Based on observation, staff interview and facility document review, the facility staff failed to ensure food items available for use were used or discarded prior to the best when used by date, in one of eight small house kitchens, the occoquan kitchen. The findings include: The facility staff failed to store mayonnaise in a safe manner. Five (12 ounce) bottles of unopened mayonnaise with a manufacturer's best when used by date of 2/12/23 were observed in the occoquan kitchen pantry. On 4/3/23 at 12:12 p.m., observation of the occoquan kitchen was conducted. Five (12 ounce) bottles of unopened mayonnaise with a manufacturer's best when used by date of 2/12/23 were observed available for use, on the shelf, in the pantry. On 4/4/23 at 9:56 a.m., an interview was conducted with OSM (other staff member) #5, the sous chef. OSM #5 stated unopened mayonnaise should be discarded after the best when used by date. OSM #5 stated, I don't want residents to get sick, and the quality has gone down. On 4/4/23 at 4:35 p.m., ASM (administrative staff member) #2, the interim administrator, ASM #3, the director of nursing, and OSM (other staff member) #6, the director of dining services, were made aware of the above concern. The facility policy titled, Intake and Storage of Food documented, 4. Before use food will be checked for expiration date and discarded if expired.

Based on staff interview, facility document review and clinical record review, the facility staff failed to implement the comprehensive care plan for two of 26 residents in the survey sample, Residents #56 and #28. The findings include: 1. For Resident #56 (R56), the facility staff failed to implement the resident's comprehensive care plan for psychotropic drug use monitoring. R56's comprehensive care plan dated 9/27/22 documented, Psychotropic Drug Use .observe for side effects . A review of R56's clinical record revealed a physician's order dated 11/3/22 for quetiapine (1) 50 mg (milligrams) twice daily. A review of R56's MARs (medication administration records) for January 2023 through April 2023 revealed the resident was administered quetiapine 50 mg twice daily 1/1/23 through 4/2/23. Further review of R56's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for January 2023 through April 2023) failed to reveal the resident was observed for side effects from the medication quetiapine. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2, in regard to the comprehensive care plan. RN #2 stated, It's sort of like an outline for the patient's care so everybody can be on the same page. Everybody can be on the same page for the goals and for everyone from interdisciplinary teams to see what the plan is for this resident . RN #2 stated residents' care plans are available for nurses to review. In regard to psychotropic medication use, RN #2 stated residents should be monitored for side effects from psychotropic medications and this should be documented in the ID notes (nurses' notes). On 4/4/23 at 4:42 p.m., ASM (administrative staff member) #2, the interim administrator, and ASM #3, the interim director of nursing, were made aware of the above concern. The facility policy titled, Resident Centered Care Planning documented, Care plan interventions provide direction to the nursing and interdisciplinary staff regarding specific actions and treatments identified as useful or necessary in helping the resident achieve established goals and objectives. Reference: (1) Quetiapine is used to treat schizophrenia, bipolar disorder and depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html. 2. For Resident #28 (R28), the facility staff failed to implement the resident's comprehensive care plan for psychotropic drug use monitoring. R28's comprehensive care plan dated 3/12/23 documented, Psychotropic Drug Use .monitor for side effects . A review of R28's clinical record revealed a physician's order dated 3/9/23 for citalopram (1) 10 mg (milligrams) once daily. A review of R28's MARs (medication administration records) for March 2023 and April 2023 revealed the resident was administered citalopram once daily 3/10/23 through 4/2/23. Further review of R28's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for March 2023 and April 2023) failed to reveal the resident was monitored for side effects from the medication citalopram. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2, in regard to the comprehensive care plan. RN #2 stated, It's sort of like an outline for the patient's care so everybody can be on the same page. Everybody can be on the same page for the goals and for everyone from interdisciplinary teams to see what the plan is for this resident . RN #2 stated residents' care plans are available for nurses to review. In regard to psychotropic medication use, RN #2 stated residents should be monitored for side effects from psychotropic medications and this should be documented in the ID notes (nurses' notes). On 4/4/23 at 4:42 p.m., ASM (administrative staff member) #2, the interim administrator, and ASM #3, the interim director of nursing, were made aware of the above concern. Reference: (1) Citalopram is used to treat depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699001.html.

Based on staff interview, facility document review and clinical record review, the facility staff failed to ensure residents were free from unnecessary psychotropic medications for two of 26 residents in the survey sample, Residents #56 and #28. The findings include: 1. For Resident #56 (R56), the facility staff failed to monitor the resident for side effects from the antipsychotic medication quetiapine (1). A review of R56's clinical record revealed a physician's order dated 11/3/22 for quetiapine 50 mg (milligrams) twice daily. A review of R56's MARs (medication administration records) for January 2023 through April 2023 revealed the resident was administered quetiapine 50 mg twice daily (1/1/23 through 4/2/23). Further review of R56's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for January 2023 through April 2023) failed to reveal the resident was monitored for side effects from the medication quetiapine. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated residents should be monitored for side effects from psychotropic medications and this should be documented in the ID notes (nurses' notes). On 4/4/23 at 4:42 p.m., ASM (administrative staff member) #2, the interim administrator, and ASM #3, the interim director of nursing, were made aware of the above concern. The facility policy titled, Antipsychotic Medication Use documented, 17. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmias; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA (transient ischemic attack). Reference: (1) Quetiapine is used to treat schizophrenia, bipolar disorder and depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a698019.html. 2. For Resident #28 (R28), the facility staff failed to monitor the resident for side effects from the antidepressant medication citalopram (1). A review of R28's clinical record revealed a physician's order dated 3/9/23 for citalopram 10 mg (milligrams) once daily. A review of R28's MARs (medication administration records) for March 2023 and April 2023 revealed the resident was administered citalopram once daily (3/10/23 through 4/2/23). Further review of R28's clinical record (including the MARs, behavior sheets, assessments, and nurses' notes for March 2023 and April 2023) failed to reveal the resident was monitored for side effects from the medication citalopram. On 4/4/23 at 3:17 p.m., an interview was conducted with RN (registered nurse) #2. RN #2 stated residents should be monitored for side effects from psychotropic medications and this should be documented in the ID notes (nurses' notes). On 4/4/23 at 4:42 p.m., ASM (administrative staff member) #2, the interim administrator, and ASM #3, the interim director of nursing, were made aware of the above concern. Reference: (1) Citalopram is used to treat depression. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a699001.html.

Based on observation, staff interview and facility document review, the facility staff failed to maintain the dumpster area in a clean and sanitary manner for one of one dumpster. The findings include: The facility staff failed to maintain the dumpster area in a clean and sanitary manner. Trash and debris were observed on the ground around the dumpster. On 4/4/23 at 9:45 a.m., observation of the dumpster was conducted with OSM (other staff member) #2, the registered dietitian, and OSM #4, a cook. Trash and debris (including four gloves that were folded inside out, saran wrap, paper debris, an empty specimen cup, a plastic drink cup and a plastic drink cup lid) were observed on the ground around the dumpster. OSM #4 stated the utility department staff goes out to the dumpster to dump trash every hour or so and they should make sure there is not all of that debris around the dumpster. On 4/4/23 at 4:35 p.m., ASM (administrative staff member) #2, the interim administrator, ASM #3, the director of nursing, and OSM (other staff member) #6, the director of dining services, were made aware of the above concern. The facility policy titled, Disposing of Garbage and Refuse documented, 2. Waste must be properly contained and covered in dumpsters/compactors .5. The garbage storage area must be maintained in a sanitary condition to prevent the harborage and feeding of pests .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review it was determined facility staff failed Store, food in accordance with professional standards for food service safety in one of eight kitchens observed, [NAME] small house kitchen. The facility failed to dispose of plain Greek yogurt with a best by date of 9/19/21 and honey mustard dressing with a use by date of 1/13/21 located on the [NAME] small house kitchen. The findings include: On 10/12/2021 at approximately 1:30 p.m., an observation was made of the [NAME] small house kitchen in the facility. Observation of the French door refrigerator located in the kitchen area revealed an unopened 32 ounce container of plain Greek yogurt. The container was observed to have the manufacturers date documenting Best by 19 [DATE]. Observation of the standing side by side refrigerator/freezer located in the pantry area of the [NAME] small house kitchen revealed a one gallon container of honey mustard dressing approximately one-quarter full. The container was observed to have a manufacturer's date of mfg: 21/Jan/2020 with a facility label documenting prep date: 12/13/20, Use by: 1/13/21. On 10/12/2021 at 1:44 p.m., an interview was conducted with CNA (certified nursing assistant)/Care Partner #1. CNA #1 stated that they worked in the [NAME] small house kitchen serving resident meals and maintaining the kitchen area. CNA #1 stated that they checked for expired items each morning prior to breakfast and the night shift staff also checked for any expired items or food items that may have gone bad. CNA #1 observed the 32 ounce container of plain Greek yogurt and stated that they used the manufacturer's best by date on the container as the date to discard items. CNA #1 stated that the container with the best by date of 19 [DATE] should have been discarded and not available for use in the refrigerator. CNA #1 observed the one gallon container of honey mustard dressing with the label documenting use by 1/13/21 and stated that they only kept dressings for one month after opening and they were not sure how that container was not caught during their checks. CNA #1 stated the container was approximately one-quarter full. On 10/13/2021 at 3:07 p.m., an interview was conducted with OSM (other staff member) #1, executive chef and OSM #2, the director of dining. OSM #2 stated that they had checks in place to ensure expired items were removed promptly. OSM #2 stated that the cooks came in and checked the kitchens once a day and the overnight care partner staff had a checklist in place to complete. OSM #2 stated that any opened refrigerated items were dated when opened. OSM #2 stated that they dated the one gallon dressing containers with the first day of prep and then a one month use by date. OSM #2 stated that some of the products did not come with an expiration date or a best by date and that was the reason for their labeling system. OSM #2 stated that products that had a best by date from the manufacturer were discarded on that date. OSM #2 stated that they used the best by date as the expiration date. On 10/13/2021 at approximately 3:15 p.m., a request was made to OSM #1 and OSM #2 for the manufacturer's recommendations for shelf life storage of the one gallon honey mustard dressing after opening and for the best by dates on the plain Greek yogurt. On 10/13/2021 at 4:20 p.m., OSM #1 stated that they had checked with the manufacturer regarding the one gallon dressing containers and they did not provide any specific guidelines for shelf life after opening so they followed their policy of discarding after one month. OSM #1 stated that the manufacturer also did not have any specific guidelines for use regarding the best by dates and both items should have been discarded prior to 10/12/2021. On 10/13/2021 at approximately 10:00 a.m., a request was made to ASM (administrative staff member) #2, the director of nursing for the facility policy on storage of refrigerated food items in the kitchen. The facility policy Intake and Storage of Food dated 4/1/2017 documented in part, .Before use food will be checked for expiration date and discarded if expired . On 10/13/2021 at approximately 4:45 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the director of nursing were made aware of the findings. No further information was provided prior to exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility document review and clinical record review, it was determined that the facility staff failed to serve food in a manner to promote dignity for one of 31 residents in the survey sample, Resident # 37. During a dining observation, in the [NAME] household unit dining room, Resident # 37 was observed sitting at the dining room table and waiting 23 minutes to be served and assisted with eating his meal by staff, while watching seven residents seated at the table with him, eat their dinner. The findings include: Resident # 37 was admitted to the facility on [DATE] and a readmission on [DATE] with diagnoses that included but were not limited to: Alzheimer's disease (1), dysphagia (2), atrial fibrillation (3) and chronic respiratory failure (4). Resident # 37's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/04/18, coded Resident # 37 as scoring a 3 (three) on the brief interview for mental status (BIMS) of a score of 0 - 15, 3 (three) - being severely impaired of cognition for making daily decisions. Resident # 37 was coded as requiring total dependence for activities of daily living of one staff member and as requiring extensive assistance of one staff member for eating. The comprehensive care plan for Resident # 37 dated 03/20/2018 documented, ADL Function: Self-neglect related to advanced dementia AEB (as evidenced by) (Resident # 37) requires total assistance with bed mobility, transferring, toileting, dressing, grooming, bathing and eating r/t (related to) cognitive impairment due to advanced dementia, decline, [sic] Osteoarthritis and degenerative disk disease. Start Date: 03/20/2018. Under Intervention it documented, Provide 1:1 (one to one) assistance with feeding r/t dysphagia and Alzheimer's Dementia. Start Date: 03/20/2018. On 01/29/19 at 5:06 p.m., an observation was conducted of the [NAME] household unit dining room. An observation of the dining room table revealed eight residents were seated at the table, 7 women and Resident # 37. At 5:22 p.m., salads were served to the seven women and they began eating; Resident # 37 seated at the end of the table had a glass of juice and a glass of water and a place setting in front of him on the table. Further observation revealed Resident # 37 had not receive a salad nor had he received a sip if his water or juice. At 5:38 p.m., the seven women were served the main meal consisting of pot roast, potatoes and squash and began eating; Resident # 37 seated at the end of the table still had a glass of juice and a glass of water and a place setting in front of him on the table. Further observation revealed Resident # 37 did not receive the main meal nor had he received a sip of his water or juice. At 5:44 p.m., a staff member placed Resident # 37's meal in front of him. At 5:45 p.m., a staff member sat down next to Resident # 37 and began assisting Resident # 37 with his food and drink. Resident # 37 sat at the dining room table and waited approximately 23 minutes before his meal was provided and a staff member to begin to assisting him with eating, while watching the other seven residents seated at the table with him, eat their dinner. On 01/29/19 at approximately 5:55 p.m., an interview was conducted with CNA (certified nursing assistant) # 3. When asked why Resident # 37 had to wait approximately 23 minutes to eat when everyone else was eating, CNA # 3 stated, They should not have to wait. We serve the ladies first and serve (Resident # 37) within five or ten minutes. When asked if it was appropriate and dignified for Resident # 37 to wait over 20 minutes to eat while everyone else at the table was eating, CNA # 3 stated, No. He requires one to one assistance; he should be eating at the same time as everyone else. The facility's RESIDENT RIGHTS documented, 15. The right to be treated with courtesy, respect and dignity. On 01/30/19 at approximately 5:45 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of clinical services were made aware of the findings. No further information was provided prior to exit. References: (1) A brain disorder that seriously affects a person's ability to carry out daily activities). This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/alzheimersdisease.html. (2) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (3) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. (4) When not enough oxygen passes from your lungs into your blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/respiratoryfailure.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review, and clinical record review, it was determined that the facility staff failed to meet the appropriate transfer requirements for three of 31 residents in the survey sample; Resident # 46, # 21, and # 69. 1. The facility staff failed to evidence that Resident #46's comprehensive care plan goals were sent with the resident to the hospital for the facility initiated transfer dated 01/06/2019. 2. The facility staff failed to evidence that Resident # 21's comprehensive care plan goals were sent with the resident to the hospital for facility initiated transfer dated 01/07/2019. 3. The facility staff failed to provide the receiving facility with the Resident #69's comprehensive care plan goals for a facility initiated transfer to hospital that occurred on 12/11/18. The findings include: 1. The facility staff failed to evidence that Resident #46's comprehensive care plan goals were sent with the resident to the hospital for the facility initiated transfer dated 01/06/2019. Resident # 46 was admitted to the facility on [DATE] with a readmission of 01/09/19 with diagnoses that included but were not limited to pain, hemiplegia (1), type 2 (two) diabetes (2), dementia (3) gastroesophageal reflux disease (4), and hypertension (5). Resident # 46's most recent MDS (minimum data set), 5 (five)-day assessment with an ARD (assessment reference date) of 01/16/19, coded Resident # 46 as scoring a 2 (two) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 2 (two) - being moderately impaired of cognition for making daily decisions. Resident # 46 was coded as requiring extensive assistance of one staff member for activities of daily living. The nurse's Progress Notes, dated 01/06/2019 for Resident # 46 documented, Around 1800 (6:00 p.m.), writer was notified by charge nurse of resident's hypoglycemia episode. Upon assessment, resident noted lethargic, difficult to arouse with verbal stimulation touch, noted with SOB (shortness of breath), and expiratory wheezing, O2 (oxygen) 2L (two liters) administered, neb (nebulizer) tx (treatment) administered but wheezing continues. Message sent to urgent care, resident sent to (Name of Hospital) ER (emergency room) via (by) 911 with RP (responsible party) (Name of Responsible Party) at bedside. Bed hold policy and notice of transfer given to RP. Call placed to (Name of Hospital) ER at 2255 (10:55 p.m.), resident is being admitted for AMS (altered mental status) and acute asthma. Review of the facility's Health & (and) Emergency/EMS (emergency medical services) Transport Information dated 01/06/19 for Resident # 46 failed evidence documentation that the residents comprehensive care plan goals were sent to (Name of Hospital) for this facility initiated transfer of Resident # 46. On 01/31/19 at 8:19 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services. When asked to describe the process followed for a facility initiated transfer of a resident to the hospital, ASM # 2 stated, Obtain the physician's order, talk to resident and/or the responsible party about the transfer, proved bed hold, complete a transfer form-,call rescue, and they are transported. Notification to the ombudsman is done by the social worker, and the care plan goals are part of the transfer form. After review of Resident # 46's Health & (and) Emergency/EMS (emergency medical services) Transport Information dated 01/06/19, ASM # 2 agreed the form failed evidence documentation that the residents comprehensive care plan goals were sent to the receiving facility at the time of Resident # 46's facility initiated transfer on 01/06/19. The facility's policy Facility-initiated Transfer documented, Procedure: 1. The licensed nurse (Nursing Supervisor or designee) will provide the receiving providers (hospital) with the following information upon transfer. e. Comprehensive Care Plan Goals. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (3) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. (4) Stomach contents to leak back, or reflux, into the esophagus and irritate it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/gerd.html. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 2. The facility staff failed to evidence that Resident # 21's comprehensive care plan goals were sent with the resident to the hospital for facility initiated transfer dated 01/07/2019. Resident # 21 was admitted to the facility on [DATE] with a readmission of 01/10/19 with diagnoses that included but were not limited to pain, hyperlipidemia (1), cerebral infarction (2), and asthma (3). Resident # 21's most recent MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 01/23/19, coded Resident # 21 coded as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15- being cognitively for making daily decisions. Resident # 21 was coded as requiring extensive assistance of one staff member for activities of daily living. A nurse's Progress Notes, dated 01/07/2019 for Resident # 21 at 1605 (4:05 p.m.) documented, Physician transport with two crew from (Name of Doctor ' s Office) arrived at 1430 (2:30 p.m.), Resident is transferred from her bed to a stretcher by the crew, she is transferred to (Name of Hospital) at 1510 (3:10 p.m.). Writer called (Name of Hospital) and gave report to (Name of Nurse). Completed EMS (emergency medical service) form, immunization, Transfer to and from form, reason for transfer (nurse ID note), labs (laboratory results), insurance card, medication list sent with resident. Review of the facility's Health & (and) Emergency/EMS (emergency medical services) Transport Information dated 01/07/19 for Resident # 21 failed evidence documentation that the care plan goals were sent to (Name of Hospital) upon the facility initiated transfer of Resident # 21. On 01/31/19 at 8:19 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services. When asked to describe the process followed for a facility initiated transfer of a resident to the hospital, ASM # 2 stated, Obtain the physician's order, talk to resident and/or the responsible party about the transfer, proved bed hold, complete a transfer form-,call rescue, and they are transported. Notification to the ombudsman is done by the social worker, and the care plan goals are part of the transfer form. After review of Resident # 21's Health & (and) Emergency/EMS (emergency medical services) Transport Information dated 01/06/19 ASM # 2 agreed the form failed to evidence the residents comprehensive care plan goals were sent to the receiving facility at the time of Resident # 21's facility initiated transfer on 01/07/19. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) Cholesterol is a fat (also called a lipid) that your body needs to work properly. Too much bad cholesterol can increase your chance of getting heart disease, stroke, and other problems. The medical term for high blood cholesterol is lipid disorder, hyperlipidemia, or hypercholesterolemia. This information was obtained from the website: https://medlineplus.gov/ency/article/000403.htm. (2) A stroke. When blood flow to a part of the brain stops. A stroke is sometimes called a brain attack. If blood flow is cut off for longer than a few seconds, the brain cannot get nutrients and oxygen. Brain cells can die, causing lasting damage. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm . (3) A disease that causes the airways of the lungs to swell and narrow. It leads to wheezing, shortness of breath, chest tightness, and coughing. Information was obtained from the website: https://medlineplus.gov/ency/article/000141.htm. 3. The facility staff failed to provide the receiving facility with the Resident #69's comprehensive care plan goals for a facility initiated transfer to hospital that occurred on 12/11/18. Resident #69 was admitted to the facility on [DATE], with the diagnoses of but not limited to: cervical fracture, aphasia, diabetes, glaucoma, high blood pressure, hypothyroidism, Lyme disease, macular degeneration, and psoriasis. The most recent MDS (Minimum Data Set) was an admission assessment with an ARD (Assessment Reference Date) of 12/26/18. The resident was coded as being cognitively intact in ability to make daily life decisions. A review of the clinical record revealed nurses notes dated 12/11/18, that documented Resident #69 was transferred to the hospital. The note documented in part, No improvement seen, condition remain the same. All paper work in place, Staff at bedside, resident shows no distress. 911 call, family updated. Further review of the clinical record failed to reveal evidence that the comprehensive care plan goals were provided to the receiving hospital. On 1/31/19 at 8:20 a.m., in an interview with ASM #2 (Administrative Staff Member - the Director of Nursing - DON), she stated that the information documented on the hospital transfer form is reflective of what the care plan goals are. She provided a copy of this document as it was completed for Resident #69 on 12/11/18. This document included demographic information, insurance information, Living Will / Do Not Resuscitate information. The document included, Medical Condition which was not completed Medical History which was not completed, allergies, Medications which was not completed, immunizations status, Mobility abilities, assistive devices such as hearing aids and glasses, emergency contact information, and a hand written notation of the general reason the resident was being sent to the hospital. There was nothing-documenting comprehensive care plan goals, and the information provided was incomplete and insufficient to address the goals of the comprehensive care plan. On 1/31/19 at 10:46 a.m., in an interview with RN #3 (Registered Nurse) when asked if care plan goals are sent to the hospital when a resident is transferred, RN #3 stated, We have not sent them to the hospital. On 1/31/19 at 10:52 a.m., in an interview with RN #2, she stated, We send the care plan goals. We were inserviced 2 weeks ago. When asked if the comprehensive care plan goals were being sent in December 2018 when Resident #69 went to the hospital, RN #2 stated, I can't say if care plan goals were sent in December. It was a new inservice (the one from 2 weeks ago). I don't remember sending it back then. At this time, RN #2 showed the inservice information she received to this writer. It documented the following: Checklist for Facility-Initiated Transfers to Hospital 1. The licensed nurse (nursing supervisor or designee) will provide the hospital with the following information: * Print EMS form and complete to include: Immunizations Transfer to and from Reason for transfer Any other pertinent information (such as labs or x-ray) * Print Advanced Directives from (facility electronic system) * Print Insurance cards from (facility electronic system) * Print Medication list from (facility electronic system) 2. The licensed nurse (nursing supervisor or designee) will provide the resident (and resident responsible party if present): * Print Bed Hold notice * Print and complete notice of transfer or Discharge form 3. The licensed nurse will document in the electronic record that all the items were provided and family notified. 4. The licensed nurse will make a copy of the EMS form, Notice of Transfer or Discharge form, and checklist. Copies are to be put in the ADON [assistant director of nursing] office for review. On 1/31/19 at 11:08 a.m., in an interview with RN #2, after reviewing the above document she provided, when asked if it addresses anything about sending the comprehensive care plan goals, RN #2 stated, It doesn't. No further information was provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and clinical record review, it was determined that the facility staff failed to complete a discharge minimum data set (MDS) assessment for one of 31 residents in the survey sample; Resident #2. Resident #2 expired in the facility on [DATE]. The most recent MDS in the facility's system was a quarterly MDS with an ARD (assessment reference date) of [DATE]. As of [DATE], the date of the survey, there had been no discharge MDS assessment completed. The findings include: Resident #2 was admitted to the facility on [DATE] with the diagnoses of but not limited to high blood pressure, hypothyroidism, heart disease, chronic kidney disease, and Rheumatoid Arthritis. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of [DATE]. The resident was coded as mildly cognitively impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for transfers, dressing, and toileting; limited assistance for hygiene; supervision for eating; and was continent of bowel and bladder. A review of the clinical record revealed a nurse's note dated [DATE] that documented, At 0605 (6:05 a.m.) when this nurse was doing rounds observed resident unresponsive, no BP (blood pressure) no pulse, no respirations. Writer called nurse supervisor, he came immediately assessed resident pronounced her death. Resident was last seen at 0400 (4:00 a.m.) during rounds sleeping bed comfortably with no distress. At 0520 (5:20 a.m.) care partner (certified nursing assistant) took resident to bath room and helped transferred to bed comfortably A review of the clinical record failed to reveal any evidence of a discharge, death in facility MDS assessment. On [DATE] at 5:14 p.m., in an interview with RN #4 (Registered Nurse) the MDS coordinator, she stated, You are right, it wasn't done. She stated the facility has 7 days to complete the MDS after discharge and then another 14 days to submit it. RN #4 stated it should have been done by approximately [DATE]. RN #4 stated it was not done because it did not show up on her calendar as an incomplete/missed MDS. On [DATE] at 6:01 p.m., RN #4 was asked about the policy used by the facility to complete MDS assessments, RN #4 stated the RAI Manual (Resident Assessment Instrument). On [DATE] at 6:01 p.m., the ASM (administrative staff member) #1, the Administrator and ASM #2, director of clinical services were made aware of the findings. No further information was provided. According to the RAI Manual, [DATE], page 2-10, Death In Facility refers to when the resident dies in the facility or dies while on a leave of absence (LOA) (see LOA definition). The facility must complete a Death in Facility tracking record. No Discharge assessment is required. And, on page 2-18 in a table, was documented that the Death in Facility MDS must be completed no later than death date plus 7 calendar days, and submitted by death date plus 14 calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review it was determined that the facility staff failed to ensure the comprehensive care plan was implemented for two of 31 residents in the survey sample, Resident # 72 and Resident #70. 1. During multiple observations, Resident #72 was receiving oxygen at 2 (two) and a half, liters instead of the 2 L (two liters) ordered by the physician and per the residents comprehensive care plan. 2. The facility staff failed to implement Resident #70's comprehensive care plan to offer non-pharmacological pain relief methods as needed and prior to the administering as needed pain medication to Resident #70. The findings include: 1. Resident # 72 was admitted to the facility on [DATE] with a readmission [DATE] with diagnoses, which included but were not limited to: heart failure (1), atrial fibrillation (2), dysphagia (3) and pleural effusion (4). Resident # 72's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/27/18, coded Resident # 72 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. Resident # 72 was coded as requiring limited to extensive assistance of one staff member for activities of daily living. Under section O. Special Treatment, Procedures and Programs Resident # 72 was coded for C. Oxygen therapy. The POS (physician's order sheet) for Resident # 72 dated 01/30 2019documented, Continuous O2 (oxygen) therapy at 2/L (two liters) via (by) NC (nasal cannula) for SOB (shortness of breath) / COPD (chronic obstructive pulmonary disease). Order Date: 09/10/2018. The comprehensive care plan for Resident # 72 dated 03/13/2018 documented, Ineffective airway clearance related to COPD, pneumonia, parapneumonic right pleural effusion as evidenced by: increased coughing, oxygen saturation dropping with exertion. Under Interventions it documented, Continuous O2 (oxygen) therapy at 2/L (two liters) via (by) NC (nasal cannula) On 01/29/19 at 12:22 p.m., an observation of Resident # 72 revealed she was sitting up in an armchair reading the paper receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate was set at two and a half liters per minute. On 01/30/19 at 7:59 a.m., an observation of Resident # 72 revealed she was lying in bed receiving oxygen by nasal cannula. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two and a half liters per minute. 01/31/19 at 7:42 a.m., an observation of Resident # 72 revealed she was lying in bed awake receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two and a half liters per minute. On 01/31/19 at 7:44 a.m., an observation of Resident # 72's oxygen concentrator and interview was conducted with LPN (licensed practical nurse) # 3. When asked how to read the flow rate on the oxygen concentrator LPN # 3 stated, The liter line should be in the middle of the ball. When asked to read the flow rate on the oxygen concentrator for Resident # 72, LPN # 3 stated, It's at two and a half liters. When asked what physician's order was for Resident # 72's oxygen, LPN # 3 stated Two liters. When asked how often the flow rate on oxygen concentrators is checked, LPN # 3 stated, Every shift. According to Fundamentals of Nursing [NAME] and [NAME] 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care (5) On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. Reference: (1) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. (2) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. (3) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (4) A buildup of fluid between the layers of tissue that line the lungs and chest cavity. This information was obtained from the website: https://medlineplus.gov/ency/article/000086.htm. (5) Fundamentals of Nursing [NAME] & [NAME] 2007 [NAME] Company Philadelphia pages 65-77 2. The facility staff failed to implement Resident #70's comprehensive care plan to offer non-pharmacological pain relief methods as needed and prior to the administering as needed pain medication to Resident #70. Resident # 70 was admitted to the facility on [DATE] with a readmission of 06/26/17 with diagnoses that included but were not limited to heart disease (1), atrial fibrillation (2), atherosclerosis (3) anemia (4), and hypertension (5). Resident # 70's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/18, coded Resident # 70 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15- being cognitively for making daily decisions. Resident # 70 was coded as requiring limited to extensive assistance of one staff member for activities of daily living. Section J Health Considerations coded Resident # 70 as having occasional moderate pain. The comprehensive care plan for Resident # 70 dated 03/30/2018 documented, Category : 019 Pain. Impaired comfort R/T (related to) lumbar spondylosis. Under Interventions it documented, Offer non-pharmacological pain relief methods as needed. Start Date: 03/30/2018. The Physician's Order Sheet for resident # 70 dated 01/30/2019 documented, Tramadol 50MG [6] (milligram) tablet- Give ½ (half) tab (tablet (25 MG) Every 8 (eight) hours) as needed for moderate to severe pain. Start Date: 10/25/18. The eMAR (electronic medication administration record) dated 01/2019 for Resident # 70 documented, Tramadol 50MG [6] (milligram) tablet- Give ½ (half) tab (tablet (25 MG) Every 8 (eight) hours) as needed for moderate to severe pain. Start Date: 10/25/18. Review of the eMAR revealed Tramadol 50mg was administered on the following dates: - 01/01/19 at 5 300 a.m., with a pain level of six, - 01/02/19 at 12:27 a.m., with a pain level of seven, - 01/04/19 at 2:13 a.m., with a pain level of six, - 01/05 at 11:30 a.m., with a pain level of seven, - 01/07/19 at 1:50 a.m., with a pain level of six, - 01/08/19 at 2:00 a.m. with a pain level of five, - 01/09/19 at 2:40 a.m., with a pain level of five, - 01/10/19 at 3:30 a.m., with a pain level of six, - 01/14/19 at 11:01 a.m., with a pain level of eight, - 01/18/19 at 5:32 a.m., with a pain level of four, - 01/19/19 at 3:07 a.m. with a pain level of six, - 01/20/19 at 4:30 a.m., with a pain level of seven, - 01/23/19 at 5:11 a.m., with a pain level of six and on - 01/27/19 at 4:13 a.m., with a pain level of six. Further review of the eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of Tramadol. Review of the nurse's progress notes for Resident # 70 dated 01/01/19 through 01/29/19 failed to evidence documentation of non-pharmacological interventions prior to the administration of acetaminophen. On 01/31/19 at 9:58 a.m., an interview was conducted with LPN (licensed practical nurse) # 2. When asked to describe the procedure for assessing a resident's pain, LPN # 2 stated, Ask them (resident) on a scale of 1 (one) to 10 how severe the pain is, given the rate of pain I would give what has been prescribed. I would do vitals and ask the location of the pain and would try to alleviate the pain before giving the pain medication but if the pain level is high I would just give the pain medication. When asked how often non-pharmacological interventions should be attempted, LPN # 2 stated, Every time except when the pain level is high. When asked where the non-pharmacological interventions attempted are documented, LPN # 2 stated, In the notes (nurse's notes) and if it above a four I don't try anything but I don't document it all the time. When it isn't documented I can't say it was done. On 01/31/19 at 10:21 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services regarding the implementation and documentation of non-pharmacological intervention prior to the administration of as needed pain medication. ASM # 2 stated, Should be attempted prior to the administration of PRN (as needed) pain meds (medication and documented in the nurse's notes. According to Fundamentals of Nursing [NAME] and [NAME] 2007 pages 65-77 documented, A written care plan serves as a communication tool among health care team members that helps ensure continuity of care .The nursing care plan is a vital source of information about the patient's problems, needs, and goals. It contains detailed instructions for achieving the goals established for the patient and is used to direct care (6) On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) There are many different forms of heart disease. The most common cause of heart disease is narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart itself. This is called coronary artery disease and happens slowly over time. It's the major reason people have heart attacks. Other kinds of heart problems may happen to the valves in the heart, or the heart may not pump well and cause heart failure. Some people are born with heart disease. This information was obtained from the website: https://medlineplus.gov/heartdiseases.html. (2) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. (3) A disease in which plaque builds up inside your arteries. Plaque is a sticky substance made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. That limits the flow of oxygen-rich blood to your body. This information was obtained from the website: https://medlineplus.gov/atherosclerosis.html. (4) Low iron. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anemia.html. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. (6) Fundamentals of Nursing [NAME] & [NAME] 2007 [NAME] Company Philadelphia pages 65-77

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review it was determined that the facility staff failed to ensure respiratory care and services were provided in accordance with professional standard of practice and the comprehensive person-centered care plan for one of 31 residents in the survey sample, Resident # 72. The facility staff failed to administer Resident # 72's oxygen according to the physician's orders. The findings include: Resident # 72 was admitted to the facility on [DATE] with a readmission [DATE] with diagnoses that included but were not limited to: heart failure (1), atrial fibrillation (2), dysphagia (3) and pleural effusion (4). Resident # 72's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/27/18, coded Resident # 72 as scoring a 10 on the brief interview for mental status (BIMS) of a score of 0 - 15, 10 - being moderately impaired of cognition for making daily decisions. Resident # 72 was coded as requiring limited to extensive assistance of one staff member for activities of daily living. Under section O. Special Treatment, Procedures and Programs Resident # 72 was coded for C. Oxygen therapy. On 01/29/19 at 12:22 p.m., an observation of Resident # 72 revealed she was sitting up in an armchair reading the paper receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate was set at two and a half liters per minute. On 01/30/19 at 7:59 a.m., an observation of Resident # 72 revealed she was lying in bed receiving oxygen by nasal cannula. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two and a half liters per minute. 01/31/19 at 7:42 a.m., an observation of Resident # 72 revealed she was lying in bed awake receiving oxygen by nasal cannula connected to an oxygen concentrator. Observation of the oxygen flow meter on the oxygen concentrator revealed the oxygen flow rate at two and a half liters per minute. The POS (physician's order sheet) for Resident # 72 dated 01/30 2019documented, Continuous O2 (oxygen) therapy at 2/L (two liters) via (by) NC (nasal cannula) for SOB (shortness of breath) / COPD (chronic obstructive pulmonary disease). Order Date: 09/10/2018. The comprehensive care plan for Resident # 72 dated 03/13/2018 documented, Ineffective airway clearance related to COPD, pneumonia, paraneumonic right pleural effusion as evidenced by: increased coughing, oxygen saturation dropping with exertion. Under Interventions it documented, Continuous O2 (oxygen) therapy at 2/L (two liters) via (by) NC (nasal cannula) for SOB (shortness of breath) / COPD (chronic obstructive pulmonary disease). Start Date: 03/13/2018 On 01/31/19 at 7:44 a.m., an observation of Resident # 72's oxygen concentrator and interview was conducted with LPN (licensed practical nurse) # 3. When asked how to read the flow rate on the oxygen concentrator LPN # 3 stated, The liter line should be in the middle of the ball. When asked to read the flow rate on the oxygen concentrator for Resident # 72, LPN # 3 stated, It's at two and a half liters. When asked what physician's order was for Resident # 72's oxygen, LPN # 3 stated Two liters. When asked how often the flow rate on oxygen concentrators is checked, LPN # 3 stated, Every shift. According to Fundamentals of Nursing, [NAME] and [NAME], 6th edition, page 1122, Oxygen should be treated as a drug. It has dangerous side effects, such as atelectasis or oxygen toxicity. As with any drug, the dosage or concentration of oxygen should be continuously monitored. The nurse should routinely check the physician's orders to verify that the client is receiving the prescribed oxygen concentration. The six rights of medication administration also pertain to oxygen administration. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. Reference: (1) A condition in which the heart is no longer able to pump oxygen-rich blood to the rest of the body efficiently. This causes symptoms to occur throughout the body. This information was obtained from the website: https://medlineplus.gov/ency/article/000158.htm. (2) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. (3) A swallowing disorder. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/swallowingdisorders.html. (4) A buildup of fluid between the layers of tissue that line the lungs and chest cavity. This information was obtained from the website: https://medlineplus.gov/ency/article/000086.htm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and clinical record review, it was determined that facility staff failed to provide pain management for two of 31 residents in the survey sample, Residents # 46 and # 70. 1. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #46. 2. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #70. The findings include: 1. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #46. Resident # 46 was admitted to the facility on [DATE] with a readmission of 01/09/19 with diagnoses that included but were not limited to pain, hemiplegia (1), type 2 (two) diabetes (2), dementia (3) gastroesophageal reflux disease (4), and hypertension (5). Resident # 46's most recent MDS (minimum data set), 5 (five)-day assessment with an ARD (assessment reference date) of 01/16/19, coded Resident # 46 as scoring a 2 (two) on the staff assessment for mental status (BIMS) of a score of 0 - 15, 2 (two)- being moderately impaired of cognition for making daily decisions. Resident # 46 was coded as requiring extensive assistance of one staff member for activities of daily living. The Physician's Order Sheet dated 01/30/2019 documented, Acetaminophen 500MG (milligram) tablet- one tab (tablet) po (by mouth) every 6 (six) hours as needed for break through pain. Start Date: 01/09/19. The eMAR (electronic medication administration record) dated 01/2019 for Resident # 46 documented, Acetaminophen 500MG (milligram) tablet- one tab (tablet) po (by mouth) every 6 (six) hours as needed for break through pain. Start Date: 01/09/19. Review of the eMAR revealed acetaminophen 500mg was administered on 01/17/19 at 3:54 p.m., with a pain level of four. Further review of the eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of acetaminophen. Review of the nurse's progress notes for Resident # 46 dated 01/17/19 failed to evidence documentation of non-pharmacological interventions prior to the administration of acetaminophen. The comprehensive care plan for Resident # 46 dated 01/09/2019 documented, Category : 019 Pain. Impaired comfort R/T (related to) diabetes, CVA (cerebral vascular disease), impaired mobility, advanced age, c/o (complaint of) acute pain of right lower extremity. Start Date: 01/09/2019. Under Intervention it documented, Determine location, onset, duration and character of pain. Start Date: 01/09/2019. Complete pain assessment as ordered and per facility protocol using PAINAID Scale. Start Date: 01/09/2019. Further review of the comprehensive car plan for Resident # 46 failed to evidence documentation of the use of non-pharmacological interventions. On 01/31/19 at 9:58 a.m., an interview was conducted with LPN (licensed practical nurse) # 2. When asked to describe the procedure for assessing a resident's pain, LPN # 2 stated, Ask them (resident) on a scale of 1 (one) to 10 how severe the pain is, given the rate of pain I would give what has been prescribed. I would do vitals and ask the location of the pain and would try to alleviate the pain before giving the pain medication but if the pain level is high I would just give the pain medication. When asked how often non-pharmacological interventions should be attempted, LPN # 2 stated, Every time except when the pain level is high. When asked where the non-pharmacological interventions attempted are documented, LPN # 2 stated, In the notes (nurse's notes) and if it above a four I don't try anything but I don't document it all the time. When it isn't documented I can't say it was done. On 01/31/19 at 10:21 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services regarding the implementation and documentation of non-pharmacological intervention prior to the administration of as needed pain medication. ASM # 2 stated, Should be attempted prior to the administration of PRN (as needed) pain meds (medication) and documented in the nurse's notes. The facility's policy Pain Management documented, Non-Pharmacological Interventions. Pharmacological Interventions may help manage pain effectively when used either independently or in conjunction with pharmacologic agents. The nurse is required to document the effectiveness of the required nonphamacological intervention as well as the documenting the effectiveness of the pharmacological intervention. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) Also called: Hemiplegia, Palsy, Paraplegia, Quadriplegia. Paralysis is the loss of muscle function in part of your body. It happens when something goes wrong with the way messages pass between your brain and muscles. Paralysis can be complete or partial. It can occur on one or both sides of your body. It can also occur in just one area, or it can be widespread. This information was obtained from the website: https://medlineplus.gov/paralysis.html. (2) A chronic disease in which the body cannot regulate the amount of sugar in the blood. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/ency/article/001214.htm. (3) A loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. This information was obtained from the website: https://medlineplus.gov/ency/article/000739.htm. (4) Stomach contents to leak back, or reflux, into the esophagus and irritate it. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/gerd.html. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html. 2. The facility staff failed to implement non-pharmacological interventions prior to the administering as needed pain medication to Resident #70. Resident # 70 was admitted to the facility on [DATE] with a readmission of 06/26/17 with diagnoses that included but were not limited to heart disease (1), atrial fibrillation (2), atherosclerosis (3) anemia (4), and hypertension (5). Resident # 70's most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 12/26/18, coded Resident # 70 as scoring a 15 on the brief interview for mental status (BIMS) of a score of 0 - 15, 15- being cognitively for making daily decisions. Resident # 70 was coded as requiring limited to extensive assistance of one staff member for activities of daily living. Section J Health Considerations coded Resident # 70 as having occasional moderate pain. The Physician's Order Sheet for resident # 70 dated 01/30/2019 documented, Tramadol 50MG [6] (milligram) tablet- Give ½ (half) tab (tablet (25 MG) Every 8 (eight) hours) as needed for moderate to severe pain. Start Date: 10/25/18. The eMAR (electronic medication administration record) dated 01/2019 for Resident # 70 documented, Tramadol 50MG [6] (milligram) tablet- Give ½ (half) tab (tablet (25 MG) Every 8 (eight) hours) as needed for moderate to severe pain. Start Date: 10/25/18. Review of the eMAR revealed Tramadol 50mg was administered on the following dates: - 01/01/19 at 5 300 a.m., with a pain level of six, - 01/02/19 at 12:27 a.m., with a pain level of seven, - 01/04/19 at 2:13 a.m., with a pain level of six, - 01/05 at 11:30 a.m., with a pain level of seven, - 01/07/19 at 1:50 a.m., with a pain level of six, - 01/08/19 at 2:00 a.m. with a pain level of five, - 01/09/19 at 2:40 a.m., with a pain level of five, - 01/10/19 at 3:30 a.m., with a pain level of six, - 01/14/19 at 11:01 a.m., with a pain level of eight, - 01/18/19 at 5:32 a.m., with a pain level of four, - 01/19/19 at 3:07 a.m. with a pain level of six, - 01/20/19 at 4:30 a.m., with a pain level of seven, - 01/23/19 at 5:11 a.m., with a pain level of six and on - 01/27/19 at 4:13 a.m., with a pain level of six. Further review of the eMAR failed to evidence documentation of non-pharmacological interventions prior to the administration of Tramadol. Review of the nurse's progress notes for Resident # 70 dated 01/01/19 through 01/29/19 failed to evidence documentation of non-pharmacological interventions prior to the administration of acetaminophen. The comprehensive care plan for Resident # 70 dated 03/30/2018 documented, Category : 019 Pain. Impaired comfort R/T (related to) lumbar spondolyosis. Under Interventions it documented, Offer non-pharmacological pain relief methods as needed. Start Date: 03/30/2018. On 01/31/19 at 9:58 a.m., an interview was conducted with LPN (licensed practical nurse) # 2. When asked to describe the procedure for assessing a resident's pain, LPN # 2 stated, Ask them (resident) on a scale of 1 (one) to 10 how severe the pain is, given the rate of pain I would give what has been prescribed. I would do vitals and ask the location of the pain and would try to alleviate the pain before giving the pain medication but if the pain level is high I would just give the pain medication. When asked how often non-pharmacological interventions should be attempted, LPN # 2 stated, Every time except when the pain level is high. When asked where the non-pharmacological interventions attempted are documented, LPN # 2 stated, In the notes (nurse's notes) and if it above a four I don't try anything but I don't document it all the time. When it isn't documented I can't say it was done. On 01/31/19 at 10:21 a.m., an interview was conducted with ASM (administrative staff member) # 2, director clinical services regarding the implementation and documentation of non-pharmacological intervention prior to the administration of as needed pain medication. ASM # 2 stated, Should be attempted prior to the administration of PRN (as needed) pain meds (medication and documented in the nurse's notes. On 01/31/19 at approximately 10:45 a.m., ASM (administrative staff member) # 2, director of clinical services was made aware of the findings. No further information was provided prior to exit. References: (1) There are many different forms of heart disease. The most common cause of heart disease is narrowing or blockage of the coronary arteries, the blood vessels that supply blood to the heart itself. This is called coronary artery disease and happens slowly over time. It's the major reason people have heart attacks. Other kinds of heart problems may happen to the valves in the heart, or the heart may not pump well and cause heart failure. Some people are born with heart disease. This information was obtained from the website: https://medlineplus.gov/heartdiseases.html. (2) A problem with the speed or rhythm of the heartbeat. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/atrialfibrillation.html. (3) A disease in which plaque builds up inside your arteries. Plaque is a sticky substance made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. That limits the flow of oxygen-rich blood to your body. This information was obtained from the website: https://medlineplus.gov/atherosclerosis.html. (4) Low iron. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/anemia.html. (5) High blood pressure. This information was obtained from the website: https://www.nlm.nih.gov/medlineplus/highbloodpressure.html.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that the facility staff failed to maintain a complete and accurate clinical record for three of 31 residents in the survey sample, Residents #223, #127 and #68. 1. The facility staff failed to document non-pharmacological interventions that were offered to Resident #223 prior to administering as needed pain medication to the resident on multiple dates in January 2019. 2. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #127, on 8 occasions in January 2019. 3. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #68, on 10 occasions in January 2019. The findings include: 1. The facility staff failed to document non-pharmacological interventions that were offered to Resident #223 prior to administering as needed pain medication to the resident on multiple dates in January 2019. Resident #223 was admitted to the facility on [DATE]. Resident #223's diagnoses included but were not limited to vertebrae fracture, high blood pressure and a history of a fall. Resident #223's admission MDS (minimum data set) was not complete. Resident #223's admission nursing assessment dated [DATE], documented the resident was oriented. Resident #223's care plan dated 1/25/19 documented, Impaired comfort related to L1 (lumbar one vertebrae) Compression fracture .Provide PRN (as needed) medication as per MD (medical doctor) orders. The care plan failed to document information regarding non-pharmacological interventions. Review of Resident #223's clinical record revealed the following physician's orders: 1/25/19- Percocet (1) 5-325 mg (milligrams) - one tablet every six hours as needed for severe pain. 1/25/19- Tramadol (2) 50 mg- one tablet every 12 hours as needed for moderate back pain. 1/25/19- Acetaminophen (3) 325 mg- two tablets every eight hours as needed for generalized pain. Review of Resident #223's January 2019 eMAR (electronic medication administration record) revealed the resident was administered the above medications on the following dates: Percocet on 1/25/19 through 1/30/19. Tramadol on 1/26/19 and 1/28/19 through 1/30/19. Tylenol on 1/27/19 through 1/30/19. Further review of Resident #223's clinical record (including the January 2019 eMAR and nurses' notes) failed to reveal documentation that non-pharmacological interventions were offered to the resident prior to the administration of as needed Percocet, as needed Tramadol and as needed Tylenol on the above dates. On 1/30/19 at 4:55 p.m., an interview was conducted with Resident #223. Resident #223 was asked if nurses offer non-pharmacological interventions such as repositioning, heat, or cold therapy before giving her as needed pain medication. Resident #223 stated, No. I don't think so. On 1/30/19 at 5:07 p.m., an interview was conducted with RN (registered nurse) #1 (a nurse who administered some of the above as needed pain medications on some of the above dates). RN #1 was asked what should be done prior to administering as needed pain medication. RN #1 stated, You have to assess the resident first. When asked if anything else should be done, RN #1 stated, You can also check if their last prn (as needed pain medication) was effective. When asked if nurses should offer non-pharmacological interventions prior to administering as needed pain medication, RN #1 stated, That depends. You need a doctor's order. When asked to clarify that statement, RN #1 stated nurses sometimes, but not always, need a doctor's orders for non-pharmacological interventions. When asked if she offers residents non-pharmacological interventions, RN #1 stated, Yes. When asked to describe the non-pharmacological interventions she offers Resident #223, RN #1 stated she repositions the resident prior to administering as needed pain medication. When asked if she documents the non-pharmacological interventions, she offers Resident #223, RN #1 stated, No. When asked if that should be documented, RN #1 stated, Yeah. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. On 1/31/19 at 7:26 a.m., an interview was conducted with LPN (licensed practical nurse) #1 (another nurse who administered some of the above as needed pain medications on some of the above dates). LPN #1 was asked what should be done prior to administering as needed pain medication. LPN #1 stated, Whenever a resident asks for pain medication I'll ask them to rate their pain. I'll try to do non-pharmacological interventions first. If that don't work I'll given them what I'm supposed to according to the pain scale. LPN #1 was asked to describe the non-pharmacological interventions she offers Resident #223. LPN #1 stated assists the resident with repositioning and has provided a blanket to the resident. When asked if she documents the non-pharmacological interventions she offers Resident #223, LPN #1 stated, Sometimes I do. LPN #1 confirmed she does not always document the non-pharmacological interventions she provides although she is supposed to. The facility policy titled, Pain Management documented, Non-Pharmacological interventions may help manage pain effectively when used either independently or in conjunction with pharmacological agents .The nurse is required to document the effectiveness of the required nonpharmacological intervention . No further information was presented prior to exit. 2. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #127, on 8 occasions in January 2019. Resident #127 was admitted to the facility on [DATE] with the diagnoses of but not limited to hip fracture, laceration to the head, and vascular dementia. The MDS (Minimum Data Set) had not yet been completed due to the recent admission time frame. The admission nursing assessment dated [DATE] documented the resident as oriented to person and place, but not time; as requiring assistance with activities of daily living; and as being continent of bowel and bladder. A review of the clinical record revealed a physician's order dated 1/21/19 for Oxycodone {1} 5 mg (milligram) tablet, take 2.5 mg (half tablet) every 6 hours as needed for post-surgical pain. A review of the January 2019 MAR (Medication Administration Record) revealed that Resident #127 received the as-needed Oxycodone once each day on the dates of January 24, 25, 26, 27, 28, 29, and 30, 2019. Further review of the clinical record failed to reveal any evidence of non-pharmacological interventions being offered or attempted. On 1/31/19 at 10:43 a.m., in an interview with RN #3 (Registered Nurse), RN #3 stated, Usually she (Resident #127) rates pain at a 5 most of the time. When you touch the right leg, she will grimace and guard herself. Her behavior expresses pain. Her daughter assisted with communication of pain. When she has pain, we turn her, reposition her to make her comfortable; sometimes she allows us to apply heat, it helps to relax her. When asked about documenting these non-pharmacological interventions, RN #3 stated, I have not documented on the non-pharmacological. It should be documented as part of her pain management. A review of the care plan for Resident #127 included one for pain, however, it did not include the use of, or documentation of non-pharmacological interventions. A review of the facility policy, Pain Management documented, Non-Pharmacological interventions may help manage pain effectively when used either independently or in conjunction with pharmacological agents The nurse is required to document the effectiveness of the required nonpharmacological intervention On 1/31/19 at approximately 10:30 a.m., ASM #2 (Administrative Staff Member, the director of clinical services) was made aware of the findings. No further information was provided by the end of the survey. {1} Oxycodone is used to relieve moderate to severe pain. Information obtained from https://medlineplus.gov/druginfo/meds/a682132.html 3. The facility staff failed to document the use of non-pharmacological interventions before administering pain medication to Resident #68, on 10 occasions in January 2019. Resident #68 was admitted to the facility on [DATE] with the diagnoses of but not limited to Parkinson's disease, dementia, benign prostatic hyperplasia, chronic kidney disease, high blood pressure, chronic back pain, and was on Hospice. The most recent MDS (Minimum Data Set) was a quarterly assessment with an ARD (Assessment Reference Date) of 11/2/18. The resident was coded as moderately impaired in ability to make daily life decisions. The resident was coded as requiring total care for bathing; extensive care for dressing, toileting and hygiene; limited assistance for transfers; supervision for ambulation and eating; and was coded as continent of bowel and as having an indwelling catheter for bladder. A review of the clinical record revealed a physician's order dated 4/18/18 for Tylenol {1} 325 mg (milligrams), give 2 tabs [tablets] (650 mg) every 4 hours as needed for generalized discomfort. Also noted, was a physician's order dated 4/18/18 for Oxycodone {2} 5 mg tablet, give 1 tablet every 4 hours as needed for severe breakthrough pain. A review of the January 2019 MAR (Medication Administration Record) revealed that Resident #68 received the Tylenol once on 1/7/19; and the Oxycodone once on each date of January 4, 5, 7, 8, 14, 19, 20, 21, and 22, 2019, without documented evidence of non-pharmacological interventions being offered or attempted. On 1/31/19 at 10:48 a.m., in an interview with RN #2 (Registered Nurse), RN #2 stated, Knowing him (Resident #68) I find out what he has been doing, if he has been walking too much, I have him sit down, put a pillow behind him, give him water, let him sit. If he says this is not going away after monitoring for 5-10 minutes, I rate the scale 1-10 how painful, where it is, etc. When asked if she documents the non-pharmacological interventions that she attempted, RN #2 stated, That's the problem. We haven't been in the process of documenting that. A review of the care plan for Resident #68 included one for pain, however, it did not include the use of, or documentation of non-pharmacological interventions. A review of the facility policy, Pain Management documented, Non-Pharmacological interventions may help manage pain effectively when used either independently or in conjunction with pharmacological agents The nurse is required to document the effectiveness of the required nonpharmacological intervention On 1/31/19 at approximately 10:30 a.m., ASM #2 (Administrative Staff Member, the director of clinical services) was made aware of the findings. No further information was provided by the end of the survey. {1} Tylenol is used to relieve mild to moderate pain. Information obtained from https://medlineplus.gov/druginfo/meds/a681004.html {2} Oxycodone is used to relieve moderate to severe pain. Information obtained from https://medlineplus.gov/druginfo/meds/a682132.html (1) Percocet is used to treat pain. This information was obtained from the website: https://medlineplus.gov/ency/article/000949.htm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. CNA (Certified nursing assistant) #1 failed to change gloves in between touching cabinet handles and the food contact areas of a bowl and a plate that was used to serve food in the Maherrin household unit. On 1/29/19 at 12:36 p.m., a dining observation was conducted in the Maherrin household unit. The following was observed: -CNA #1 washed her hands and applied a pair of disposable gloves. CNA #1 opened a cabinet with a gloved hand and removed bowls from the cabinet. While handling the bowls, CNA #1's gloved hand that was used to open the cabinet was observed touching the food contact area of a bowl. Soup was then placed in that bowl and served to a resident. -CNA #1 washed her hands and applied a pair of disposable gloves. CNA #1 opened a cabinet with both gloved hands and removed plates from the cabinet. While handling the plates, CNA #1's gloved hands that were used to open the cabinet were observed touching the food contact area of a plate. Food was then placed on that plate and served to a resident. On 1/30/19 at 2:42 p.m., an interview was conducted with CNA #1. CNA #1 was asked if she should touch the inside of a serving bowl or plate with the same gloves that were worn while touching the handles of a cabinet. CNA #1 stated she should wash her hands and change gloves after touching the handle of a cabinet because she does not know what is on the handle. When asked if touching the inside of a serving bowl or plate with the same gloves worn while touching a cabinet handle is an infection control issue, CNA #1 stated, Yes. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Proper Handling Of Food Glassware Dishes And Utensils documented, 1. The food contact area of plates bowls glasses or cups should not be touched . No further information was presented prior to exit. Based on observation and staff interview, it was determined that the facility staff failed to serve food in a sanitary manner in two of eight resident dining rooms. 1. CNA (Certified nursing assistant) # 3 failed to change gloves in between touching cabinet and drawer handles, oven door handle and the food contact areas of serving platters, casserole dish and dinner plates that was used to serve food in the [NAME] household unit. 2. CNA (Certified nursing assistant) #1 failed to change gloves in between touching cabinet handles and the food contact areas of a bowl and a plate that was used to serve food in the Maherrin household unit. The findings include: 1. CNA (Certified nursing assistant) # 3 failed to change gloves in between touching cabinet and drawer handles, oven door handle and the food contact areas of serving platters, casserole dish and dinner plates that was used to serve food in the [NAME] household unit. On 1/29/19 at 5:06 p.m., an observation of the evening meal was conducted on the [NAME] household unit. CNA (certified nursing assistant) # 3 was observed in the kitchen area, wearing plastic gloves preparing and serving food. While wearing the gloves CNA # 3 was observed opening and closing the oven door, placing the serving dishes of food on the kitchen island, opening and closing kitchen cabinets and drawers to retrieve dinner plates and serving utensils. While wearing the same gloves CNA # 3 removed the plastic wrap on the serving platters of cooked squash and roasted potatoes, carried them to the dining table one at a time and carried it to each resident sitting at the table. Observation of CNA # 3's placement of her thumbs revealed they were on the surface of the serving platter next to the food. CNA # 3 then placed the platter next to each resident, asked the resident if they would like that food item and how much. CNA #3 then picked up the residents dinner plate placing her thumb on the food surface of the plate and then placed the food item on the plate. This process was observed for the service of the squash and roasted potatoes for four of the eight residents seated at the dining table. While still wearing the same gloves, CNA # 3 opened the oven, removed the casserole dish containing the pot roast, placed it on a serving tray on the kitchen island and closed the oven door. After removing the lid from the casserole dish, CNA # 3 picked up the tray with the casserole dish, placed her thumbs over the outside edge and on the inside edge of the casserole dish to keep it from sliding on the tray and then took it to the dining table to serve the residents. CNA # 3 carried the tray and casserole dish to each resident at the dining table with her thumbs over the outside edge and and on the inside edge of the casserole dish to keep it from sliding on the tray, and asked the residents if they would like that food item. CNA #3 then picked up the resident dinner plates placing her thumb on the food surface of the plate and served the food item onto the plate. This process was observed for four of the eight residents seated at the dining table On 1/29/19 at 5:55p.m., an interview was conducted with CNA # 3. When asked to describe the purpose for wearing gloves during food preparation and service, CNA # 3 stated, For sanitary reasons to keep the food from being contaminated. When asked if her thumbs or fingers should on the inside of the serving dishes or dinner plates CNA # 3 stated, No. When asked if she changed her gloves between tasks and before serving, the residents' their food, CNA # 3 stated, No. On 01/30/19 at approximately 5:45 p.m., ASM (administrative staff member) # 1, the administrator and ASM # 2, director of clinical services were made aware of the findings. No further information was provided prior to exit. (2) Tramadol is used to treat pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a695011.html (3) Acetaminophen is used to treat pain. This information was obtained from the website: https://medlineplus.gov/druginfo/meds/a681004.html

Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a safe and sanitary manner, in two of eight facility household kitchens, the Maherrin household kitchen and the Rappahannock household kitchen. 1. a. The facility staff failed to label and store food in a safe and sanitary manner in the Maherrin household kitchen. 1. b. The facility staff failed to hold cold food at a safe temperature in the Maherrin and Rappahannock household kitchens. 2. The facility staff failed to store dishware in a safe and sanitary manner in the Maherrin and Rappahannock household kitchens. The findings include: 1. a. The facility staff failed to label and store food in a safe and sanitary manner in the Maherrin household kitchen. On 1/29/19 at 12:22 p.m., observation of the Maherrin household kitchen was conducted. The following was observed: In the refrigerator: - An opened glass jar of homemade apricot pineapple jam that documented a resident's name on the top label. The top label documented, Apricot Pineapple Jam 2017. The jar did not contain manufacturer's information. A facility sticker on the jar documented a prep date of 12/22/18 and a use by date of 1/22/19. In the freezer: -An opened plain disposable container that contained a pink frozen substance. The container did not contain manufacturer's information. A facility sticker on the container identified the substance as sherbet and documented a prep date of 1/6/19 and a use by date of 1/9/19. -An opened plain disposable container that contained a white frozen substance that resembled ice cream. The container did not contain manufacturer's information and it was not labeled with any information. -An opened quart container of lactose free ice cream. The container was not fully closed and the top of the container was busted, exposing the contents to potential contaminates. On 1/30/19 at 5:13 p.m., an interview was conducted with OSM (other staff member) #1 (the sous chef). OSM #1 was asked about the facility process for labeling and storing food. OSM #1 stated condiments including dressings are labeled and used for 30 days after being opened; dry foods are labeled and used for 30 days after being opened, and juices, milk, deli meats and eggs are kept for four days after being opened. OSM #1 stated the facility staff labels opened food with the name of the item, the day it was opened or prepped and the day the item needs to be used by. OSM #1 confirmed everything that is opened should be labeled and the integrity of the packaging should not be damaged. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Intake and Storage of Food documented, Storage practices which maintain food quality will be used .If the product expiration date is not indicated, use a food label to indicate food receipt and expiration date . No further information was presented prior to exit. 1. b. The facility staff failed to hold cold food at a safe temperature in the Maherrin and Rappahannock household kitchens. On 1/29/19 at 12:36 p.m., observation of CNA (certified nursing assistant) #1 obtaining the holding temperatures of food in the Maherrin household kitchen was conducted. CNA #1 obtained the temperature of sliced provolone cheese that was prepared for sandwiches. The holding temperature of the cheese was 50 degrees Fahrenheit. The cheese was then placed on sandwiches that were served to two residents. On 1/30/19 at 11:49 a.m., observation of CNA #2 obtaining the holding temperatures of food in the Rappahannock household kitchen was conducted. CNA #2 obtained the temperature of club sandwiches that contained sliced turkey, bacon, lettuce, tomatoes and mayonnaise. The holding temperature of the sandwiches was 53 degrees Fahrenheit. The sandwiches were then served to four residents. On 1/30/19 at 2:42 p.m., an interview was conducted with CNA #1. CNA #1 was asked if there was any parameters for cold food holding temperatures and what should be done if the temperature does not meet those parameters. CNA #1 stated she sets the food out and lets it warm up if it is too cold for residents. CNA #1 then stated she calls the cook if the food is too cold. CNA #1 was asked if there was any safety concerns for cold food, being held too warm. CNA #1 stated cold food should stay cold but not below the normal temperature. When asked what the normal temperature was, CNA #1 stated 41 degrees. On 1/30/19 at 3:02 p.m., an interview was conducted with CNA #2. CNA #2 was asked at what temperature cold food should be held. CNA #2 stated 40 degrees and lower. CNA #2 was asked what should be done if the holding temperature of cold food is above 40 degrees. CNA #2 stated the food should be put back in the refrigerator. On 1/30/19 at 5:13 p.m., an interview was conducted with OSM (other staff member) #1 (the sous chef). OSM #1 confirmed CNAs obtain the holding temperatures of food prior to serving in each household. OSM #1 stated the holding temperature of cold food should be below 41 degrees. When asked why, OSM #1 stated, So bacteria won't start growing on it. As long as it's 41, it should not grow. When asked what should be done if the holding temperature of cold food is above 41 degrees, OSM #1 stated the food should be put back in the refrigerator or freezer to get it to the temperature it needs to be. When asked if cold food held at a temperature above 41 should be served to residents, OSM #1 stated, No. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Serving Food at the correct temperature documented To ensure that all meals are prepared and served in a safe and sanitary manner, the dining services and nursing staff shall prepare and serve meals in a safe and sanitary manner and in accordance with all applicable government regulations .4. Foods that are to be served chilled should remain in the refrigeration until served. Chilled foods should be served at 41 F (degrees Fahrenheit) or below . No further information was presented prior to exit. 2. The facility staff failed to store dishware in a safe and sanitary manner in the Maherrin and Rappahannock household kitchens. On 1/29/19 at 12:22 p.m., observation of the Maherrin household kitchen was conducted. An eight-cup pitcher was stored lying down in a cabinet. A small puddle of water was observed inside the pitcher. On 1/30/19 at 11:59 a.m., observation of the Rappahannock household kitchen was conducted. An eight-cup pitcher was stored lying down in a cabinet. A small puddle of water was observed inside the pitcher. On 1/30/19 at 5:13 p.m., an interview was conducted with OSM (other staff member) #1 (the sous chef). OSM #1 was asked about the facility process followed for washing and storing pitchers and if the pitchers should be completely dry before being stored. OSM #1 stated, Yes. We let them air dry on the mats on top of the dishwasher. When asked why, OSM #1 stated, So no bacteria will get stuck on them and the moisture won't draw in any airborne stuff; so dust won't collect on them. On 1/30/19 at 5:51 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of clinical services) were made aware of the above concern. The facility policy titled, Washing Dishes documented, 9. Place dishes in dishwasher racks. Avoid overloading and nesting. 10. Close door and start machine. 11. Upon completion of dishwashing, empty the dishwasher and place dishes in storage . No further information was presented prior to exit.