (4 days). Medical record review of Resident #30's medication administration record (MAR) dated 9/2018, revealed no documentation the resident received a laxative or an enema. Interview with the Director of Nursing (DON) on 11/7/18 at 1:12 PM, in the DON's office, confirmed the facility failed to follow a physician's order for Resident #30.