Every finding on record at Community Care on Palm

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. [NAME] 1 was performing food preparation without a beard restraint and the Dietary Aide had bangs exposed outside the hairnet while working in the kitchen.2. The stovetop was covered with a thick, crusty layer of black and brown grease.3. The interior and exterior surfaces of the oven were coated with heavy, dark buildup, exterior side of the oven door and its handle were coated with thick, heavy residue of old grease and dark deposits, and the bottom part of the oven was coated in a layer of sticky dust and oil residue.These failures had the potential to expose residents who received food from the kitchen to contaminants and could put them at risk of food-borne illnesses.4. An opened, unsealed bag of brown sugar was found unlabeled and undated.This failure had the potential for the food product to go bad, become contaminated, or attract pests to the kitchen.Findings:1. During an observation in the kitchen on 4/13/2026, at 7:53 AM, [NAME] 1 was performing food preparation without a beard restraint and the Dietary Aide had bangs exposed outside the hairnet while working in the kitchen. During an interview on 4/16/2026, at 8:24 AM, with the Assistant Dietary Services Supervisor (ADSS), ADSS stated kitchen staff should always be wearing hair nets and beard restraints properly. ADSS stated facility protocol required kitchen staff to have their hair completely covered. During a concurrent interview and record review on 4/16/2026, at 8:24 AM, with ADSS, the facility's undated Policy & Procedure (P&P) titled, Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices was reviewed. The P&P indicated, Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. ADSS stated that kitchen staff should be wearing hair and beard nets properly at all times. 2. During a concurrent observation of the kitchen and interview on 4/13/2026, at 7:57 AM with ADSS, the kitchen stove was covered with a thick, crusty layer of brown and black grease. The ADSS confirmed the stove was covered with grease.3. During a concurrent observation and interview on 4/13/2026 at 7:57 AM with ADSS, the interior and exterior surfaces of the oven were coated with heavy, dark buildup. The exterior side of the oven door and its handle were coated with thick, heavy residue of old grease and dark deposits, and the bottom part of the oven was coated in a layer of sticky dust and oil residue. The ADSS verified these findings and acknowledged that the oven surfaces had not been maintained and were coated with old grease and oil buildup.During a concurrent interview and record review on 4/13/2026, at 3:30 PM, with ADSS, the facility's undated P&P titled, Sanitization was reviewed. The P&P indicated, All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. The ADSS acknowledged the stove and oven required cleaning.4. During a concurrent observation of the kitchen and interview on 4/13/2026, at 7:59 AM, with ADSS, an opened, unsealed bag of brown sugar was found unlabeled and undated. The ADSS confirmed the bag of brown sugar should be labeled and dated.A review of the facility's undated P&P titled, Food Storage (Dry, Refrigerated, and Frozen) indicated, All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded.

Based on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for five of five sampled residents (Residents 36, 53, 41, 21, and 1) on psychotropic (affecting brain activities associated with mental processes and behavior) medications. This failure had the potential for residents or their representatives to not be fully informed of the risks and benefits of psychotropic medications before receiving treatment.Findings: 1. A review of Resident 36's physician's orders indicated Resident 36 had orders for the following psychotropic medications: - Sertraline (generic for Zoloft, a psychotropic medication to treat depression) 50 milligrams (mg) by mouth one time a day for depression, dated 4/4/25; - Lorazepam (generic for Ativan, a psychotropic medication to treat anxiety) 0.5 mg by mouth two times a day for anxiety, dated 7/21/25 and 4/3/26; - Divalproex (generic for Depakote, a psychotropic medication to treat mood disorders) delayed release (DR) 1000 mg by mouth at bedtime for bipolar disorder (mood disorder that causes intense mood swings), dated 3/15/26; and - Trazodone (generic for Desyrel, a psychotropic medication to treat depression) 150 mg by mouth at bedtime for depression, dated 2/11/26. During a concurrent interview and record review on 4/15/26 at 12:13 PM with the Director of Nursing (DON), Resident 36's psychotropic informed consent forms, dated 9/21/24 to 1/12/25, were reviewed. The records indicated no evidence of informed consent for the ordered doses of sertraline, lorazepam, divalproex, or trazodone. The DON stated there were no additional informed consents for Resident 36. 2. A review of Resident 53's physician's orders, dated 11/26/25, indicated Resident 53 had orders for risperidone (generic for Risperdal, a psychotropic medication to treat mental illness) 1.75 mg by mouth at bedtime for schizophrenia (a mental illness characterized by disturbances in thought). During a concurrent interview and record review on 4/15/26 at 4:48 PM with the DON, Resident 53's Psychotherapeutic Drug Informed Consent Form, dated 4/3/26, was reviewed. The record indicated informed consent for Resident 53's risperidone was obtained on 4/3/26, after the date on the initial order. The DON stated this was the only informed consent the facility had for Resident 53. 3. A review of Resident 41's medication administration record (MAR, daily documentation record used by nurses to document medications and treatments given to a resident), dated March 2026, indicated Resident 41 had orders for the following psychotropic medications: - Escitalopram (generic for Lexapro, a psychotropic medication to treat depression) 15 mg by mouth one time a day for depression, dated 12/2/25; - Lithium carbonate (a psychotropic medication to treat mental illness and mood disorders) 600 mg by mouth at bedtime for schizophrenia, dated 12/12/25; - Chlorpromazine (generic for Thorazine, a psychotropic medication to treat mental illness) 75 mg by mouth two times a day for schizophrenia, dated 12/2/25; and - Haloperidol (generic for Haldol, a psychotropic medication to treat mental illness) 10 mg by mouth two times a day for schizophrenia, dated 2/13/26. A review of Resident 41's physician's orders indicated additional orders for lithium carbonate, Give 600 mg by mouth one time a day for schizophrenia, dated 4/8/26. During an interview on 4/15/26 at 4:54 PM with the DON, the DON stated the facility did not have documented informed consent for Resident 41's psychotropic medications. 4. A review of Resident 21's physician's orders, dated 1/25/25, indicated Resident 21 had orders for haloperidol decanoate (generic for Haldol Decanoate, a long-acting injectable psychotropic medication given every four weeks to treat mental illness) 100 mg per milliliter (ml). During an interview on 4/16/26 at 8:18 AM with the DON, the DON stated the facility did not have documented informed consent for Resident 21's psychotropic medication. 5. A review of Resident 1's NAQ - Psychotropic Assessment, dated 3/4/26, indicated the physician ordered Zyprexa (brand name for olanzapine, a psychotropic medication to treat mental illness) 10 mg injection every eight hours as needed for schizophrenia. A review of Resident 1's physician's orders, dated 3/17/26, indicated Resident 1 had additional orders for Zyprexa, Inject 10 mg intramuscularly [into the muscle] every 8 hours as needed for schizophrenia. A review of Resident 1's Psychotherapeutic Drug Informed Consent Form, dated 3/28/26, indicated informed consent for Resident 1's Zyprexa was obtained on 3/28/26, after the date on the initial orders. During an interview on 4/15/26 at 11:19 AM with the DON, the DON stated the facility needed to obtain informed consent before starting psychotropic medications for residents. The DON stated informed consent was supposed to be obtained for new psychotropic medication orders or whenever the dose was increased. A review of the facility's policy and procedure (P&P) titled, Informed Consent for Psychotropic Drugs, undated, indicated: This policy.outlines responsibilities for obtaining, verifying, and documenting informed consent to protect resident rights, promote safety, and facilitate appropriate use of these medications. This policy applies to all residents.prescribed psychotropic drugs, including new initiations, dose increases, or changes. Obtain informed consent for all psychotropic medications prior to initiation or dose increase. Document the discussion, resident/representative's understanding, and consent/refusal in the medical record. Facility Role: Verify (but not obtain) informed consent; ensure documentation in the medical record . and Initiation or Dose Increase: Prescriber obtains consent before administration. A review of the facility's P&P titled, Psychotropic Medication Use, dated 1/6/25, indicated, Informed Consent or Refusal.Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review.with the resident/representative prior to obtaining documented consent or refusal.

Based on observation, interview, and record review, the facility had a medication error rate of 17.14% when six medication errors occurred out of 35 opportunities during the medication administration observation for four out of five residents (Residents 28, 7, 6, and 40). These failures resulted in medications not given according to the physician's orders and had the potential for residents to not receive the full therapeutic effect of medications. These failures also had the potential for blockages to develop in Resident 6's gastrostomy tube (G-tube or feeding tube, a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach). Findings: 1. During a medication pass observation on 4/14/26, at 8:14 AM, at Resident 28's bedside, Licensed Vocational Nurse 5 (LVN 5) was observed administering nine medications to Resident 28. The medications included two 125 milligram (mg) capsules of delayed release divalproex (generic for Depakote Sprinkles, a medication to treat mood disorders) for a dose of 250 mg. A review of Resident 28's physician's orders, dated 4/3/26, indicated Resident 28 had orders for Divalproex Sodium Oral Tablet Delayed Release (generic for Depakote, a medication to treat mood disorders), Give 500 mg by mouth two times a day for Bipolar disorder [mood disorder that causes intense mood swings]. During an interview on 4/14/26, at 11:43 AM, with LVN 5, LVN 5 stated she gave 250 mg of divalproex capsules to Resident 28 during the morning medication pass. LVN 5 verified Resident 28 was supposed to get 500 mg of divalproex delayed release tablets. 2. During a medication pass observation on 4/14/26, at 8:27 AM, at Resident 7's bedside, LVN 5 was observed administering nine medications to Resident 7. The medications included one 100 mg capsule of gabapentin (generic for Neurontin, a medication to treat nerve pain). A review of Resident 7's physician's orders, dated 3/16/26, indicated Resident 7 had orders for Gabarone [brand name for gabapentin] Oral Tablet 100 MG, Give 100 mg by mouth two times a day for Nerve Pain. During an interview on 4/14/26, at 11:31 AM, with LVN 5, LVN 5 stated she gave Resident 7 a gabapentin capsule during the morning medication pass. LVN 5 stated she was supposed to give Resident 7 a gabapentin 100 mg tablet. During an interview on 4/15/26, at 10:03 AM, with LVN 4, LVN 4 stated nurses needed to call the physician before switching between dosage forms such as capsules and tablets. LVN 4 stated the physician could have ordered the specific dosage form because of a resident's ability to swallow or another clinical reason. 3a. During a medication pass observation on 4/14/26, at 9:16 AM, at Resident 6's bedside, LVN 5 was observed administering eight medications to Resident 6 through the G-tube. The medications included 7.5 milliliters (ml) of ferrous sulfate (iron supplement) 220 mg per 5 ml. A review of Resident 6's physician's orders, dated 3/17/26, indicated Resident 6 had orders for Iron Oral Liquid (Iron Glycinate [iron supplement]), Give 7.5 ml via G-Tube one time a day for supplement. During an interview on 4/14/26, at 11:25 AM, with LVN 5, LVN 5 stated she gave Resident 6 ferrous sulfate during the morning medication pass. LVN 5 stated Resident 6 had orders for iron glycinate, not ferrous sulfate. LVN 5 stated she did not give iron glycinate as ordered by the physician. During an interview on 4/15/26, at 10:35 AM, with the Director of Staff Development (DSD), the DSD stated nurses were expected to contact the physician to ask about changing the medication before administration. 3b. During a concurrent observation and interview on 4/14/26, at 9:16 AM, with LVN 5, outside Resident 6's room, LVN 5 prepared eight medications for Resident 6's medication pass. The medications included three liquids: ferrous sulfate, valproic acid (generic for Depakene, a medication to treat mood disorders), and levetiracetam (generic for Keppra, a seizure medication). LVN 5 verified she prepared three liquids for Resident 6's morning medication pass. A review of Resident 6's physician's orders, dated 5/12/22, indicated Resident 6 had orders for docusate liquid (generic for Colace, a medication to treat constipation) 50 mg per 5 ml, Give 10 ml via G-Tube two times a day for constipation. During an interview on 4/14/26, at 11:25 AM, with LVN 5, LVN 5 stated Resident 6 was supposed to get docusate during the morning medication pass. LVN 5 stated the docusate was not given. 3c. During a medication pass observation on 4/14/26, at 9:16 AM, at Resident 6's bedside, LVN 5 was observed administering eight medications to Resident 6 through the G-tube. LVN 5 first put 30 ml of water into Resident 6's G-tube (also known as a G-tube flush). LVN 5 then administered each medication one at a time through the G-tube. LVN 5 did not flush the G-tube between each medication. After all medications were given, LVN 5 flushed the G-tube with 30 ml of water. During an interview on 4/14/26, at 10:04 AM, with LVN 5, LVN 5 stated G-tube medications were given one at a time. LVN 5 further stated the G-tube was supposed to be flushed before starting the G-tube medication pass and after all the medications were given. LVN 5 verified she did not flush the G-tube between each of Resident 6's medications. During an interview on 4/15/26, at 10:43 AM, with the DSD, the DSD stated nurses were supposed to flush the G-tube with 10 ml of water between each medication during medication pass. The DSD stated flushing the G-tube between medications was important to prevent clogs. During a concurrent interview and record review on 4/15/26, at 12:30 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral [into the body through the mouth or feeding tube] Tube, dated November 2018, was reviewed. The P&P indicated, If administering more than one medication, flush with 15 mL warm purified water (or prescribed amount) between medications. The DON stated nurses were supposed to flush the G-tube with water between each medication during medication pass. 4. During a concurrent interview and medication pass observation on 4/14/26, at 3:42 PM, outside Resident 40's room, LVN 3 was observed administering five medications to Resident 40. The medications were one tablet each of divalproex extended release 500 mg, lisinopril (a medication to treat high blood pressure) 20 mg, metformin (a medication to treat diabetes) 1000 mg, olanzapine (an antipsychotic medication to treat mental illness) 10 mg, and sodium chloride (a supplement) 1 gram (gm, unit of measurement). LVN 3 verified she gave five medications to Resident 40 for the afternoon medication pass. A review of Resident 40's physician's orders, dated 3/23/26, indicated Resident 40 had orders for quetiapine (generic for Seroquel, an antipsychotic medication to treat mental illness) 200 mg, Give 200 mg by mouth two times a day for Schizophrenia. A review of Resident 40's medication administration record (MAR, daily documentation record used by nurses to document medications and treatments given to a resident), dated April 2026, indicated Resident 40's quetiapine was ordered to be given two times a day at 8:00 AM and 4:00 PM. During an interview on 4/14/26, at 4:58 PM, with LVN 3, LVN 3 stated she did not give quetiapine to Resident 40. LVN 3 stated she was supposed to give the medication during the afternoon medication pass. During an interview on 4/15/26, at 10:48 AM with the DSD, the DSD stated it was always the expectation for nurses to follow physician orders. During an interview on 4/15/26, at 12:20 PM, with the DON, the DON stated the nurse needed a reason to omit a medication and the nurse needed to notify the provider. A review of the facility's P&P titled, Administering Medications, dated April 2019, indicated, Medications are administered in accordance with prescriber orders.

Based on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 47) was treated with dignity and respect when a Certified Nursing Assistant (CNA 1) stood over the resident while feeding her.This failure had the potential to cause diminished dignity, loss of individuality, and decreased psychosocial well-being during the dining experience for Resident 47.Findings:A review of Resident 47's admission Record (demographic clinical information) indicated the resident was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, unspecified (blood clot cuts off blood flow to a part of the brain), Schizophrenia, unspecified (a brain disorder that causes people to interpret reality abnormally often resulting in disorganized thinking), and Depression.During an observation on 4/13/26, at 12:56 PM, in Resident 47's room, CNA 1 was observed feeding Resident 47 lunch while standing over the resident, who was seated in a wheelchair. CNA 1 continued to feed Resident 47 with a spoon while standing.During an interview with CNA 1 on 4/13/26, at 1:05 PM, CNA 1 stated she was expected to obtain a chair and sit while assisting Resident 47 with meals. CNA 1 further stated that sitting beside the resident at eye level was important for resident comfort. CNA 1 acknowledged she should have obtained a chair and been seated while feeding the resident.During an interview with the Director of Staff Development (DSD) on 4/13/26, at 2:25 PM, the DSD stated staff were expected to position themselves at the resident's eye level when providing feeding assistance. The DSD stated CNA 1 should have obtained a chair and sat beside Resident 47 while assisting with the meal to prevent the resident from feeling intimidated.A review of the facility's policy and procedure (P&P) titled, Quality of Life-Dignity, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being level of satisfaction with life, feeling of self-worth and self-esteem.1. Resident are treated with dignity and respect at all times.A review of the facility's P&P titled, Assistance with Meals, revised July 2017, indicated, 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example.a. not standing over resident while assisting them with meals.

Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from unnecessary psychotropic medications (medications that affect brain activities associated with mental processes and behavior) when Resident 1 received an as needed antipsychotic medication (type of psychotropic medication) without physician evaluation. This failure had the potential for Resident 1 to inappropriately receive an as needed antipsychotic medication and had a risk of medication side effects, such as sedation and falls. Findings: A review of Resident 1's admission record, dated 4/16/26, indicated Resident 1 was initially admitted to the facility on [DATE]. The admission record indicated Resident 1's diagnoses included schizophrenia (a mental illness characterized by disturbances in thought). A review of Resident 1's physician's orders, dated 3/17/26, indicated Resident 1 had renewed orders for Zyprexa (brand name for olanzapine, an antipsychotic medication to treat mental illness) 10 milligram (mg) injection, Inject 10 mg intramuscularly [into the muscle] every 8 hours as needed for Schizophrenia [a mental illness characterized by disturbances in thought] m/b [manifested by] verbal/physical aggression for 14 Days. During an interview on 4/16/26 at 2:35 PM with the Director of Nursing (DON), the DON stated there was no physician evaluation of Resident 1 for the renewed as needed (PRN) antipsychotic medication ordered on 3/17/26. The DON acknowledged the physician was supposed to evaluate Resident 1 before ordering the PRN Zyprexa. A review of the Prescribing Information (PI, detailed description of a medication available to clinicians) for Zyprexa injection, dated 2/11/26, retrieved from DailyMed, indicated somnolence [sleepiness] as an adverse reaction. A review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 1/6/25, indicated, PRN orders for psychotropic medications are limited to 14 days.For psychotropic medications that ARE antipsychotics: PRN orders cannot be renewed unless the attending physician or prescriber evaluates the resident and documents the appropriateness of the medication.

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS, a resident assessment tool) for two of five sampled residents (Residents 21 and 53). This failure had the potential for Residents 21 and 53 to not receive necessary care or services related to their antipsychotic medications (medications to treat mental illness). Findings: 1. A review of Resident 21's MDS Section N - Medications, dated 2/25/26, indicated Resident 21 was receiving antipsychotic medication at the time of the assessment. The record further indicated the physician documented gradual dose reduction (GDR, stepwise tapering of a medication to determine if symptoms can be managed at a lower dose) of the antipsychotic was contraindicated on 8/14/23. During a concurrent interview and record review on 4/16/26 at 8:46 AM with the MDS Coordinator (MDSC), Resident 21's Plan of Care Note, dated 2/13/26, and MDS Section N, dated 2/25/26, were reviewed. The MDSC stated the note indicated the prescriber documented GDR of Resident 21's antipsychotics was contraindicated. The MDSC stated the GDR date on the MDS was incorrect and needed to be corrected. 2. A review of Resident 53's MDS Section N - Medications, dated 3/2/26, indicated Resident 53 was receiving antipsychotic medication at the time of the assessment. The record further indicated the physician documented GDR of the antipsychotic was contraindicated on 9/14/23. During a concurrent interview and record review on 4/16/26 at 10:22 AM with the MDSC, Resident 53's Plan of Care Note, dated 2/13/26, and MDS Section N, dated 3/2/26, were reviewed. The MDSC stated the note indicated the prescriber documented GDR of Resident 53's antipsychotic was contraindicated. The MDSC stated the GDR date on the MDS was incorrect. During an interview on 4/16/26 at 10:42 AM with the MDSC, the MDSC stated the MDS was a comprehensive assessment of the resident at a specific point of time. The MDSC stated accuracy in the MDS was important to reflect accurate information and to know whether services were being provided. The MDSC further stated incorrect information in the MDS could lead to needed services not being provided to the resident. During an interview on 4/16/26 at 10:58 AM with the Director of Nursing (DON), the DON stated the MDS was expected to be accurate. When asked why the MDS needed to be accurate, the DON stated an inaccurate MDS was not current for the resident's care. A review of the facility's policy and procedure (P&P) titled, Comprehensive Assessments, dated October 2023, indicated, Comprehensive MDS assessments are conducted to assist in developing person-centered care plans and These assessments are used to develop, review and revise the resident's comprehensive care plan.

Based on interview and record review, the facility failed to ensure an individualized care plan was developed when one of two residents (Resident 32) did not have a care plan for an actual fall.This failure had the potential to result in recurrent falls and serious injury due to lack of interventions to ensure Resident 32's safety following the initial fall event.Findings:1. A review of Resident 32's admission Record. (a document showing a summary of the resident's information) dated 4/15/2026 indicated Resident 32 was admitted to the facility on [DATE] with a diagnosis of abnormalities of gait and mobility.During an interview on 4/14/2026, at 8:23 AM, with Resident 32, Resident 32 stated I fell. Resident 32 stated that he lost his balance and fell while getting out of bed on the previous day.A review of Resident 32's Care Plan Report, undated, indicated there was no care plan problem related to Resident 32's fall incident on 4/13/2026. During a concurrent interview and record review on 4/15/2026, at 4:32 PM, with Licensed Vocational Nurse 6 (LVN 6) in the presence of Registered Nurse 1 (RN 1), Resident 32's Care Plan Report, undated, was reviewed. LVN 6 and RN 1 confirmed Resident 32 had an actual unwitnessed fall on 4/13/2026 and did not have a care plan developed for the fall.During a concurrent interview and record review on 4/15/2026, at 4:52 PM, with the Minimum Data Set Coordinator (MDSC), Resident 32's Care Plan Report, undated, was reviewed. The MDSC confirmed that no care plan was developed for Resident 32 following the fall on 4/13/2026. MDSC further clarified that a short-term care plan should have been documented and initiated by RN 1.A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, undated, indicated A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.A review of the facility's P&P titled, Falls and Fall Risk, Managing, undated, indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review, the facility failed to ensure accurate accountability of controlled medications (controlled substances [CS], those with high potential for abuse and addiction) when the Controlled Substance Records (CSR, accountability records) for one of three randomly selected residents (Resident 41) did not reconcile with the Medication Administration Records (MAR, daily documentation record used by a licensed nurse to document medications and treatments given to a resident). This failure resulted in inaccurate accountability of controlled substances and the potential for unidentified discrepancies and possible abuse or diversion of controlled substances. Findings:A review of Resident 41's physician's orders, dated 3/19/26, indicated Resident 41 had orders for tramadol (a controlled medication for pain) 50 milligrams (mg), Give 1 tablet by mouth every 6 hours as needed for severe pain. During a concurrent interview and record review on 4/14/26, at 4:10 PM, with Licensed Vocational Nurse 3 (LVN 3), Resident 41's CSR, dated 3/20/26, and MAR, dated March 2026, were reviewed. The CSR indicated nursing staff removed one tablet of tramadol 50 mg on 3/24/26 at 7:48 AM and one on 3/27/26 at 8:05 AM. The MAR indicated tramadol was not administered to Resident 41 on 3/24/26 or 3/27/26. LVN 3 stated Resident 41's MAR was missing documentation. LVN 3 stated it looked like the tramadol was not given to Resident 41 on 3/24/26 or 3/27/26. LVN 3 stated the medication administration needed to be documented on the MAR. During an interview on 4/15/26, at 10:07 AM, with LVN 4, LVN 4 stated nurses were supposed to verify the counts of controlled substances at each shift change to identify discrepancies. LVN 4 stated nurses were supposed to document administration of controlled substances in the CSR and the MAR. LVN 4 stated the CSR and the MAR should match. During an interview on 4/15/26, at 10:35 AM, with the Director of Staff Development (DSD), the DSD stated the expectation was for nurses to sign out the controlled medication on the CSR and to document the administration in the MAR. The DSD stated the purpose of narcotic accountability procedures was to identify discrepancies. During an interview on 4/15/26, at 10:55 AM, with the Director of Nursing (DON), the DON stated the nurse was supposed to document the removed tramadol in both the CSR and the administration in the MAR. A review of the facility's policy and procedure (P&P) titled, Documentation of Medication Administration, dated April 2007, was reviewed. The P&P indicated, Administration of medication must be documented immediately after (never before) it is given.

Based on observation, interview and record review, the facility failed to implement infection prevention and control practices to provide a safe and sanitary environment when a used urinal was found on one of 49 residents (Resident 32)'s bedside table. This deficient practice had the potential to expose residents to infection-causing substances in the facility. Findings:During an observation on 4/13/2026, at 9:23 AM, a urinal with bloody urine was found on Resident 32's bedside table next to a water pitcher. Bloody urine was observed on the outside of the urinal near the opening at the top and the lid was open.During an observation on 4/13/2026, at 3:20 PM, a urinal with bloody urine was found on Resident 32's bedside table next to a water pitcher and an empty food tray. Bloody urine was observed on the outside of the urinal near the opening at the top, and the lid was open.During an interview on 4/13/26, at 3:23 PM, with Certified Nursing Assistant 2 (CNA 2), CNA 2 verified the urinal with urine was on Resident 32's bedside table next to an empty food tray and confirmed the urinal should not be stored there.During a concurrent interview and record review on 4/16/2026, at 11:51 PM, with the Infection Preventionist (IP), the facility's undated policy and procedure (P&P) titled, Policies and Practices - Infection Control was reviewed. The P&P indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The IP stated the policy was not followed when the urinal with bloody urine was found on Resident 32's bedside table.

Based on observation, interview, and record review, the facility failed to provide food at appropriate temperatures according to the residents' preferences for three out of five sample residents, Residents 3, 4, and 5.This failure had the potential for Residents 3, 4, and 5 to be at risk for decreased nutritional intake which could cause unplanned weight loss and affect their overall nutritional status.Findings: On December 22, 2025, at 7:17 a.m., during a concurrent observation and interview, Resident 3 was sitting in his wheelchair in the dining room and was served breakfast. Resident 3 began eating his food, and stated the food was warm, but sometimes his breakfast was cold, and he had to wait 20 minutes to get his food in the dining room.On December 22, 2025, at 7:18 a.m., during an observation in the dining room, Resident 4 was served breakfast. On December 22, 2025, at 7:40 a.m., during a concurrent observation and interview, Resident 5 was sitting in her bed, and was almost finished with her breakfast. Resident 5 stated her breakfast was cold and that the food is often cold. On December 22, 2025, at 8:14 a.m., during a concurrent observation and interview, Resident 4 was in his room sitting in bed and watching television. Resident 4 stated his breakfast was lukewarm and almost cold. Resident 4 stated he thought that by eating in the dining room, which was close to the kitchen, he would receive warm food, but he did not. Resident 4 stated there were other times his food was served cold but since nothing changed after he reported it he stopped complaining about the cold food.On December 22, 2025, at 10:12 a.m., during a telephone interview, the Registered Dietitian (RD) stated the expectation is the food should be palatable (pleasant and acceptable to the taste), warm and up to the residents' expectations. On December 22, 2025, at 11:54 a.m., during an interview, the ADM stated the residents should not be served cold food.A review of Resident 3's admission Record indicated he was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure). Resident 3's History and Physical (H&P) dated November 4, 2025, indicated he has the capacity to understand and make decisions.A review of Resident 4's admission Record indicated he was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (high blood sugar). Resident 4's H&P dated July 12, 2025, indicated he has the capacity to understand and make decisions.A review of Resident 5's admission Record indicated she was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. Resident 5's H&P dated November 12, 2025, indicated she has the capacity to understand and make decisions.A review of the facility's policy and procedure titled, Food and Nutrition Services dated October 2017, indicated, .each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Food and nutrition staff will inspect food trays to ensure .the food appears palatable and attractive and it is served at a safe and appetizing temperature .

Based on observation, interview, and record review, the facility failed to ensure a care plan was initiated and/or developed to address the diagnoses of epistaxis (bleeding from the nose) for one of one residents reviewed for quality of care (Resident 1).This failure had the potential for Resident 1 to not be monitored for epistaxis complications and delayed treatment, increasing the risk of further harm. Findings:On November 25, 2025, at 8:00 a.m. an unannounced visit was conducted at the facility to investigate a facility reported incident.On November 25, 2025, at 8:00 a.m., an observation with a concurrent interview was conducted with Resident 1. Resident 1 was observed in bed, alert and interviewable. Red stains resembling blood were observed on Resident 1's gown, specifically in the chest area. Similar stains were also noted on a washcloth located beside Resident 1. Resident 1 stated she experienced nose bleeds often. On November 25,2025, at 8: 15a.m, an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 1 had episodes of nose bleeding since she started working at the facility about a month ago. LVN 1 stated Resident 1's episodes of nose bleeds have been referred to her primary physician.On November 25, 2025, Resident 1's record was reviewed. Resident 1 was readmitted to the facility on [DATE] with diagnoses including Right Distal Femur Fracture (broken leg).The Nurse Practitioner (NP) progress notes, dated November 4, 9, 12, 16, 19, and 24, 2025, indicated Resident 1 had epistaxis. There was no documented evidence that a care plan was developed to address Resident 1's epistaxis during these dates.On November 25,2025 at 9:30 a.m., an interview with a concurrent record review was conducted with the Director of Nursing (DON). The DON stated:- Resident 1 had history of nose bleeding prior to her hospitalization on November 4, 2025;-Resident 1 had epistaxis as noted by the NP on November 4, 9, 12, 16, 19, and 24, 2025;-Resident 1 was being monitored for the side effects of anticoagulant (blood-thinning medicine that helps prevent clots) and antiplatelet (medicine that prevents blood cells from sticking together to make clots) medication, such as nosebleeds. The electronic Medication Administration Record (eMAR) dated November 1 to 30, 2025, showed no episodes of nose bleeds from November 9 to 25, 2025.- There was no documentation the licensed nurses identified and referred to the physician Resident 1's episodes of epistaxis from November 9 to 24, 2025;- There was no care plan developed or initiated to address Resident 1's epistaxis since she was re-admitted from the acute hospital on November 4, 2025; and- A care plan should have been initiated on November 4, 2025, to monitor Resident 1's need for interventions to address epistaxis. In addition, a care plan was needed to communicate the plan of care to address Resident 1's epistaxis. The facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated and revised in December 2016, indicated, .Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence .Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition .When the resident has been readmitted to the facility from a hospital/rehabilitation stay; and at least quarterly .

Based on observation, interview, and record review, the facility failed to ensure two of two residents reviewed for breathing treatment therapy (Residents 4 and 2), were monitored during and after nebulizer treatments (breathing treatments that turn liquid medicine into a mist).This failure placed the residents at risk for delayed treatment related to possible complications of the nebulizing treatment such as rapid heart rate, restlessness, chest pain and/or difficulty breathing.Findings:1.On November 25, 2025, at 8:30 a.m., and observation was conducted with Resident 4. Resident was in bed, alert, and non-verbal. A nebulizer mask (mask used to breathe in medicated mist) was observed connected over her nose and mouth. The medication chamber (small cup that holds the liquid medicine) was observed empty. There was no licensed nurse observed beside Resident 4.On November 25, 2025, at 8:45 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated she should have stayed in the room with Resident 4 during the breathing treatment per facility policy. On November 25, 2025, at 9:10 a.m., an observation with a concurrent interview was conducted with LVN 1. She stated she was the licensed nurse assigned to Resident 4 and she administered the breathing treatment (misted medication session) at 8:00 a.m. LVN 1 stated each breathing treatment last approximately 15-20 minutes. LVN 1 stated she had left the room because another resident had called for assistance. LVN 1 stated the correct procedure was to remain with the resident during the breathing treatment to observe for difficulty breathing (trouble catching their breath). LVN 1 stated the possible outcome of leaving the mask on the resident after the medication was gone was that the resident may become anxious, have trouble breathing, or refuse the next treatment. On November 25, 2025, at 9:10 a.m. LVN 1 was observed removing the nebulizing mask off Resident 4.On November 25, 2025, Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnosis including hypoxia (low oxygen level in the blood).The physician's order dated December 4, 2024, indicated to administer .Albuterol Inhalation Solution 0.5-2.5 (3) MG(milligram-unit of measurement)/3(ML) (millimeter-unit of measurement) (Ipratropium-Albuterol) 1 Vial (nebulizer medication treatment/misted medication) . To be given three times a day for shortness of breath. The electronic Medication Administration Record (eMAR) dated November 25, 2025, indicated LVN 1 administered the medication Albuterol to Resident 4 at 8 a.m.On November 25, 2025 at 9:30 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the licensed nurse was expected to remain with the resident during breathing treatment and remove the nebulizer face mask when the treatment was completed. 2. On November 25, 2025, at 8:54 a.m., an observation was conducted with Resident 2. Resident 2 was observed in bed, alert and oriented. Resident 2 had a nebulizer face mask in place with no medication solution remaining in the medication chamber. Resident 2 was observed with no licensed nurse present at bedside. On November 25, 2025, at 9:10 a.m., an interview was conducted with LVN 2. LVN 2 stated the correct way to administer a nebulizer treatment (breathing-mist medication) is to observe the resident for any difficulty breathing (trouble catching their breath) and remain with the resident during medication administration. LVN 2 stated it was not acceptable to leave the mask on Resident 2 for an hour because there is no medication solution left. LVN 2 stated she gave the breathing treatment medication, left the resident, and did not turn off the machine until 9:10 a.m. LVN 2 stated the possible outcome of leaving the mask on for that length of time is the resident might become anxious and refuse the next breathing treatment. LVN 2 stated she left the room because she was called out to assist another resident. LVN 2 stated that Resident 2 had the face mask on for an hour. LVN 2 stated each breathing treatment (mist medication session) lasts approximately 15 minutes. On November 25, 2025, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnosis including Chronic Respiratory Failure with Hypoxia (low oxygen in the blood)A physician order dated April 4,2025, indicated to administer, .Budenoside Inhalation suspension (breathing treatment medication) 0.5 MG (milligrams- unit of measurement)/2ML (milliliters - unit of measurement) 1 mg inhale two times a day related to for Chronic Obstructive Pulmonary Disease with Exacerbation (a long-term lung disease that makes it hard to breath, with a recent flare-up/worsening episode) . The electronic Medication Administration Record (eMAR) dated November 25, 2025 indicated LVN 2 administered the medication Budenoside at 8:00 a.m. On November 25,2025 at 9:30 a.m., an interview was conducted with the Director of Nursing (DON) The DON stated the licensed nurse should have removed Resident 2's nebulizer face mask once the medication was completed and monitored the resident during and after the treatment for any signs of difficulty breathing, anxiety, or distress. The DON stated this practice was required to ensure resident safety during breathing treatments.The facility's policy and procedure titled, Administering Medications Through a Small Volume Nebulizer, dated October 2010 was reviewed. The policy indicated, .The purpose of this procedure is to safely and aseptically (free from contamination) administer aerosolized particles of medication into the resident's airway . General guidelines are to follow the medication administration guidelines in the policy entitled Administering Medications .Steps in the Procedure .Assemble nebulizer equipment and attach to the source of gas per manufacture's instructions .Turn off the nebulizer and check the outflow port for visible mist .Instruct the resident to take a deep breath, pause briefly and then exhale normally .Encourage the resident to repeat the above breathing pattern until the medication is completely nebulized, or until the designated time of treatment has been reached .Remain with the resident for the treatment .Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment .Encourage the resident to cough and expectorate as needed .Administer therapy until it is gone .When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup .Obtain post-treatment pulse, respiratory rate and lung sounds .

Based on interview and record review, the facility failed to ensure pharmacy services were provided to meet the needs of the resident when one prescribed medication was not administered as ordered on twelve separate occasions for one of one resident (Resident 23). This failure had the potential to result in ineffective treatment of Resident 23's symptoms and interrupted care. Findings: Resident 23's record was reviewed. Resident 23 was readmitted to the facility on [DATE], with diagnoses which included dementia with psychotic disturbances (a cognitive decline accompanied by psychosis - hallucinations and/or delusions) and impulse disorder (inability to resist urges or impulses that can lead to harmful or disruptive behaviors). A review of Resident 23's Physician Order, dated March 14, 2025, indicated, .increase Rexulti (antipsychotic medicine used to treat dementia that helps balance chemicals in the brain known to affect mood and thoughts.) 0.5 mg (milligram - a unit of measurement) to Rexulti 2 mg by mouth one time a day for unspecified psychosis manifested by delusions . A review of Resident 23's Medication Administration Record (MAR), for the month of March and April 2025, indicated Rexulti 2 mg was not administered on March 15, 19, 27, 28, and 30, and on April 1, 2, 3, 5, 6, 7, 8, 2025 - 12 missed doses total. A review of Resident 23's Progress Notes indicated, - Dated March 15, 19, and 27, 2025, indicated .pending rx (prescription) delivery, physician notified . - Dated March 28, 2025, indicated .pending authorization . - Dated March 30, 2025, did not indicate the medication Rexulti was administered. - Dated April 1, 2, and 3, 2025, indicated .pending auth (authorization) .followed up with pharmacy . - Dated April 5 and 6, 2025, indicated .medication not on hand will follow up with pharmacy MD (physician) aware no new orders at this time . - Dated April 7 and 8, 2025, indicated .pending auth, MD aware no new orders . - Dated April 10, 2025, at 7:10 a.m., indicated .discontinue Rexulti 2mg . On April 10, 2025, at 11:15 a.m. an interview and a concurrent record review was conducted with the DON. The DON stated the medication was not available due to delayed delivery, pending insurance authorization, and lack of follow-up with pharmacy. The DON stated, the medication should have been given or substituted with a covered alternative. On April 11, 2025, at 9:06 a.m., an interview and concurrent record review was conducted with the Pharmacist. The Pharmacist stated Rexulti 2 mg was prescribed and should not have been missed. The facility's policy and procedure titled, Administering Medication revised, April 2019, was reviewed. The policy indicated, .The director of nursing services supervises and directs all personnel who administer medications .Medications are administered in accordance with prescribed orders, including any required time frame .

Based on observations, interviews, and record review, the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. Dietary staff, including the dietitian, were not aware of the manufacturer's recommended time guidelines for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces); 2. [NAME] 2 did not demonstrate competency in performing assigned duties; (Cross reference 803) 3. [NAME] 1 did not demonstrate competency in performing assigned duties; and (Cross reference 803) 4. [NAME] 3 did not follow the prescribed recipe when preparing pureed macaroni and cheese during dinner on April 9, 2025. These failures had the potential to cause foodborne illness for 49 out of 50 sampled residents and compromised the nutritional status of residents receiving food from the facility's kitchen. Findings: 1. A review of the Quat sanitizer manufacturer's guidelines posted above 2 compartment sink at the kitchen indicated, Dip test paper for 10 seconds in test solution On April 8, 2025, at 10:45 a.m., a concurrent observation and interview was conducted with [NAME] 1 (CK 1). CK 1 was asked to test the Quat sanitizer solution in the sanitizer bucket. CK 1 dipped the test strip into sanitizer solution for 3 seconds and stated she needed to dip the test strip for 3 seconds to check the concentration of the Quat sanitizer. On April 8, 2025, at 11:05 a.m., a concurrent observation and interview was conducted with Diet Aide 1 (DA 1). DA 1 was asked to test the Quat sanitizer solution in the sanitizer bucket. DA 1 stated she need to dip the test strip into sanitizer solution for 5 seconds to check the concentration of the Quat sanitizer. On April 9, 2025, at 12:08 p.m., a concurrent observation and interview was conducted with DA 2. DA 2 was asked to test the Quat sanitizer solution in the sanitizer bucket. DA 2 stated she was not sure how long she needed to dip the test strip into sanitizer solution. On April 10, 2025, at 2:20 p.m., an interview was conducted with the Registered Dietitian 1 (RD 1) and Dietary Supervisor (DSS). The DSS stated the test strip needed to be dipped into the Quat sanitizer solution for 10 - 15 seconds to check the concentration of the Quat sanitizer. RD 1 was unsure of the duration but agreed the DSS statement. The RD stated failure to follow the manufacturer's guideline for testing Quat sanitizer could result in an inaccurate reading of Quat sanitizer concentration. The RD explained that inaccurate reading of Quat sanitizer concentration could lead to inadequate sanitation of food contact surfaces. 2. During general food production observations, issues were observed related to [NAME] 2 (CK 2) competency: a.) During an observation, on 4/9/2025, at 10:41 a.m., [NAME] 2 did not follow the recipes when preparing pureed peas and meat. b.) On April 9, 2025, at 11:59 a.m., during an observation before lunch tray plating started, it was noted that rice was not available on the trayline (a system of food preparation in which trays move along an assembly line). Resident 3, who was on a physician ordered renal diet, should have been served rice according to the [NAME] Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diets) and the resident was served oven-brown potatoes, the same food items as residents on the regular diet. c.) During an observation of noon meal plating, on 4/9/22, at 12:03 p.m., CK 2 was observed using a 3 oz scoop instead of the required 4 oz scoop to serve mechanical soft meat for residents on mechanical soft diets, as outlined in the [NAME] Spreadsheet. During a phone interview on April 10, 2025, at 3:16 p.m., with RD 2. RD 2 stated Cooks are expected to follow recipes, the [NAME] Spreadsheet, and the menu when preparing food. During a review of the facility Job Description, titled LINE COOK/PREP COOK, undated, the job description indicated, The purpose of your job position is to prepare, cook, and present well-balance meals .to the highest quality incorporating .dietary needs as required by the residents and staff of the facility. 3. During general food production observations, issues were observed related to CK 1 competency: a.) During a general food production observation on April 8, 2025, from 8:37 a.m. until 11:54 a.m., before the start of the lunch tray plating, corn was not available on the trayline. Resident 3 who had a physician-ordered renal diet and Resident 33 who had a physician-ordered heart-healthy diet should have been served corn. Residents 3 and 33 were served the same food item as residents on a regular diet-pinto beans. b.) On April 8, 2025, at 12:27 p.m., a concurrent observation, Resident 34, who had a physician-ordered consistent carbohydrate diet, was served an extra taco during lunch. During an interview on April 10, 2025, at 3:16 p.m., with the RD 2. The RD 2 stated Cooks were required to follow the [NAME] Spreadsheet when preparing and serving food. During a review of the facility Job Description, titled LINE COOK/PREP COOK, undated, the job description indicated, The purpose of your job position is to prepare, cook, and present well-balance meals .to the highest quality incorporating .dietary needs as required by the residents and staff of the facility. 4. During a review of the posted menu on 4/9/2025 indicated, Dinner: Creamy Ranch Macaroni and Cheese On April 9, 2025, at 6:01 p.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DSS) in the dining room. During observation of pureed diets, an unidentified dark brown pureed food item was being served as an entree. The DSS stated CK 3 had modified the recipe for pureed Creamy Ranch Macaroni and Cheese by adding chicken, beef broth and a small amount of Macaroni and Cheese to increase the protein and calories content. During a phone interview on April 10, 2025, at 3:16 p.m., with RD 2. RD 2 stated she unaware CK 3 had modified the recipe. RD 2 stated as a best practice, cooks are required to consult the dietitian prior to modifying any recipes. During a review of the facility Job Description, titled LINE COOK/PREP COOK, undated, the job description indicated, The purpose of your job position is to prepare, cook, and present well-balance meals .to the highest quality incorporating .dietary needs as required by the residents and staff of the facility. During a review of the facility provided Recipe titled, Creamy Ranch Macaroni and Cheese, indicated, .Diet Notes: Meals need to be modified to suit individual patient/resident tolerance as determined by appropriate healthcare provider at the community level. The recipe did not include chicken and beef broth as ingredients.

Based on observations, interviews and record reviews, the facility failed to ensure: 1. [NAME] 2 followed the recipe when preparing pureed meat and peas during lunch on April 9, 2025; 2. [NAME] 2 used the correct scoop to portion mechanical soft meat during lunch on April 9, 2025; 3. Resident 34, who had a physician-ordered Consistent Carbohydrate (CCHO) diet, was served the correct portion of taco during lunch on April 8, 2025; 4. Resident 3, who had a physician-ordered renal diet, was served appropriate food items during lunch on April 9, 2025, and April 10, 2025; and 5. Resident 33, who had physician-ordered heart healthy diet, was served appropriate food items during lunch on April 9, 2025. These failures had the potential to result in residents receiving food that did not meet their prescribed dietary needs, which could lead to nutrition-related health complications. Findings: (Cross Reference 802) 1. During a general food production observation and interview conducted on April 9, 2025, at 10:41 a.m., in the kitchen with [NAME] 2 (CK 2), CK 2 was observed preparing pureed peas. CK 2 blended peas with white bread together to make pureed peas. CK 2 stated he added six slices of white bread to make 12 servings of pureed peas. During the process, CK 2 did not refer to the pureed vegetable recipe. During a general food production observation and interview conducted on April 9, 2025, at 11:45 a.m., with CK 2. CK 2 was observed preparing pureed meat. CK 2 placed some beef, slices of white bread, some unmeasured meat juice and beef broth into a food processor. CK 2 stated he used 10 servings of beef and five slices of white bread as stabilizer to prepare the pureed meat. During the process, CK 2 did not refer to the pureed meat recipe during preparation. During a phone interview on April 10, 2025, at 3:16 p.m., with the Registered Dietitian 2 (RD 2). The RD 2 stated this was unusual practice for cooks to add bread to make pureed diet and unaware CK 2 adding breads into pureed food items. The RD explained adding breads into pureed food items would alter the nutritional content by increasing the carbohydrate level. The RD stated all food service staff were required to follow recipes when preparing food. During a review of the facility provided recipes for the Pureed vegetables and Pureed Meat, the recipes did not indicate adding breads as stabilizer. During a review of the facility document titled, The Facility's Resident Diet order Listing Report, dated April 8, 2025, indicated Nine residents, Residents 6, 8,10, 19, 20, 26, 28, 33 and 42 were on a pureed diet (the food texture should be smooth for residents who have difficulty chewing and/ or swallowing ability). During a review of the facility's Policy and Procedure (P&P) titled, Standardized Recipes, Revised dated April 2007, the P&P indicated, .Standardized recipes will be used to prepare foods. 2. During a review of the [NAME] Spreadsheet (the document used to guide dietary staff on food items, portions, and therapeutic diets) on April 9, 2025, indicated, Mechanical soft diet: Meat used number (#) 8 scoop [4 ounces (oz- a unit of measurement]. On April 9, 2025, at 12:03 p.m., a concurrent observation and interview was conducted with CK 2 at the trayline (a system of food preparation in which trays move along an assembly line). CK 2 was observed using a # 10 scoop (3 oz) to serve mechanical soft meat for residents on mechanical soft diet. CK 2 confirmed that the scoop he used was 3 ounces, not the required 4 oz. During a phone interview on April 10, 2025, at 3:16 p.m., with RD 2. RD 2 stated CK 2 did not serve the correct portion size by using a 3 oz scoop. The RD stated, using a smaller scoop could result in residents not receiving adequate calories. RD 2 stated all food service staff were required to follow menu and the [NAME] spreadsheets. During a review of the facility document titled, The Facility's Resident Diet order Listing Report, dated April 8, 2025, indicated ten residents, Residents 2, 3, 9, 21, 22, 24, 25, 34, 37, and 46 were on a Mechanical soft diet. During a review of the facility's Policy and Procedure (P&P) titled, Menus, Revised dated October 2017, the P&P indicated, Menus are developed and prepared to meet resident .needs while following established national guidelines for nutritional adequacy.1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutritional Board. 3. During a review of the [NAME] Spreadsheet on April 8, 2025, indicated, CCHO: Beef Soft Taco 1 Each. On April 8, 2025, at 12:27 p.m., a concurrent observation, interview and review of Resident 34's meal tray card were conducted with the Activity Director (AD). Resident 34's meal tray card indicated CCHO diet. Observation revealed that Resident 34 was served two tacos. The AD confirmed that Resident 34 had been served two Tacos. On April 10, 2025, at 3:16 p.m., a concurrent interview and review of the [NAME] spreadsheet dated 4/8/25 were conducted with RD 1. RD 1 stated residents on a CCHO diet should receive one Taco. RD 1 further stated [NAME] 1 should have followed the [NAME] spreadsheet. RD 1 explained that not following the [NAME] spreadsheet and serving extra food items could potentially cause hyperglycemia (high blood sugar) and weight gain. During a review of the Resident's 34 Order Summary Report, dated 4/9/2025, Physician's Diet order indicated, Order date: 5/28/2024: CCHO. During a review of the facility provided Recipe titled, Beef Soft Tacos, indicated, CCHO: Beef Soft Taco - 1 Each. During a review of the facility provided document titled, DIET DESCRIPTIONS, indicated, Consistent Carbohydrates (CCHO). This diet is based upon the regular diet. However, because the carbohydrate content of meals produces the largest influence on blood sugar levels, meals are planned to provide a consistent amount of carbohydrates from day to day. 4. During a review of the [NAME] Spreadsheet on April 8, 2025, indicated, Renal diet served Seasoned Corn. During a general food production observation on April 8, 2025, from 8:37 a.m. to 11:54 a.m., before the start of lunch tray plating, it was noted that corn was not available on the steam table at the trayline. Resident 3, who had a physician-ordered renal diet, was served the same food item as residents on a regular diet - pinto beans, and should have been served corn per [NAME] Spreadsheet. During a review of the [NAME] Spreadsheet on April 9, 2025, indicated, Renal diet served low salt Seasoned Rice. On April 9, 2025, at 11:59 a.m., during an observation before lunch tray plating, rice was not available on the steam table. Resident 3 was served oven-browned potatoes, the same item served to residents on the regular diet, and should been served rice per the [NAME] Spreadsheet. During an interview on April 10, 2025, at 3:16 p.m., with the RD 1. The RD 1 stated it was important for dietary staff to follow the [NAME] Spreadsheet guidance on different food items needed to be served on different therapeutic diets. The RD stated pinto beans are high in phosphorus, and potatoes are high in potassium. RD 1 stated, consumption of these foods could negatively affect a renal diet resident's blood phosphorus and potassium levels, which may compromise their medical and nutritional status. During a review of the Resident's 3 Order Summary Report, dated 4/9/2025, Physician's Diet order indicated, Order date: 8/30/2024: Renal 80 gram protein diet During a review of the facility provided Recipe titled, Pinto Beans, indicated, NOT APPROPRIATE for the following diet(s).RENAL . During a review of the facility provided Recipe titled, Oven Browned Potatoes, indicated, NOT APPROPRIATE for the following diet(s).RENAL. During a review of the facility provided document titled, RENAL DIET, indicated, The Renal Diet, .is intended to control the intake of potassium, sodium, phosphorus, and protein when the resident has very little or no kidney function and is on dialysis. This diet is designed to reduce the amount of fluid and waste that builds up . 5. During a review of the [NAME] Spreadsheet on April 8, 2025, indicated, Heart Healthy diet served Seasoned Corn. During a general food production observation on April 8, 2025, from 8:37 a.m. until 11:54 a.m., before the start of a lunch tray plating, there was no corn available on the steam table at the trayline. Resident 33, who had a physician-ordered Heart Healthy diet should have been served corn per the [NAME] Spreadsheet but was instead served the same food item as residents on a regular diet - pinto beans. During a phone interview on April 10, 2025, at 3:16 p.m., with RD 2. RD 2 stated cooks should make the effort to follow the Cooks Spreadsheet. RD 2 stated, otherwise, residents on therapeutic diets may be served food items not appropriate for their diet which could result in residents not receiving proper nutrients. During a review of the Resident's 33 Order Summary Report, dated 4/9/2025, Physician's Diet order indicated, Order date: 2/10/2025: Heart Healthy diet During a review of the facility provided Recipe titled, Pinto Beans, indicated, NOT APPROPRIATE for the following diet(s).HEART HEALTHY. During a review of the facility provided document titled, HEART HEALTHY DIET, indicated, General Information. The Heart Healthy (Low Fat/Low Cholesterol/2-2.5 gram Sodium) diet is intended for lowering the risk of developing heart disease by limiting the intake of fat, cholesterol and sodium.

Based on observation, interview, and record review, the facility failed to ensure a resident with a prescribed nectar-thick liquid consistency, as ordered by the physician, was served regular thin liquid coffee, for one of nine residents (Resident 8). This failure had the potential to cause resident to choke or aspirate (inhalation of food or liquid into the lungs), placing them at risk for serious health complications. Findings: On April 8, 2025, at 12:17 p.m., during a concurrent observation and interview with the Certified Nursing Assistant (CNA). Resident 8 was observed eating her lunch in the dining room. Resident 8 was served a cup of regular thin liquid coffee. The CNA who was assisting Resident 8 with feeding, stated, the coffee was provided ready to drink and stated she had not checked the consistency. The CNA stated, Resident 8 should not have received a thin liquid. On April 10, 2025, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE], with diagnoses which included dysphagia (difficulty in swallowing). A review of Resident 8's History and Physical, dated May 15, 2024, indicated Resident 8 was not capable of making her own decisions. A review of Resident 8's Order Summary, dated January 19, 2025, indicated, .Puree texture, Nectar Thick Liquid consistency . A review of Resident 8's Nutritional Assessment Form, dated February 19, 2025, indicated Resident 8 had a swallowing problem. On April 10, 2024, at 3:34 p.m., during an interview with Registered Dietician (RD) 2. RD 2 stated dietary and nursing staff should follow dietary order. RD2 further stated serving a thin liquid instead of nectar-thickened liquid could lead to choking or aspiration. A review of the facility's diet manual section titled, Mildly Thick, was reviewed. The manual dated July 2019, indicated, .No oral processing or chewing required-can be swallowed directly . A review of the facility's diet manual section titled, Pureed Fish/Meat/Poultry, dated August 2018, indicated, .Process until meat is smooth in consistency .Ensure mixture achieves moist mashed potato or pudding-like consistency .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Dust was observed on kitchen equipment and in various locations within the kitchen; 2. An expired sanitizer test strip was found in use. 3. A box of nutritional shake was stored next to defrosting raw meat in the refrigerator; 4. Wilted cilantro was found stored in Reach in Refrigerator # (number) 1; 5. An open bottle of lemonade syrup was stored next to a sanitizer solution bucket; 6. Dust accumulation was oberved on the floor under a table counter; 7. Black grime buildup was observed on the outside of the oven; 8. Three white plastic spatula, two serving tongs handle, and one small spatula had chipped; 9. A trash bag was used as a liner to store a bulk quantity of sugar; and 10. One unlabeled soda was found in a resident's refrigerator. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 49 out of 49 residents who received food prepared in the kitchen. 11. Pureed meat and bread were not prepared in the correct texture and consistency. This failure had the potential to cause difficulties with swallowing, increase the risk of choking or aspiration (food entering the lungs), and impact the resident's nutritional intake. Findings: 1. On [DATE], at 8:57 a.m., a concurrent observation and interview with the Dietary Service Supervisor (DSS) was conducted in the kitchen, in the reach-in refrigerator area. The fan grids were observed to covered in dust. The DSS confirmed fan's grids were covered with dust. On [DATE], at 10:03 a.m., a concurrent observation and interview with the DSS was conducted, in the kitchen. Dust was noted behind and above the convection oven. The DSS confirmed behind and above the convention oven was dusty. On [DATE], at 2:38 p.m., an interview with Registered Dietitian (RD 1) was conducted. RD 1 stated, dust in food preparation area could cause cross-contamination. During a review of the U.S. Food and Drug Administration's (FDA) Food Code 2022, Section ,d+[DATE].13 Nonfood-Contact Surfaces, the Food Code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 2. On [DATE], at 10:45 a.m., a concurrent observation and interview with the DSS was conducted, in the kitchen. A Quat sanitizer test strip (brand of sanitizer test strip) was observed with an expiration date of [DATE]. The DSS stated the Quat sanitizer test strip was expired, should have been tossed away, and should not be use. On [DATE], at 2:38 p.m., an interview with RD 1 was conducted. RD 1 stated expired strip should have been removed and replaced with updated strip. RD 1 stated expired strip could give inaccurate readings, making sanitizing solutions ineffective. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Environment Surfaces, dated [DATE], indicated, .Manufacturer's instructions will be followed for proper use of disinfecting (or detergent) products including .shelf-life .safe use and disposal . 3. On [DATE], at 8:51 a.m., a concurrent observation, interview, and record review with the DSS was conducted, in the kitchen, in front of the Reach-in refrigerator # 1. A ready-to-drink shake was stored next to raw defrosting meat in Reach-in Refrigerator # 1, against a posted storage guidelines, Ready-to-Eat-Foods stored at (Top Shelf). The DSS stated the staff kept the ready to drink shake in the bottom of the refrigerator beside the defrost raw meat. The DSS further stated it should have been stored on top of the shelves to prevent contamination of food. On [DATE], at 2:39 p.m., an interview with RD 1 was conducted. RD 1 stated staff should follow proper storage of the food. RD 1 further stated ready to drink food should have been placed on top of the shelves and not on the bottom shelves next to defrost meat to prevent potential contamination. A review of the facility's policy and procedure titled, Food Receiving and Storage, dated [DATE], indicated, .Foods shall be received in a manner that complies with safe food handling practices .Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods . 4. On [DATE], at 8:57 a.m., a concurrent observation and interview with the DSS was conducted, in the kitchen. Wilted cilantro was observed in REach-in Refrigerator $ !. The DSS stated the wilted cilantro should have been discarded and should have been replaced with fresh item. On [DATE], at 2:39 p.m., an interview with RD 1 was conducted. RD 1 stated the wilted cilantro should have been tossed and should not been stored in the refrigerator. RD 1 further stated the vegetable should be kept fresh. A review of the facility's policy and procedure titled, Food Receiving and Storage, dated [DATE], indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices . 5. On [DATE], at 9:38 a.m., a concurrent observation and interview with the DSS was conducted in the kitchen at Prep area. An open bottle of pink lemonade syrup was stored next to a bucket of Quat sanitizer under a prep table. The DSS stated the bottle of pink lemonade syrup should not be stored next to the red bucket sanitizer. The DSS further stated the red bucket sanitizer would contaminate the open pink lemonade syrup. On [DATE], at 2:40 p.m., an interview with RD 1 was conducted. RD 1 stated the red bucket sanitizer, and the plastic bottle of pink lemonade should not placed next to each other. RD 1 further stated the pink lemonade would potentially contaminate from the red bucket sanitizer. A review of the facility's policy and procedure titled, Food Receiving and Storage, dated [DATE], indicated, .Foods shall be received in a manner that complies with safe food handling practices .Food services, or other designated staff, will maintain clean food storage areas at all times .Soaps, detergents, cleaning compounds or similar substances will be stored in separate areas from food storage and labeled clearly . 6. On [DATE], at 9:38 a.m., a concurrent observation and interview with the DSS was conducted, in the kitchen at Prep area. Dust was noted under a kitche prep table. The DSS confirmed the dust was accumulated under the table counter. The DSS further stated the area under the table counter was hard to reach and was missed during cleaning. On [DATE], at 2:40 p.m., an interview with RD 1 was conducted. RD 1 stated dust should have been removed and cleaned under the table to prevent contamination of the kitchen. A review of the facility's policy and procedure titled, Sanitization, dated [DATE], indicated, .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish . 7. On [DATE], at 10:03 a.m., a concurrent observation and interview with the DSS was conducted in the kitchen. The exterior of the oven was observed to have accumulated black grime. The DSS stated the black grime should have been removed and the oven cleaned. On [DATE], at 2:42 p.m., an interview with RD 1 was conducted. RD 1 stated the oven should have been cleaned and should not have accumulation of grime, as it could potentially contaminate food being cooked. A review of the facility's policy and procedure titled, Sanitization, dated [DATE], indicated, .The food service area shall be maintained in a clean and sanitary manner .All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish . 8. On [DATE], at 10:10 a.m., a concurrent observation and interview with the DSS was conducted in the prep area of the kitchen. Several pieces of equipments were observed with chipped and damaged surfaces including: -Three white plastic spatula; -Two serving tongs (damaged handles) and; -One small spatula. The DSS stated any equipment with chipped and damaged should have been replaced. The DSS further stated such damage could result in contamination if pieces chipped off into food. On [DATE], at 2:43 p.m., an interview with RD 1 was conducted. RD 1 stated the damaged spatulas and serving tongs that were damaged should have been replaced with a new equipment to prevent accumulation of food in rough surfaces and to prevent mixture of chipped part surfaces to the food. A review of the facility's policy and procedure titled, Sanitization, dated [DATE], indicated, .The food service area shall be maintained in a clean and sanitary manner .All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . 9. On [DATE], at 10:33 a.m., a concurrent observation and interview with the DSS was conducted in the kitchen's dry storage area. A bulk quantity of sugar was observed stored inside a clear plastic trash bag being used as a liner. The DSS further stated plastic trash bag should not be used as a liner for storage of bulk sugar. The DSS was asked who among the dietary staff used the trash bag and she stated, I don't know. On [DATE], at 2:43 p.m., an interview with RD 1 was conducted. RD 1 stated the bulk of sugar should have been stored in food grade plastic liner and not in ordinary plastic bag. A review of the facility's policy and procedure titled, Food Receiving and Storage, dated [DATE], indicated, .Foods shall be received in a manner that complies with safe food handling practices .Food services, or other designated staff, will maintain clean food storage areas at all times . 10. On [DATE], at 3:10 p.m., a concurrent observation and interview with the Licensed Vocational Nurse (LVN) was conducted in the nurse's station. One unlabeled 7.5 oz. (ounce-unit of measurement) diet soda in can was observed inside resident's refrigerator. The LVN stated it should have been labeled with name of resident and date received. The LVN further stated food and drinks without labeled would be unsafe to resident to consumed it. On [DATE], at 3:38 p.m., an interview with RD 2 was conducted. RD 2 stated staff should follow the facility's policy and procedure in food storage. The RD 2 further stated, drinks and food should be labeled with resident's name and date received. A review of the facility's policy and procedure titled, Food Receiving and Storage, dated [DATE], indicated, .Foods shall be received in a manner that complies with safe food handling practices .All foods belonging to residents must be labeled with the resident's name, the item and the use by date .cleaning compounds or similar substances will be stored in separate areas from food storage and labeled clearly . 11. On [DATE], at 12:26 p.m., a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) for pureed diet (food texture need to blend until smooth for residents who have difficulty chewing and/or swallowing) was conducted with the Dietary Supervisor (DSS). The pureed bread was observed to have a grainy texture. After tasting the pureed bread, the DSS stated, the pureed bread was not smooth and had a grainy consistency. The DSS stated, the pureed beef texture was not smooth and still contained intact meat fibers. The DSS stated, [NAME] 2 should have blended the beef and bread for a longer period to achieve the required smooth, mashed potato-like texture. On [DATE], at 3:40 p.m., during an interview with facility Registered Dietitian (RD) 2, RD 2 stated the texture and consistency of pureed food should be smooth, not grainy. The RD further stated, residents on a pureed diet could potentially choke if the correct texture was not followed. A review of the facility's diet manual section titled Mechanically Altered Diet Explanation, dated [DATE], indicated, .Puree diet: Puree all foods to the consistency of smooth, moist mashed potatoes or pudding -like consistency . A review of the facility's diet manual section titled, Pureed Fish/Meat/Poultry, dated [DATE], indicated, .Process until meat is smooth in consistency .Ensure mixture achieves moist mashed potato or pudding-like consistency .

Based on observation, interview, and record review, the facility failed to ensure a comprehensive nutritional assessment was completed within 14 calendar days after admission for one of three residents reviewed (Resident 42). This failure had the potential to delay the provision of resident-centered care (care focusing on the needs of individuals) and nutritional interventions necessary to address the resident's health needs. Findings: On April 8, 2025, at 12:26 p.m., during a concurrent observation and interview in Resident 42's room, Resident 42 was observed eating her lunch meal. Resident 42 stated she had a new denture and was ready to eat regular food. Resident 42 further stated, she was tired of eating baby food and she did not like to lose weight. On April 10, 2025, Resident 42's record was reviewed. Resident 42 was admitted to the facility on [DATE], with diagnoses which included protein-calorie malnutrition (inadequate intake of nutritional food). A review of Resident 42's History and Physical, dated March 11, 2025, indicated Resident 42 was mentally capable of understanding. A review of Resident 42's Nutritional Assessment Form, dated March 28, 2025, indicated showed a goal weight range of 110-115 pounds and a current diet order of a regular pureed diet with thin liquids. A further review of Resident 42's Nutritional Assessment Form indicated the nutritional assessment was completed 17 days after admission. On April 10, 2025, at 8:20 a.m., during a concurrent interview and record review with the Registered Nurse (RN), the RN stated Resident 42 had been readmitted on [DATE], and the nutritional assessment was not completed until March 28, 2025, 17 days wafer admission. The RN stated, the nutritional assessment should have been completed upon admission to determine the resident's nutritional status, identify potential problems, and initiate timely interventions. The RN stated, the delay could contribute to malnutrition, functional decline, weight loss and reduced food intake. On April 10, 2025, at 3:50 p.m., during a concurrent interview and record review with Registered Dietician (RD) 2. RD 2 stated she did not recall the last time she had seen Resident 42. RD 2 stated, a nutritional assessment should have been completed within 14 days of admission per regulation. RD 2 stated, a delay in assessment could result in unmet nutritional needs and unplanned weight loss. A review of the facility's policy and procedure titled, Nutritional Assessment, dated October 2017, indicated, .As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition .The nutritional assessment will be conducted .Dietician .an estimate of calorie, protein, nutrient and fluid needs .whether the resident's current intake is adequate to meet his or her nutritional needs .

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were properly stored and disposed of when expired sterile (entirely free of microorganisms) dressings (medical bandage designed to protect a wound from infection), were found inside a treatment cart and were readily available for use. This failure had the potential to result in residents receiving wound treatments with expired dressings, leading to ineffective treatment and an increased risk of infection. Findings: On [DATE], at 11:55 a.m., during a treatment cart inspection with the Registered Nurse (RN), expired dressings were found stored in the cart and available for use. One pack of sterile, non-adhesive (designed to not stick to the wound) foam dressing with an expiration date of [DATE], and five packs of sterile gauze (made from woven fabric) dressings with an expiration date of [DATE], were observed in the treatment cart. In a concurrent interview, the RN stated the expired dressings should not have been kept in the treatment cart, readily available for use and should have been discarded. On [DATE], at 1:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the expired dressings should not be stored in the treatment cart. The facility's policy and procedure, titled, Storage of Medications, revised [DATE], was reviewed. The policy indicated, .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on observation, interview, and record review, the facility failed to ensure the therapeutic diet order (diet ordered by a physician) prescribed by the physician was followed for one of three residents (Resident 42) who had an order for a fortified diet (additional nutrients). This failure had the potential for Resident 42 to not receive adequate nutrition, which could further compromise her medical status. Findings: On April 8, 2025, at 12:26 p.m., during a concurrent observation and interview in Resident 42's room, Resident 42's meal tray card indicated a fortified diet. Resident 42 was served a full eight oz cup (ounce-unit of measurement) of tea. Resident 42 stated, she was always served tea at lunch but would prefer milk. Resident 42 further stated, I don't want to lose weight. On April 10, 2025, Resident 42's record was reviewed. Resident 42 was admitted to the facility on [DATE], with diagnoses which included mild protein-calorie malnutrition (deficiency of protein and/or calories). A review of Resident 42's History and Physical, dated March 11, 2025, indicated Resident 1 was mentally capable of understanding. A review of Resident 42's Order Summary, dated March 11, 2025, indicated, .Regular diet Pureed texture, Thin liquid consistency, fortified diet, 4 oz. heath shake with breakfast and at 1000 & 1400, and snack at bedtime . On April 9, 2024, at 5:45 p.m., during a concurrent observation and interview at bedside with the Licensed Vocational Nurse (LVN), the LVN stated, the resident's meal card indicated a fortified diet and there was no pudding served. The LVN stated she was unable to determine if the meal provided met the fortified diet requirement. On April 10, 2025, at 9:51 a.m., during a concurrent interview with the Registered Nurse (RN). The RN stated she did not know how dietary staff prepared the fortified diet. The RN further stated if resident would not receive a fortified diet, it could result in weight loss and functional decline. On April 10, 2025, at 3:47 p.m., during an interview with Registered Dietician (RD) 2, RD 2 stated she expected dietary staff to follow physician's orders and the facility's policy on therapeutic diets. RD 2 stated, Resident 42 should have received a fortified diet as ordered, and not following the therapeutic diet order could lead to weight loss, decline in function, and possible hospitalization . A review of the facility's diet manual section titled, Special Nutrition Program, dated August 2019, indicated, .The Special Nutrition Program (SNP) is a fortified food program that should provide for the increased nutritional requirements of residents .

Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physical abuse for one out of six residents reviewed (Resident 2), when another resident (Resident 1) hit Resident 2 on the head with a cane. This failure resulted in Resident 2 sustaining four lacerations (deep cut/tear in skin) on his head and bruising to his hands and shoulder. Resident 2 was transferred to the acute hospital, where he received 18 staples (surgical staples - used to close large wounds or deep cuts) to treat his head wounds. Findings: On June 4, 2024, at 9:10 a.m., an unannounced visit was made to the facility to investigate a facility-reported resident-to-resident altercation between Resident 1 and Resident 2 on June 1, 2024. On June 4, 2024, at 9:30 a.m., Resident 1 was interviewed. Resident 1 was alert and oriented. Resident 1 stated he did hit his former roommate (Resident 2) in the head with a cane because he thought Resident 2 messed with his radio. Resident 1 stated the cane was not his and he did not remember how he got the cane. On June 4, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain dysfunction), schizoaffective disorder, bipolar type (schizophrenia - hallucinations, delusions, mixed with extreme mood swings), Alzheimer ' s disease (memory loss and confusion), and impulse disorder (difficulty controlling emotions and behaviors). Resident 1 ' s BIMS (Brief Interview for Mental Status - an assessment tool) score was 10, indicating moderate cognitive (thinking) impairment. Resident 1's care plan, dated December 20, 2023, was reviewed. The care plan indicated, .Episodes of physical and verbal aggression: [episodes of agitation .breaking windows, property destruction, removing signs from walls, taking iPad chargers, etc .Goal .Will demonstrate effective coping skills . Resident 1's care plan, dated January 24, 2024, was reviewed. The care plan indicated, .Impulse control disorder m/b (manifested by) mood swings . Resident 1's psychiatry (physician who treats mental illness) note, dated May 16, 2024, was reviewed. The note indicated, .Psych consulted with resident (Resident 1) today. Pt (patient - Resident 1) continues to display behaviors that require medication to manage. Pt continues to display disruptive behaviors. Pt will pull objects off the walls such as hand sanitizer dispensers, artwork, or posters for no reason. Pt with positive symptoms of schizophrenia. Pt with positive auditory hallucinations . On June 4, 2024, at 10:40 a.m., a concurrent observation and interview was conducted with Resident 2, in his room. Resident 2 was alert and confused. Resident 2 was observed with multiple staples on the top of his head. Resident 2 stated he did not remember what happened, how he acquired the wounds. On June 4, 2024, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included disorder of the brain, epilepsy (brain disease causing seizures), legal blindness, difficulty walking, dementia (memory loss and lack of judgement), schizoaffective disorder (combination of schizophrenia - hallucinations, delusions - and mood disorder). Resident 2 ' s BIMS score was 0, indicating severe cognitive impairment. Resident 2's skin observation tool notes (a nursing assessment), dated June 1, 2024, was reviewed. The notes indicated Resident 2 sustained four lacerations to the top of his head that required 18 staples, a left-hand laceration, and discoloration to both hands and left shoulder related to the resident-to-resident altercation on June 1, 2024. On June 4, 2024, at 10:16 a.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated Resident 1 had a history of schizophrenia, had episodes of hitting himself and was violent against property (broke a window a few months ago). On June 4, 2024, at 11:15 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 1 had a history of property destruction, but no history of physical aggression. The DON stated Resident 1 ' s physical aggression towards Resident 2, on June 1, 2024, resulted in physical injuries to Resident 2 and it was the facility policy that no resident should be subjected to any kind of abuse. On June 4, 2024, at 11:38 a.m., a telephone interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 1 had a history of moments of aggression, hitting physical things and objects. On June 4, 2024, at 11:46 a.m., the Social Worker (SW) was interviewed. The SW stated she witnessed Resident 1 a few weeks ago yelling and cursing, stating I can do whatever I want and taking papers with other resident names off the wall. On June 7, 2024, at 4:15 p.m., a telephone interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated he witnessed the incident involving Resident 1 and Resident 2 on June 1, 2024, shortly after midnight. CNA 1 stated Resident 1 hit Resident 2 three times in the head with a cane. CNA 1 witnessed Resident 2 sitting on the floor in his room, and Resident 1 was in his wheelchair, leaning forward when he hit Resident 2 with the cane. CNA 1 stated there was blood on Resident 2 ' s face and head. CNA 1 stated Resident 2 sustained a bloody head injury from being hit by Resident 1 with a cane. CNA 1 stated no abuse, including resident to resident abuse was allowed, per facility policy. The facility policy and procedure titled, Abuse Prevention Program, revised December 2016, was reviewed. The policy and procedure indicated, .Our residents have the right to be free from abuse .This includes but is not limited to .physical abuse .Protect our residents from abuse by anyone including .other residents .

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for one out of six residents reviewed for accidents, when Resident 1 had access to a cane which he used to hit Resident 2. This failure resulted in Resident 2 sustaining four lacerations (deep cut/tear in skin) on his head and bruising to his hands and shoulder. Resident 2 was transferred to the acute hospital, where he received 18 staples (surgical staples - used to close large wounds or deep cuts) to treat his head wounds. Findings: On June 4, 2024, at 9:10 a.m., an unannounced visit was made to the facility to investigate a facility-reported resident-to-resident altercation. On June 4, 2024, at 9:10 a.m., the Director of Nursing (DON) was interviewed. The DON stated Resident 1 had a history of property destruction. The DON stated Resident 1 hit Resident 2 with a cane on June 1, 2024. The DON stated Resident 1 did not use or have a cane. The DON stated the cane belonged to Resident 3, who often left it around the facility, such as outside the DON office or in the hallway, where other residents had access to it. The DON stated Resident 1 ' s physical aggression towards Resident 2 resulted in physical injuries to Resident 2. On June 4, 2024, at 9:30 a.m., Resident 1 was interviewed. Resident 1 was alert and able to answer questions. Resident 1 stated he did hit his former roommate (Resident 2) in the head with a cane, at night, a few days prior but did not remember the details. Resident 1 stated the cane was not his, he did not have a cane and he did not remember how he got the cane. On June 4, 2024, Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included encephalopathy (brain dysfunction), schizoaffective disorder, bipolar type (schizophrenia - hallucinations, delusions, mixed with extreme mood swings), Alzheimer ' s disease (memory loss and confusion), and impulse disorder (difficulty controlling emotions and behaviors). Resident 1 ' s BIMS (Brief Interview for Mental Status - an assessment tool) score was 10, indicating moderate cognitive (thinking) impairment. Resident 1's care plan, dated December 20, 2023, was reviewed. The care plan indicated, .Episodes of physical and verbal aggression: [episodes of agitation .breaking windows, property destruction, removing signs from walls, taking iPad chargers, etc .Goal .Will demonstrate effective coping skills . Resident 1's care plan, dated January 24, 2024, was reviewed. The care plan indicated, .Impulse control disorder m/b (manifested by) mood swings . On June 4, 2024, at 10:40 a.m., a concurrent observation and interview was conducted with Resident 2. Resident 2 was alert and confused. Resident 2 was observed with multiple staples on the top of his head. Resident 2 stated he did not remember what happened. On June 4, 2024, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included disorder of the brain, epilepsy (brain disease causing seizures), legal blindness, difficulty walking, dementia (memory loss and lack of judgement), schizoaffective disorder (combination of schizophrenia - hallucinations, delusions - and mood disorder). Resident 2 ' s BIMS score was 0, indicating severe cognitive impairment. On June 4, 2024, at 9:53 a.m., Licensed Vocational Nurse (LVN) 2 was interviewed. LVN 2 stated Resident 1 had a history of confusion, forgetfulness, delusions, and hitting himself. LVN 2 stated Resident 1 did not have a cane, and his roommate (Resident 2) did not have a cane either. LVN 2 stated she did not know how Resident 1 got the cane. LVN 2 stated it was not safe for the residents to leave a cane out, staff should put it out of reach of residents, because it could be used as a weapon. On June 4, 2024, at 10:28 a.m., Resident 3 was interviewed. Resident 3 was alert and able to answer questions. Resident 3 stated he did have a cane, but he did not know where his cane was. Resident 3 stated he has not used the cane in a couple of months and did not need it anymore. On June 4, 2024, Resident 3's medical record was reviewed. Resident 3 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder, bipolar type, and lack of coordination. On June 4, 2024, at 10:16 a.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated Resident 1 had a history of schizophrenia, had episodes of hitting himself and was violent against property (broke a window a few months ago). On June 4, 2024, at 11:38 a.m., a telephone interview was conducted with LVN 1. LVN 1 stated Resident 1 had a history of moments of aggression, hitting physical things and objects. On June 7, 2024, at 4:15 p.m., a telephone interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated he witnessed the incident involving Resident 1 and Resident 2. CNA 1 stated Resident 1 hit Resident 2 three times in the head with a cane. CNA 1 stated Resident 2 sustained bloody head injuries from being hit by Resident 1 with a cane. CNA 1 stated Resident 1 did not have a cane and he did not know how Resident 1 got the cane. CNA 1 stated the cane should not have been left unattended for residents ' safety. The facility policy and procedure titled, Safety and Supervision of Residents, revised July 2017, was reviewed. The policy and procedure indicated, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents .

Based on observation, interview, and record review, the facility failed to ensure the safety for one of five residents reviewed for falls (Resident 1), when the fall risk care plan was not evaluated for effectiveness and updated to reflect new interventions to prevent further falls, and the fall risk assessments did not accurately reflect Resident 1's fall risk. This facility failure resulted in Resident 1 having repeated falls on November 16, 2023, November 22, 2023, and December 4, 2023. Resident 1 sustained a right radius fracture (broken bone to right arm), laceration (deep cut) requiring sutures to the area above the right eyebrow, and a mildly displaced fracture of adjacent maxillary processes (two missing front teeth) after the second fall on November 22, 2023, which required Resident 1's transfer to the acute care hospital for medical intervention. Findings: On December 5, 2023, at 8:39 a.m., an observation was conducted with Resident 1. Resident 1 was in bed asleep. Resident 1 was observed wearing a splint (supportive device) to the right arm, and wore a yellow plastic band labeled as Fall Risk on her left wrist. On December 5, 2023, at 9:26 a.m., an interview was conducted with Registered Nurse (RN) 1. RN 1 stated prior to the fall that occurred on November 22, 2023, Resident 1 walked independently, unsupervised, and had pacing tendencies. On December 5, 2023, at 9:30 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated she was the nurse assigned to render care to Resident 1 during the morning shift of December 5, 2023. CNA 2 stated prior to the fall that occurred on November 22, 2023, Resident 1 frequently walked independently and paced quickly. CNA 2 stated she was not made aware of residents who had a high fall risk. On December 5, 2023, at 9:39 a.m., an interview was conducted with CNA 3. CNA 3 stated prior to the fall that sent Resident 1 to the hospital on November 22, 2023, Resident 1 was confused and needed reminders to slow down when walking but was allowed to walk unsupervised. On December 5, 2023, at 12:56 p.m., an interview was conducted with the Physical Therapist (PT). The PT stated Resident 1 was impulsive and had poor safety awareness on admission and needed frequent reminders for safety. The PT stated Resident 1 refused to use a front wheeled walker (an assistive device) and required supervision with walking following Resident 1's first fall on November 16, 2023. The PT stated these reminders and education should have been relayed to the staff through education and in-service, but this was not done. The PT stated these safety/supervision interventions were relayed to nursing staff verbally and there was no follow-through if they were being implemented. On December 5, 2023, Resident 1 ' s medical record was reviewed. Resident 1 was admitted to the facility October 24, 2023, with diagnoses that included, generalized muscle weakness, schizophrenia (mental illness characterized by symptoms like difficulty thinking, hallucinations and false belief about reality), depression, and bipolar disorder (mental illness that causes shifts in mood, ranging from extreme highs to lows). The following facility documents were reviewed: - The Fall Risk Assessment (screening tool used to identify how likely it is that the resident will fall), dated October 25, 2023, indicated Resident 1 was a Low Risk for fall; - The Fall Risk Care Plan, dated October 25, 2023, indicated interventions for fall prevention of a.) Anticipate and meet the resident's needs. b.) Ensure that the resident's call light is within reach and encourage the resident to use it for assistance as needed. Promptly respond to call light and other requests for assistance. c.) Maintain a safe living environment, with room and halls free of clutter. - The Nursing- Change of Condition - Situation, Background, Assessment, Recommendation- Medical (COC SBAR) dated, November 16, 2023, indicated Resident 1 was found on the floor (first fall) by the staff in the dining room and did not sustain any injuries; -The Actual Fall Care Plan, dated November 16, 2023, indicated interventions that included the Interdisciplinary Team (IDT) meeting (a meeting where members of the care team work together to plan and coordinate a resident's care) to review and evaluate the cause of the fall. There was no documented evidence an IDT meeting was conducted after Resident 1 ' s fall on November 16, 2023. In addition, there was no documented evidence a fall risk assessment was conducted after Resident 1's first fall. -The COC-SBAR, dated November 22, 2023, indicated Resident 1 fell again, near the nurse ' s station and sustained injuries which required a transfer to the acute hospital for further treatment (second fall); -The Fall Risk Assessment, completed after the second fall dated November 22, 2023, indicated Resident 1 was still Low Risk for falls; -The nursing progress notes, dated, November 29, 2023, indicated Resident was readmitted to the facility on [DATE], at 1:55 p.m., with diagnoses that included a right radius fracture, laceration requiring sutures to the area above the right eyebrow, and a mildly displaced fracture of adjacent maxillary processes; -The Fall Risk Assessment, dated November 29, 2023, indicated Resident 1 was a Low Risk: for fall; There was no documented evidence an IDT meeting was conducted to evaluate and assess the cause of Resident 1 ' s second fall on November 22, 2023. In addition, there was no documented evidence, Resident 1 ' s fall care plan was updated after the second fall, and; -The COC-SBAR, dated, December 4, 2023, indicated Resident 1 was found on the floor (third fall) and it was an unwitnessed fall. The document further indicated Resident 1 did not sustain injuries and was not able to let the nurse know what happened. On December 8, 2023, at 9:30 a.m., an interview with a concurrent medical record review was conducted with the Director of Nursing (DON). The DON stated an IDT meeting should be completed after each fall to determine the root cause analysis, identify interventions to prevent future falls, and evaluate and update the fall care plan as necessary. The DON stated these updates should be communicated to the staff at shift report. The DON stated a fall risk assessment should be completed after each fall. The DON stated a fall risk assessment, and an IDT meeting was not done after Resident 1 ' s first fall on November 16, 2023. The DON stated these should have been done. The DON further stated, regarding Resident 1's second fall, the fall risk assessment completed by the licensed nurse on November 29, 2023, was inaccurate and the IDT only conducted a verbal meeting to discuss Resident 1 ' s fall. The DON stated Resident 1 ' s fall care plan and interventions were not updated after her re-admission to the facility on [DATE]. The DON stated the fall care plan should have been updated and implemented after Resident 1's re-admission. The DON stated Resident 1 ' s second and third falls may have been avoided if the IDT met and changed Resident 1 ' s interventions appropriate to address Resident 1's needs after Resident 1's first fall on November 16, 2023. The DON stated their policy and procedure on fall management was not followed by the staff. The facility ' s policy and procedure titled, Falls and Fall Risk Managing, dated January 2018 was reviewed. The policy indicated, .monitoring subsequent falls and fall risk: if a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change intervention . The facility ' s policy and procedure titled, Assessing Falls and Their Causes, dated January 2018 was reviewed. The policy indicated, .when a resident falls, a fall risk assessment is completed .

Based on interview and record review, the facility failed to ensure the menu was followed for one of three residents reviewed (Resident 1), when the facility served the resident, who was on a dysphagia ground diet (a diet where food is soft, moist, and easily mashed with a fork, for those with dysphagia [difficulty chewing or swallowing]), a ham sandwich for lunch. This failure led Resident 1 to choke and aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway) and was subsequently hospitalized in order to be stabilized. Findings: On [DATE], an unannounced visit to the facility was conducted to investigate a facility reported incident involving Resident 1. On [DATE], at 2:53 p.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated Resident 1 was still at the hospital. The ADON reviewed Resident 1's record and stated Resident 1's choking incident occurred on [DATE], during the lunch meal in the facility's dining room. Resident 1 was noted to be choking, was placed on the floor, chest compressions were started, code blue (code used in the medical field to indicate cardiac or respiratory arrest) was called to alert staff, and 911 (phone number for emergency services) was called. Resident 1 was transferred to the acute care hospital and had not returned to the facility. On [DATE], Resident 1's medical record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included protein-calorie malnutrition (not enough protein and calories in the body leading to muscle loss, fat loss and the body not functioning properly) and dementia (brain disorder marked by memory loss, personality changes and impaired reasoning). The History and Physical dated [DATE], indicated Resident 1 had fluctuating capacity to understand and make decisions. The Minimum Data Set (MDS- an assessment tool) dated [DATE], included a Brief Mini Mental Status exam (BIMS- a brief screening tool that aids in detecting cognitive status) which indicated Resident 1 had a score of 10 (a score of ,d+[DATE] means moderate impairment). The MDS also indicated Resident 1 was on a mechanically altered diet (a texture-modified diet for people who have difficulty chewing and swallowing) and had no natural teeth or tooth fragments. The physician's order dated [DATE], indicated, .Diet .DYSPHAGIA GROUND diet Mechanical Soft texture .for dysphagia . The Progress Notes, dated [DATE], included a Plan of Care Note indicating Resident 1 was on a Mechanical Soft Diet due to being edentulous (lacking teeth) . The SLP (Speech Language Pathologist) Evaluation and Plan of Treatment, dated [DATE], indicated, .Recommendations .Diet .Mechanical Soft/Ground textures, Puree Consistencies .Supervision for Oral Intake = Close Supervision .Risk Factors: Aspiration Risk . The SBAR Communication Form, (situation, background, assessment and recommendation- a communication tool between nurses and prescribers), dated [DATE], indicated, .At approximately 1217 (12:17 p.m.) resident was noted in the dining room chocking [sic], resident was placed on the floor, staff immediately paged code blue x 3 (three times) and Heimlich manuever ([sic] a first aid procedure used to treat upper airway obstruction) performed, 911 called at 1219 (12:19 p.m.), staff arrived with crash cart, paramedics arrived on scene at 1226 (12:26 p.m.), paramedics able to dislodge food with tongs, resident placed on gurney and transferred out at 1240 (12:40) p.m . On [DATE], at 12:36 p.m., the Certified Nursing Assistant (CNA) was interviewed. The CNA stated Resident 1 started choking during the lunch meal on [DATE], while in the dining room. The CNA stated another resident stated she's choking. They turned around and saw Resident 1 sitting hunched in the wheelchair touching her chest, tapping/hitting her chest with an open hand. The CNA stated the Licensed Vocational Nurse (LVN) who was with her at the time, administered the Heimlich maneuver. Resident 1 became pulseless, was laid on the floor, and chest compressions were started. A Registered Nurse came to assist and continued chest compressions until the paramedics arrived. The paramedics took over chest compressions and proceeded to check Resident 1's mouth. Something pink was observed inside Resident 1's mouth. The paramedics used tongs and were able to dislodge pieces of ham and tomato from Resident 1's mouth. Resident 1 was revived when the food was removed from her mouth, and she was transferred to the hospital thereafter. The CNA stated Resident 1 had been receiving a ham sandwich since she was admitted to the facility because she always requested it. The CNA stated Resident 1 should not have received a ham sandwich. On [DATE], at 1:06 p.m., the LVN was interviewed. The LVN confirmed Resident 1 received a sandwich for lunch on the day she choked, and stated the bread was cut more than half, but was not sure into what size pieces. The LVN further stated if it had been chopped up more, it would have been ok. On [DATE], at 1:55 p.m., the Dietary Aide (DA) was interviewed. The DA stated he worked the day Resident 1 had the choking incident. The DA stated Resident 1's diet was mechanical chopped, fine, and that particular day, when Resident 1's plate came back to the kitchen, only the bread was on the plate and the ham was gone. The DA stated Resident 1 would request sandwiches for lunch daily, and she would be given a ham sandwich. The DA stated he did not recall Resident 1 being given any other type of sandwich besides the ham sandwich for lunch. The DA stated most of the time, the sandwich was cut into pieces, but was not sure about the size of the cut-up pieces for Resident 1's ham sandwich on the day she choked. On [DATE], at 2:20 p.m., a concurrent interview with the Director of Nursing (DON) and Administrator (ADM) was conducted. When asked if Resident 1 should have had a ham sandwich for lunch on [DATE], the DON stated, No. The ADM stated the facility should have followed the physician ordered diet for Resident 1. On [DATE], the DAILY MENU Autumn 2021 for Week 1, Friday, ,d+[DATE] ([DATE]), was reviewed. The document indicated diced tomato salad in the column for Mech Soft (mechanical soft), and a notation at the bottom of the page indicating, .Mechanical Soft: Use ground or chopped meat as specified in the diet order . On [DATE], at 2:25 p.m., the Dietary Supervisor (DS) was interviewed. The DS stated Resident 1 was edentulous (having no teeth) so she was on a mechanical soft diet, and she was continually refusing the texture. When asked if Resident 1 should have received the ham sandwich, the DS stated, No, but we sometimes please the resident and give them what they want so they can eat. In the end we have to be nutrition oriented. On [DATE], Resident 1's medical record was reviewed. There was no documented evidence an IDT (Interdisciplinary Team) Review was conducted to address Resident 1's refusals of her ordered diet, or her preference for a ham sandwich for lunch. There were no care plans to address the refusals or preference for a ham sandwich prior to Resident 1's choking incident. On [DATE], the progress notes from the acute care hospital were reviewed. The notes indicated Resident 1 was admitted to the hospital on [DATE], and on [DATE], Resident 1 underwent a bronchoscopy (a procedure to look directly at the airways in the lungs using a thin lighted tube) with foreign object removal. On [DATE], the facility document titled, MECHANICAL or DENTAL SOFT, of the Diet Manual, Dietary Directions, Inc 2018, was reviewed. The document indicated, .The mechanically altered diet provides foods that are easily chewed. It is appropriate for individuals who have chewing problems, poor dentition, and minor swallowing problems .The foods are modified in texture by chopping, dicing and grinding .For menu planning purposes the diet should be planned using ground meats and diced fruits and vegetables .The following terms should be used to describe the desired texture: Chopped XXX,d+[DATE] -,d+[DATE] inch pieces, Chopped Fine/Diced/Minced XXX,d+[DATE]-,d+[DATE] inch pieces .Ground XXX,d+[DATE] inch or less pieces - consistency of ground meat .Food Groups .Meat and Substitutes .Foods Suggested .Ground, chop, chop fine, diced, or minced meats .Food Groups .Vegetables and Vegetable Juices .Foods Suggested .Cooked soft or diced vegetables .diced greens, tomatoes .

Based on observation, interview, and record review, the facility failed to monitor, to supervise and to manage, one of five residents (Resident 1) with wandering behavior. Resident 1 was assessed as high risk of wandering. In addition, the facility failed to implement interventions for Resident 1's wandering behavior. These failures resulted in a resident-to-resident altercations, and an incident of fall. Resident 1's wandering episode in another resident's room on October 14, 2021, resulted in the resident (Resident 1) being accidentally hit by a door causing an incident of fall. Resident 1 sustained a large dark purplish discoloration on the left eye, a greenish discoloration (mark) and a large bump on the left forehead, subsequently resulting in acute care hospital transfer for medical evaluation and treatment. On October 20, 2021, at 5:10 p.m., the Administrator, and the Director of Nursing (DON), were verbally notified of the immediate jeopardy situation (situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to ensure one resident with wandering behavior was monitored, supervised, and managed. In addition, the facility failed to implement interventions for Resident 1's wandering behavior. On October 20, 2021, at 7:45 p.m., the facility presented an acceptable plan of action which included the following: 1. Resident 1 was placed on one-on-one monitoring for 72 hours, effective 10/20/2021 at 1530 (3:30 p.m.) through 10/23/2021. Upon completion of the 72 hours monitoring, an evaluation will be conducted if monitoring is still needed. 2. The DON will provide an in-service to the staff, starting the pm (evening) shift (10/20/2021). 3. The License Nurse in each shift will supervise the one-on-one monitoring. The plan of action further indicated that the facility will be conducting the following: 1. An assessment of resident upon admission, quarterly and PRN (as needed). 2. IDT (Interdisciplinary Team - a group of staff meeting and working together for the benefit of the resident) review on the assessment to provide intervention; and 3. Order for monitoring for the potential wanderer. On October 23, 2021, at 4:10 p.m., the immediate jeopardy was removed in the presence of the Administrator (ADM) 1, the DON, the Assistant Director of Nursing (ADON), the Director of Staff Development (DSD), and the Business Office Manager (BOM), after an on-site verification of implementation of the plan of action. Findings: On October 20, 2021, a review of record titled, Resident Information, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), muscle weakness, lack coordination (unsteady walking), and [CONDITION(S)] (mental disturbance characterized by confused thinking and disrupted attention usually accompanied by disordered speech). A review of the Progress Notes: Q (every) shift Note, dated September 9, 2021, at 4:19 p.m., indicated, .Resident (Resident 1) opened facility doors causing alarms to sound. Resident (Resident 1) became agitated when asked not to open doors, yelling and cursing . A review of Resident 1's Wandering Risk Assessment, dated September 9, 2021, indicated, .Score of 11 .High Risk for Wandering . A review of Resident 1's MDS (Minimum Data Set - an assessment tool) dated September 14, 2021, indicated the following: a. Section C (Cognitive Pattern) - BIMS (Brief Interview for Mental Status - an assessment for cognitive status) score of 10 (moderately impaired). b. Section E (Behavior): - Behavior wandering occurred four to six days; - Does the wandering place the resident at significant risk of getting to a potentially dangerous place, indicated Yes.; and - Does the wandering significantly intrude on the privacy or activities of others? Indicated, Yes. A review of Resident 1's care plan titled, Wandering, created on September 15, 2021, indicated, Goal: The resident will not leave the facility .The resident's wandering behavior will not interfere with daily care or safety .Intervention/Tasks Assess for fall risk and intervene as indicated .Distract resident from wandering by offering pleasant diversions and activities .Observed for exit-seeking behavior and intervene as needed .Observed for fatigue and weight loss . A review of Resident 1's record titled, Progress Notes: Incident Notes - Altercation, dated September 30, 2021, at 1:19 p.m., indicated, .Resident (Resident 1) attempted to enter another resident's room. The other resident struck at resident's (Resident 1) face .resident has slight redness to her R (right) cheek . There was no documented evidence indicating the IDT met to review, to assess, and to provide interventions regarding the incident of wandering which resulted in an altercation on September 30, 2021. There was no documented evidence the care plan on wandering was updated, revised, and re-evaluated after September 15, 2021. In addition, there was no interventions added, when Resident 1 continued to wander inside other residents' room on September 30, 2021. A review of Resident 1's record titled, SBAR (Situation-Background-Assessment-Recommendation - a framework for communication between members of the health care team about a patient's condition) Communication Form, dated October 14, 2021, at 5:55 a.m., indicated, Resident was wondering (sic - wandering) in another resident room attempting to hang something on the wall when co-resident opened bathroom door and hit resident accidentally and resident lost balance and fell and hit the side of head on floor .Large bump noted after further observation .Resident noted with frequent episodes of wandering. Needs more supervision . A review of Resident 1's record titled, Progress Notes: Post-Fall Monitoring, dated October 16, 2021 at 2:20 a.m., indicated, .Left side face/facial discoloration .Resident s/p (status post) fall. Purple/blue discoloration noted on left side face and eye area . A review of Resident 1's record titled, Progress Notes: Transfer to Hospital Note, dated October 16, 2021 at 5:36 p.m., indicated, .Resident verbalized having new onset of neck pain .Resident Transferred to (name of hospital) accompanied to by EMTs (Emergency Medical Technicians) . On October 20, 2021, at 11:20 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated Resident 1 would always wander to other residents' room. She further stated the facility needed more staff to monitor the residents with wandering behavior including Resident 1. On October 20, 2021, at 11:25 a.m., during an interview, CNA 2 stated Resident 1 would wander from one room to room, because she used to be a housekeeper in a nursing home. On October 20, 2021, at 11:45 a.m., during an interview, the Licensed Vocational Nurse (LVN 1) stated Resident 1 was ambulatory (walking), and she would wander around the facility, and other resident's rooms. On October 20, 2021, at 11:50 a.m., during an interview, the Activity Director (AD) stated Resident 1 needed redirection, so she provided the resident activities such as folding clothes, games, and puzzles. The AD was asked if activities were provided during evening and at night, and she stated there were no activity staff during evening and night, so activities for the resident, would be up to nursing. On October 20, 2021, at 11:54 a.m., during a concurrent observation and interview, Resident 1 was observed in the hallway walking with an unsteady gait (shuffling or uneven when walking). She was observed with a large dark purplish discoloration on the left eye approximately eight by five cm (centimeter - unit of measurement) and a greenish discoloration (mark) on the left side of the face and the left forehead. Resident 1 was asked regarding the incidents on September 30, 2021 and October 14, 2021, and the resident was not able to recall the incident on September 30, 2021, and October 14, 2021. On October 20, 2021, at 12:15 p.m., during an interview, ADM 1 stated the facility should have increased supervision and monitoring for Resident 1, because of the increased on wandering behavior of the Resident 1. A review of Resident 1's record titled, Order Summary Report, for the month of October 1- 20, 2021, indicated the following [CONDITION(S)] medications (medication to treat behavior): [MEDICATION(S)] ([MEDICATION(S)]) (medication to treat mental disorder) Tablet 25MG (milligram - unit of measurement) Give 2 tablet by mouth one time a day for [CONDITION(S)] (mental disturbance characterized by confused thinking and disrupted attention usually accompanied by disordered speech). date ordered September 7, 2021. [MEDICATION(S)] (Lorazepam) (medication to treat anxiety - feeling of restlessness or nervousness) Tablet 0.5 MG by mouth three times a day for anxiety m/b (manifested by) verbalization of anxiety . date ordered October 7, 2021. [MEDICATION(S)] ([MEDICATION(S)]) (medication to treat mood disorder) Solution 250 MG/5ML (milliliter - unit of measurement) Give 250 mg by mouth two times a day for impulsive control DX (diagnosis) M/b screaming . date ordered October 19, 2021. Psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness) consult as needed. There was no documentation indicating Resident 1 was seen by the Psychiatrist since admission on September 7, 2021. There was no physician order to monitor Resident 1's wandering behavior. On October 26, 2021, at 2:18 p.m., during an interview, the DON stated Resident 1 should have been seen by a psychiatrist, The DON stated the facility staff should have asked the physician for an order to monitor Resident 1's wandering behavior. A review of Resident 1's record titled, Medication Administration Record (MAR), for the month of October 2021, did not indicate a monitoring for Resident 1's wandering behavior. On October 20, 2021, at 6:50 p.m., during an interview, the DON was asked on Resident 1's wandering behavior monitoring. The DON stated there was no physician order for monitoring and the MAR for the month of October 2021 did not include monitoring of the resident's wandering behavior. The DON stated there should be a wandering behavior monitoring for Resident 1. On October 26, 2021, at 2:21 p.m., during an interview, the DON stated Resident 1's care plan should have been updated, after each wandering incident. She stated the care plan to address Resident 1's wandering behavior should have been updated on September 30, 2021. A review of the facility's policy and procedure titled, Preventing Resident Abuse, dated December 2006, indicated, .Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect .Assessing residents with signs and symptoms of behavior problem and developing and implementing care plans to address behavioral issues .Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents . A review of the facility's policy and procedure titled, Wandering and Elopements, dated March 2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain resident's safety. A review of the facility's policy and procedure titled, Wandering, Unsafe Resident, dated March 12, 2009, indicated, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement .The resident's care plan will indicate the resident is at risk for elopement or other safety issues .Interventions to try to maintain safety will be included in the resident's care plan .Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident .Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior .Staff will notify the Administrator and Director of Nursing immediately, and will institute appropriate measures . A review of the facility's policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, indicated the following: The facility will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care . Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide services to the residents . Management: The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary, to protect the resident and others from harm . Interventions will be individualized and part of an overall care environment that support physical functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities . Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum .Targeted and individualized interventions for the behavioral and/or psychosocial symptoms .How the staff will monitor for effectiveness of the interventions .

Based on observation, interview, and record review, noncompliance by the facility to provide for leadership, oversight, resource, and support for 48 residents were identified when: Forty-eight residents were left without a Director of Nursing (DON) to assume ultimate responsibility to coordinate plans for the total care of each residents on May 12-31, 2021, June 1-6, 2021, and June 12-15, 2021. The facility's failure to ensure adequate 24- hour nursing coverage had the potential to result in over-all unsafe living conditions for the48 residents. Furthermore, forty-eight residents were left without a Registered Nurse (RN) on numerous occasions. The facility failure to provide for RN coverage on May 1, 2, 10, 25, 26, 2021 and June 1, 2, 3, 5, 6, 9, 14, 2021, had the potential to result in a delay of identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings: On June 15, 2021, at 08:58 a.m., the facility was visited to investigate a complaint alleging quality of care/treatment and personnel issues. Upon entry, the Infection Preventionist Nurse/Director of Staff Development (IPN/DSD) identified herself as in-charge of the facility. The IPN/DSD stated she was a Licensed Vocational Nurse (LVN). On June 15, 2021, at 09:27 a.m., the IPN/DSD was interviewed. IPN/DSD stated there was no Administrator since June 14, 2021 and there was no DON since June 11, 2021. IPN/DSD further explained there was no word yet and nothing confirmed if Corporate was sending somebody to cover administrative and operative management of the facility. On June 15, 2021, a facility tour was conducted and safety issues were identified for lack of leadership, oversight, resource, and support for nursing care services for: * 48 residents left in the facility without a DON for 30 days total on May 12-31, 2021, June 1-6, 2021 and June 12-15, 2021; * Five residents left without RN skilled care supervision for 12 days on May 1, 2, 10, 25, 26, 2021 and June 1, 2, 3, 5, 6, 9, 14, 2021; * Unsafe environment for eight residents (Resident 3, 7, 10, 11,12, 13, 14, 15) with wander guard bracelet on (elopement alarm for resident supervision) for exit door beside room [ROOM NUMBER] (broken and non-functioning) and exit door beside room [ROOM NUMBER] (alarm was intentionally disabled for staff convenience); and * Medication room inspection showed an over-flowing cabinet full of mixed medications ready for disposal. Narcotics for disposal was unsecured and easily accessible to anyone entering the medication room. On June 15, 2021, at 11:20 a.m., an Immediate Jeopardy Situation was called in the presence of the facility Interim Administrator (IA) and Regional Corporate Administrator. A request to the facility was made to provide an immediate plan of action (POA) to resolve the identified regulatory noncompliance issues regarding lack of leadership, oversight, resource, and support for 48 residents. On June 15, 2021, at 12:51 p.m., after Staffing Schedule Assignment review and Medication Room inspection with the IPN/DSD was completed, IPN/DSD stated the facility should have an RN scheduled on a daily basis. IPN/DSD stated, It might not be good when there's no RN. IPN/DSD stated if there is no RN, some resident's needs could not be met. On June 15, 2021, at 12:55 p.m., the Interim Administrator was interviewed. The Interim Administrator stated an RN/DON coverage was needed on a daily basis. On June 17, 2021, the DON JOB DESCRIPTION was reviewed. The DON job description indicated, .job position is to plan, organize, develop and direct the overall operation of .Nursing Service Department .to ensure that the highest degree of quality care is maintained at all times .Determine the staffing needs .necessary to meet the total nursing needs of the residents .Assign a sufficient number of .registered nurses .to ensure that quality care is maintained .Assist the Pharmaceutical Services .developing, maintaining, implementing .administration, storage, and control of medications and supplies .Ensure that nursing service personnel follow established infection control procedures when isolation precautions become necessary .Assist the Maintenance Director in developing a preventive maintenance program for maintaining the nursing service department's equipment and supplies in a safe and operable manner .

Based on observation, interview, and record review, the facility failed to ensure 6 of 12 sampled residents (Residents 7, 8, 26, 29, 30 and 42) received adequate supervision, evaluation of appropriate assistive devices, and resident specific intervention to prevent falls and injuries. The facility failed to implement current care plan interventions which included monitoring the residents and providing assistance with their activities of daily living needs (ADL- such as bed mobility, transferring from bed to chair and vise-versa, walking, dressing, and toileting); the use of floor mats to lessen the force of impact during a fall; maintaining a low bed; and proper use of bed and/or wheelchair alarm (a device that produces high pitch alarm which would alert staff when the resident moves or gets off the bed or wheelchair). The facility failed to follow their policy for resident falls by not assessing the residents for new fall prevention interventions. The facility failed to evaluate multiple resident falls and injuries for trends and patterns to identify why the residents were falling. The facility had an average rate of 17 falls per month since June 2015, with multiple residents having repeated falls, some falls resulting in minor skin injuries, and some falls resulting in major injuries requiring hospitalization . Injuries included extensive swelling and hematoma/contusion (bruise) of the head; fractures such as a hip fracture, pelvic fracture, nose fracture, fracture of the clavicle (collar bone), and compression fracture (collapse of a bone due to trauma) of the spine (back bone); and lacerations on the head requiring suturing. Additionally, the facility failed to ensure a safe environment for multiple residents by having wheel chairs with non-functioning brakes, and environmental surfaces with sharp or splintered areas that could cause the residents to obtain skin injuries. Due to the facility's failure to provide a system or plan to prevent multiple residents from having multiple continuous falls, and some falls resulting in injuries, the Administrator and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy situation on March 22, 2016, at 11:55 a.m. The Immediate Jeopardy was removed in the presence of the Administrator on March 22, 2015 at 3:25 p.m., after the facility provided an immediate action plan of putting measures in place to reduce or prevent the residents from having continued falls and injuries, and ensuring the safety and well-being of the residents. Findings: 1. On March 15- 22, 2016, Residents 7, 8, and 26's medical records were reviewed. Residents 7, 8, and 26 had repeated falls and sustained significant injuries that required hospitalization . a. On March 14, 2016, at 12:40 p.m., Resident 26 was observed lying in bed, awake, alert and able to answer questions verbally and appropriately. Resident 26 had a bump (swelling) on the left forehead the size of a quarter and surrounded by a blue-yellowish discoloration of the skin. The area was approximately three inches in diameter. There was also purplish-yellow discoloration on the right side of the resident's face near the right eye extending to the right cheek and approximately two by ½ (2 x ½) inches in diameter. The resident's bed was equipped with adjustment buttons (includes button to raise or lower the height of the bed), and a regular mattress. Resident 26's bed was currently elevated to a height of approximately two and ½ feet from the floor to the top of the mattress. There were no other devices found on or near the bed such as a floor mat cushion (safety cushion device used to absorb and reduce the force of a fall). On March 14, 2016, at 12:40 p.m., Resident 26 was interviewed regarding the swelling and hematoma (a solid swelling of clotted blood within the tissues) on her face. Resident 26 stated that while she was sleeping, she turned to her right side and rolled off the edge of the bed and fell on the floor. The resident stated the bruise and swelling on her forehead and right cheek were A lot bigger and It was huge after the fall. Resident 26 further stated she rolled off the bed and fell on the floor twice when she was in the other room (of the same facility). On March 15, 2016, at 2:20 p.m., an interview with Licensed Vocational Nurse (LVN) 1, who was also the MDS (Minimum Data Set - an assessment tool) and Care Plan Coordinator, was conducted. He was asked about Resident 26's fall risk status and current care plan to prevent falls. LVN 1 reviewed the resident's medical record and stated Resident 26 was considered high risk for falls. LVN 1 further explained that all residents who were high risk for falls had an identifying sticker by their room door in the shape of a foot to alert staff they were a fall risk. LVN 1 stated the residents would have a low bed, wheelchair and/or Tab alarm (an alarming device connected to the resident that sounds when the resident gets up unassisted), and a floor mat. LVN 1 was then asked to see Resident 26 in her room to evaluate whether the resident was receiving appropriate interventions to prevent falls and injuries. Resident 26's room was observed at 3:26 p.m., with LVN 1 who acknowledged there was no floor mat by the resident's bed, and the resident's bed was not at it's lowest position. After explaining to the resident about fall prevention, LVN 1 lowered the height of the resident's bed from approximately 2 and ½ feet to approximately 1 and ½ feet. A review of Resident 26's medical record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The current MDS assessment dated [DATE], indicated Resident 26 needed limited assistance with one person assist for bed mobility (such as turning/repositioning ); extensive assistance with transfers (such as from bed to chair and vise-versa); and had an unsteady balance when standing. The Physical Therapy Treatment Summary notes dated January 15, 2016, indicated that Resident 26 was a Fall risk. A review of the assessment form titled, Rehab status [REDACTED]. Date of fall: February 24, 2016, at 1 p.m. The location and reason of fall indicated, Rm (room) 19. Pt (patient) states she was asleep and rolled off of the bed. The assessment indicated protective devices (such as floor mat cushion) had not been used during the fall even though there was a physician order [REDACTED]. There was no assessment of any obvious injuries sustained during the fall, or the reason why the floor mat was not utilized as ordered to reduce possibility of serious injury during a fall. There was no rehabilitation (rehab) evaluation (such as physical therapy and/or occupational therapy), follow up plans (such as making sure floor mat would be utilized), and appropriate interventions recommended (such as the use of scooped bed {prevents rolling off the bed} and bed alarms) to prevent future incidents of falls. Date of fall: January 26, 2016, at 6:45 a.m. The location and reason of fall indicated, Patient (resident) found on the floor, right side of the bed. Rolled off bed to right side. The assessment indicated protective devices had not been used during the fall even though there was a physician order [REDACTED]. There was no assessment of any obvious injuries sustained during the fall, and the reason why the floor mat was not utilized to reduce possibility of serious injury during a fall. There was no rehab evaluation (such as physical therapy and/or occupational therapy), follow up plans (such as making sure floor mat would be utilized), and appropriate interventions recommended such as the use of scooped bed and bed alarms to prevent future incidents of falls. Transfer documentation indicated Resident 26 was transferred to an acute hospital for further treatment and evaluation of a head injury. Date of fall: January 24, 2016, at 10:30 a.m. The location and reason of fall indicated, Patient was at hallway by Room 20. Attempted to get up from w/c (wheelchair) and lost balance. There was no assessment of any obvious injuries sustained during the fall. There was no rehab evaluation, follow up plans, and appropriate interventions recommended to prevent future incidents of fall. The follow up plans included the same previous care plan interventions to educate the resident on safety and the use of call light for assistance. On March 16, 2016, at 11:05 a.m., an interview was conducted with the physical therapy staff (PTS 1) regarding post fall assessments. PTS 1 was asked about the purpose and procedure for conducting a post fall assessment. PTS 1 stated that within 24 hours after the fall, a physical therapy staff would conduct a post fall assessment to identify the cause of the fall and recommend appropriate interventions to prevent recurrence of fall. PTS 1 reviewed the post fall assessments conducted on February 24, January 26, and January 24, 2016, and was unable to find recommendations of appropriate interventions based on the assessment to prevent future falls. There was no documentation of any reason why new interventions were not necessary. PTS 1 further stated, I understand, and I agree with you. A review of Resident 26's care plan dated March 21, 2015, for the problem, High risk for falls r/t (related to) gait balance problems, included a goal that the resident Will be free of fall through 03/02/2016. The care plan interventions included to follow facility fall protocol; floor mat as ordered; bed at low position; educate the resident about safety reminders (such as locking wheel chair brakes, and encouraging the resident to call for assistance); call light within reach; and to determine possible root causes of falls. There was no documented evidence Resident 26's care plan for the use of floor mat had been implemented. The care plan was not updated based on a comprehensive fall assessment to ensure the resident received appropriate supervision and assistive devices to prevent recurrence of falls. There was no evidence the Interdisciplinary Team (IDT- includes the registered nurse and/or licensed vocational nurse, social service designee, activity staff, physician, and the resident, and/or responsible party) collaboratively evaluated the fall assessments and the plan of care including root cause analysis of repeated falls to determine why current interventions had not been successful in preventing falls. b. For Resident 8, the MDS dated [DATE], indicated he had [DIAGNOSES REDACTED]. The MDS assessment indicated Resident 8 required extensive assistance with one person assist during transfers (such as from bed to chair and vise-versa) and with dressing; had an unsteady balance when standing; and uses (propels) wheelchair to move around. On March 21, 2016, at 11:55 a.m., a concurrent observation and interview with Resident 8 and caregiver (a family member) was conducted. Resident 8 was up in wheelchair, alert and responded verbally and appropriately. Resident 8 was wearing a neck brace due to a previous neck spine surgery, and was unable to move his left arms and legs due to previous stroke. When asked how he was doing, Resident 8 stated he still had pain on the neck, head, and lower back area, and he had an incident of falling not too long ago. Resident 8 explained that he fell on the floor and hit his head when he tried to transfer himself from the bed to wheelchair. Resident 8 explained that when he was transferring from bed to chair the wheelchair brakes did not work and the wheelchair moved causing him to fall on the floor. When asked if the facility staff had been notified about the non-functioning wheelchair brakes, the caregiver/family member stated she notified the MDS/CP Coordinator that the resident's wheelchair brakes did not work and caused the resident to fall. She further requested to have the wheelchair replaced or repaired. A review of the form titled, Post Fall Assessment, dated March 6, 2016, indicated Resident 8 fell off his wheelchair on March 6, 2016, at 12:20 p.m., while attempting to put on sweater. The assessment indicated the resident hit his head on the corner of the dresser, no injuries resulted, and he complained of upper back and neck pain, dizziness, and nausea. There was no further IDT assessment to identify the root cause of the fall (such as the resident's non-functioning wheelchair brakes), whether current interventions were effective, or he needed additional interventions. Transfer documentation indicated Resident 8 was transferred to an acute hospital for further treatment and evaluation for potential neck and/or head injury. A review of Resident 8's care plan dated February 12, 2016, for the problem, Risk for falls r/t gait balance problems included a goal that the resident Will be free of fall through review date (05/02/2016). The care plan interventions included to anticipate and meet the resident's needs; follow facility fall protocol; educate the resident about safety reminders (such as locking wheel chair brakes, and encouraging the resident to call for assistance); and call light within reach. There was no documented evidence the resident care plan for falls had been implemented such as following the fall protocol to Identify the underlying causes of the fall, and to Implement additional or different interventions based on the assessment. There was no evidence the IDT had conducted an evaluation including root cause analysis of the fall to determine whether current and/or additional interventions were needed to prevent future falls. On March 22, 2016, at 9:35 a.m., an interview was conducted with the Director of Nursing (DON), the assistant DON, and in the presence of the MDS/Care Plan Coordinator. The DON reviewed the resident's medical record and acknowledged the care plan for falls had not been implemented, evaluated, and updated based on comprehensive fall assessments. c. On March 21, 2016, at 10:33 a.m., Resident 7 was observed sitting and leaning forward on the bed at the foot part of the bed. The resident's upper body was leaning forward with her head almost touching the foot board of the bed. There was a Tab alarm attached to the left bedrail located at the head of the bed, and a string with one end attached to the alarm and the other end clipped to the resident's clothes on the shoulder. The length of the string was approximately 4 feet long, and was stretched from the bed rail at the head of the bed, to the resident's location at the foot of the bed. At the same time, certified nursing assistant (CNA 5) was observed walking by Resident 7's room, and did not intervene. In an interview with CNA 5 on March 21, 2016, at 10:34 p.m., she stated Resident 7's Tab alarm should be adjusted short enough in order to activate the alarm when the resident moves around or gets off the bed. CNA 5 immediately explained to the resident and adjusted the length of the Tab alarm string to approximately 1 ½ feet. A review of Resident 7's medical record indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Physical Therapy Treatment Summary notes dated March 16, 2016, indicated precautions included the resident was a fall risk. A review of the Rehab status [REDACTED]. Date of fall: March 13, 2016, at 2:40 p.m. The location and reason of fall indicated, Near shower room, close to Room 15. Recommendations included, PT/OT evaluation and follow up plans included, Tab alarm in bed, low bed, and frequent visual checks. Date of fall: March 14, 2016, at 1:20 p.m. The location and reason of fall indicated, Unknown. Recommendations included, PT/OT evaluation, and follow up plans included, Tab alarm in bed, low bed, and educate on safety. There was no collaborative effort by the IDT to assess and evaluate the effectiveness of the care plan interventions, root cause analysis to determine why current interventions had not been successful in preventing falls (such as proper length of the string attached from the alarm device to the resident) when the resident was in bed or in wheelchair. A review of Resident 7's care plan dated February 17, 2016, for the problem, Risk for falls r/t unaware of safety needs, included a goal that the resident will be free of falls. The care plan interventions included to follow facility fall protocol; keep bed in low position; educate the resident/family about safety reminders; anticipate and meet resident needs; and call light within reach. There was no documented evidence the resident's care plan for falls had been updated based on fall assessments after two repeated falls. There was no evidence the IDT conducted an assessment to re-evaluate the cause of falls to ensure the resident received appropriate supervision and assistive devices to prevent recurrence of falls. On March 17, 2016, at 3:35 p.m., the DON was interviewed regarding how the plan of action in monitoring residents would be accomplished to prevent falls. The DON stated, We don't have a written plan. The DON further stated she talked to staff (Registered nurses, licensed vocational nurses, and certified nursing assistants) and reiterated To make the residents their best friends, and take ownership. On March 22, 2016, at 9:35 a.m., an interview was conducted with the Director of Nursing (DON), the assistant DON, and in the presence of the MDS/Care Plan Coordinator. The DON acknowledged the resident's care plan for falls had not been evaluated and updated based on comprehensive fall assessments to prevent recurrence of falls. The facility policy and procedure regarding managing falls, and fall risks, with a revised date of December 2007, indicated the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. . In conjunction with the attending physician, staff will identify and implement relevant interventions based on assessment of the nature or category of falling . 2. On March 14, 2016, at 11 a.m., Resident 29 was observed seated in her wheelchair in the hallway near Lounge 2. Resident 29 had a Tab alarm attached to her wheelchair but not attached by the clip to her body. Resident 29 was wearing socks with anti-slip grips upside down with the grips on top of her feet instead of the bottom of the feet. Concurrently, the ADON was interviewed. The ADON stated, She (the resident) sneaks and disconnects her alarm. On March 15, 2016, the clinical record for Resident 29 was reviewed. Resident 29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Order Summary Report for the current month was reviewed. The document indicated Resident 29 had a physician order [REDACTED]. The document titled Physician History and Physical, dated September 21, 2015, indicated Resident 29 did not have the capacity to understand or make healthcare decisions. The document titled MDS (Minimum Data Set, an assessment tool), dated September 7, 2015, was reviewed. The document indicated it was very important for Resident 29 to participate in her favorite activities and to spend time outside. The document indicated Resident 29 had severe long term and short term memory loss. The document further indicated Resident 29 needed extensive, one to two person physical assist, with transfers and ambulation. The document titled Morse Fall Scale, (a fall risk assessment tool), dated August 31, 2015, was reviewed. The document indicated Resident 29 scored 55 points. A score of 45 points and higher indicated the resident is at a high risk of falling. This document was updated on December 3, 2015 and March 10, 2016. Resident 29 continued to score at the level of high risk for falling. The care plan titled, The resident is high risk for falls r/t unaware of safety needs, confusion, dated September 16, 2015, indicated as some of the interventions but not all inclusive: Anticipate and meet the resident's needs, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, and Follow facility fall protocol. On November 3, 2015, the care plan was updated and added as an intervention, TAB alarm as ordered. The care plan titled, The resident is resistive to care r/t Dementia, dated October 17, 2015, indicated as an intervention initiated October 28, 2015, Will monitor resident for frequent removal and concealment of tab alarm. Resident 29 continued to fall after the Tab alarm was included as an intervention, and the care plan was never further updated or revised. Further review of Resident 29's clinical record indicated Resident 29 had fallen 10 times in the last three months. The falls were documented as follows: 1. On 12/21/15, at 4:20 p.m., Resident 29 was found on the floor, near the nurse's station. Resident 29 hit her head, but sustained no injury. 2. On 12/22/15, at 4:20 p.m., Resident 29 was found on the floor, near the nurse's station after attempting to transfer from her wheelchair to a chair. Resident 29 sustained no injury. 3. On 12/25/15 at 1:45 p.m., Resident 29 was out on the smoking patio and was found sitting on the ground on her bottom. Resident 29 sustained no injury. 4. On 1/18/16 at 7 p.m., Resident 29 was in Lounge 2 and fell off the couch while reaching for something. Resident 29 sustained no injury. 5. On 2/6/16 at 2:15 p.m., Resident 29 was in Room 3, maneuvering her wheelchair through the doorway. Resident 29 fell from her wheelchair and sustained a scratch to her lower back. 6. On 2/8/16 at 5:43 p.m., Resident 29 was near the nurses station and attempted to go out on the patio. Resident 29 fell and sustained a right hand laceration. 7. On 2/9/16 at 7:15 p.m., Resident 29 was near the nurse's station and was getting up from her wheelchair. Resident 29 fell but sustained no injury. 8. On 2/12/16 at 8:30 p.m., Resident 29 was in the lounge and slid off the couch to the floor. Resident 29 sustained no injury. 9. On 2/14/16 at 5:30 p.m., Resident 29 was out on the patio. Resident 29 fell and was found sitting on the ground, but sustained no injury. 10. On 3/15/16 at 9:50 a.m., Resident 29 was out on the smoking patio. Resident 29 fell and was found on the ground. Resident 29 sustained no injury. The care plan intervention, Anticipate and meet resident's needs was ineffective in three of the 10 subsequent falls as she was unattended outside on the facility grounds. The care plan intervention, Educate resident/family/caregivers about safety reminders . was ineffective in all of the subsequent 10 falls as Resident 29 was severely cognitively impaired with short and long term memory loss with confusion. The facility's Fall Protocol, dated October 14, 2008, was reviewed. The document indicated: .12. Each patient has a fall prevention program listed on their individual medical records/care plan and is updated quarterly and a as necessary to meet patient's (resident's) needs .23. Falls require investigation into causes of the fall and an incident report is made and the DON (Director of Nurses) assures follow-up procedures are learned out . The care plan intervention, Follow the facility fall protocol was ineffective as the root causes of the subsequent falls were not identified and the care plan was not updated and revised specific to Resident 29's needs. On March 16, 2016, at 2:15 p.m., during the environmental tour of the facility with the Maintenance Supervisor (MS), an outdoor camera was observed in the area of the smoking patio. Concurrently, the MS was interviewed and stated the smoking patio area was able to be viewed from inside the facility at the nurse's station. Upon returning inside the building and continuing the environmental tour, the television monitor was observed at the nurses station. 16 different views of the facility were observed on the television monitor. There was no screen to observe the smoking area of the patio. Three of Resident 29's last 10 falls occurred in the smoking area of the patio. On March 17, 2016, at 2:05 p.m., Resident 29 was observed unattended, self propelling in her wheelchair around the outside grounds of the facility. Resident 29's wheelchair became stuck in a rut between the sidewalk and the grass. Resident 29 scooted her bottom backwards and forwards in the seat of her wheelchair in an attempt to dislodge the wheel from the rut. When Resident 29 was observed to completely stand up from her wheelchair this Surveyor notified the facility by cell phone and asked for immediate assistance outside as a resident was at risk of falling. No audible alarm sounded from Resident 29's tab alarm. A certified nursing assistant (CNA) promptly came outside and assisted resident 29 back into a seated position in her wheelchair and freed the wheelchair from the rut. In this instance a fall with risk of injury was avoided. On March 21, 2016, at 12:15 p.m., Certified Nursing Assistant 1 (CNA 1) was interviewed. CNA 1 was asked how she identified residents in the facility that were at a high risk for falling. CNA 1 stated residents with Tab alarms, low beds, and floor mats were usually considered fall risks. CNA 1 stated, We (staff) need to be visually alert for residents needing help. CNA 1 further stated if residents were observed every 15 or 30 minutes and their whereabouts and what they were doing was charted, the staff might be too distracted and miss a potential fall about to happen. On March 21, 2016, at 1:30 p.m., CNA 4 was interviewed. CNA 4 was asked how residents at risk for falls were identified within the facility. CNA 4 stated a star was on their picture outside their door and Tab alarms are on their wheelchairs. The staff has been moving residents that fall, to the lounges that are closer to the nurse's station, and observing them. CNA 4 further stated, We walk around a lot and watch for who falls. 3. During the initial tour of the facility on March 14, 2016 and the environmental tour of the facility on March 16, 2015, the tops and side edges of the bedside cabinets in Rooms 2 A, 6 A, 8 B, 11 B, 14 A, 18 B, 22 A and 23 A were observed to be splintered and shredded. On March 16, 2016, at 1:30 p.m., the Maintenance Supervisor (MS) was interviewed. The MS stated he was the only person working in his department. The MS further stated, Right now I am working on patching the walls and painting. 4. During the environmental tour on March 16, 2016, at 2 p.m., the patio table in the outdoor smoking area was observed splintered and shredding wood particles. Additionally, three wooden benches in the residents' outdoor garden courtyard were observed with paint chips missing (causing rough uneven edges), splintered, and weathered. Concurrently the MS was interviewed. The MS stated, They have to be repainted every year. Review of facility's policy titled, Maintenance Service indicated, .Responsibility of Maintenance Service . .Functions 2. Functions of maintenance personnel include, but are not limited to: b. Maintaining the building in good repair and free from hazards. Review of facility's policy titled, Components of Fall Prevention Program indicated, 18. Maintenance is done promptly on any property that is damaged or in need of repair. 4. During the initial tour of the facility on March 14, 2016, at 9:05 a.m., the Formica covering over the sink counter in room 26 was observed to be broken and peeling in two places. Further observation revealed the broken Formica was observed to have many thin sharp edges that could result in skin cuts and injuries to the residents. In an interview with the Maintenance Supervisor on this same day at 9:24 a.m., he confirmed the Formica covering was broken and peeling over the sink counter top. On March 15, 2016, at 9 a.m., the facility's maintenance request log sheet was reviewed. A look back of six months did not indicate the staff had identified the broken Formica on the sink counter in room 26, or reported it to the maintenance department for needing repair. 5. On March 22, 2016, at 8:50 a.m., an inspection of the residents' wheelchairs was conducted. Sampled Resident 40 and unsampled Resident 45 were observed sitting in their wheelchairs at a dinning table with other residents. Further observation revealed their wheelchair brakes were not working properly to lock the wheelchair in a fixed position and prevent it from moving. When the wheelchair brakes were applied, the wheels were still able to roll forward or backward. In a concurrent interview with the Certified Nursing Assistant (CNA 5) and Licensed Vocational Nurse (LVN 3), they both confirmed the wheelchair brakes were not working properly. Unsampled Resident 38 was observed on March 22, 2016, at 9:00 a.m., sitting in her wheelchair at a dinning table with other residents. Further observation revealed her wheelchair brakes were not working properly. When the wheelchair brakes were applied, the wheels were still able to roll forward or backward. In a concurrent interview with CNA 3 and LVN 3, they both confirmed the wheelchair brakes were not working properly. Unsampled Resident 46 was observed on March 22, 2016, at 9:01 a.m., sitting in her wheelchair in the west lounge. Further observation revealed her right wheelchair brake was not locking when the brakes were applied. When the right wheelchair brake was applied, the right wheel was still able to roll forward or backward. In a concurrent interview with LVN 3 she confirmed the right wheel brake was not working properly. On March 22, 2016, at 9:14 a.m., Unsampled Resident 25's wheelchair was observed and revealed the right handle of the wheelchair brake was wrapped in black tape. Further observation revealed the black tape was torn in several places, creased, and leaving rough edges that could cause the resident to have skin injuries. In an interview with Unsampled Resident 25 on March 22, 2016, at 9:14 a.m., she stated, It looks kind of tacky. In a concurrent interview with the Maintenance Supervisor, he confirmed the covering over Unsampled Resident 25's right handle wheelchair needed repair. 6. Resident 30 was observed on March 21, 2016, at 2:00 p.m. She was alert with confusion. Resident 30's record was reviewed on March 21, 2016, and indicated she was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Post Fall Assessment forms indicated the resident had falls on the following dates: a. February 13, 2015 b. February 26, 2015 c. March 5, 2015 d. March 26, 2005 e. June 3, 2015 f. June 4, 2015 g. June 9, 2015 h. July

Based on observation, interview, and record review, the facility failed to: 1. Ensure a dietary cook (DC 1) was able to verbalize the cool down process for large or dense cooked food items. 2. Ensure DC 1 was performing and able to verbalize the sanitation processes utilizing the two compartment sink to wash dishes. 3. Ensure dishware used to prepare meals for the residents were stored in a sanitary manner. 4. Ensure the low temperature dishwasher machine provided the correct water temperature during the washing of dishes and utensils. 5. Ensure the top portion of the dishwasher machine was clean without a brown sticky substance. 6. Ensure a box of frozen cinnamon roles were discarded when unused. 7. Ensure the lid on the oatmeal storage barrel was clean and free of brown substances. 8. Ensure the cove (bottom molding) on the wall in the dry storage room was clean, and the cove at the left bottom wall was replaced. 9. Ensure accurate recording of temperatures for cooked foods on the trayline ready to be served to the residents. 10. Ensure the table mounted can opener was clear of crusted food particles. 11. Ensure the kitchen was free of spider webs, had clean kitchen floor tiles, clean walls, and clean light switch panels. These failed practices had the potential to affect a universe of 49 residents of the facility with cross contamination of infectious microorganisms, and development of foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) that could cause adverse medial complications such as nausea, vomiting, diarrhea, dehydration, and hospitalization . Due to the facility's failure to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, the Administrator and the Assistant Director of Nurses were verbally notified of an Immediate Jeopardy situation on December 31, 2015, at 12:35 p.m. The immediate Jeopardy was removed in the presence of the Administrator on December 31, 2015, at 2:35 p.m., after the facility's immediate plan of action was put into place to ensure safe food handling practices within the dietary department. Findings: 1. An unannounced visit was made to the facility on [DATE], at 1:05 p.m., to investigate a self reported event involving a gastrointestinal (relating to the stomach and intestines) outbreak affecting 8 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8), and one dietary staff (Staff 1) who became ill on the same day of December 28, 2015. Review of the facility's form titled, [MEDICATION NAME] (affecting the intestines) OUTBREAK LOG, dated December 28, 2015, indicated the following documentation all starting on December 28, 2015: a. Resident 1 had symptoms of diarrhea, vomiting, and nausea. b. Resident 2 had symptoms of diarrhea, vomiting and nausea. Resident 2 received [MEDICATION NAME] (medication to relieve nausea). c. Resident 3 had symptoms of diarrhea, vomiting and nausea. d. Resident 4 had symptoms of diarrhea, vomiting, nausea, and headache. e. Resident 5 had symptoms of diarrhea. f. Resident 6 had symptoms of diarrhea. g. Resident 7 had symptoms of diarrhea, vomiting, and nausea. h. Resident 8 had symptoms of vomiting and nausea. Resident 8 received [MEDICATION NAME] for nausea. i. Staff 1 had symptoms of vomiting, nausea, and sore throat. Staff 1 was sent home from work that day. An interview was conducted with the Assistant Director of Nursing (ADON) on December 29, 2015, at 1:22 p.m. The ADON stated in addition to the eight residents and one dietary staff that became ill, four more residents (Residents 9, 10, 11, and 12) became ill with diarrhea, and a certified nursing assistant (CNA 1) became ill with vomiting and diarrhea. During an interview with the dietary cook (DC 1) on December 29, 2015, at 4:05 p.m., she was asked to explain the facility's procedure for the cool down process of high density or high volume cooked foods. She stated cooked chicken and beef should cool from 180° (degrees) Fahrenheit (F) to 160° F in 20 to 25 minutes. DC 1 did not know and was not able to verbalize the cool down process. In an concurrent interview with the Dietary Supervisor (DS) she stated, We'll work on that. Review of a facility form titled, PROPER TEMPERATURES FOR MEAL PREPARATION AND SERVICE, dated 2011, indicated the following documentation: . Two Tiered Cooling: Internal temperature of food must be reduced from 140° F to 70° F in 2 hours and cooled from 70° F to 41° F in 4 hours. 2. A second visit was made to the facility on [DATE], at 9:49 a.m. Observation of DC 1 on December 30, 2015, at 11:02 a.m., revealed she was hand washing a strainer, two serving spoons, a potato masher, a steam table pan, and a cookie sheet in one sink of the two compartment sink using a dishwashing sponge. DC 1 washed the dishes with soap, rinsed them with water, and then set them aside on a counter. DC 1 was then observed to put the dishes away while they were still wet. Further observation revealed she did not use the dishwashing machine and did not follow the hand washing methods per the facility's policy using the two compartment sink. In a concurrent interview with DC 1 (with the assistance of Spanish interpreter, Assistant Dietary Supervisor/ADS), DC 1 was asked about the facility's policy for hand washing dishes in a two compartment sink. DC 1 was not able to verbalize the facility's procedure. Review of the undated facility's policy titled, SANITATION AND INFECTION CONTROL, indicated the facility had two methods for hand washing dishes as follows: SUBJECT: WAREWASHING (HANDWASHING METHOD) PROCEDURES: TWO COMPARTMENT SINK - METHOD 1 1. Compartment should be designated as follows: Compartment 1 - Wash Compartment 2 - Rinse and Sanitize 2. Wash dishes in hot water (110° - 120°F) in proper concentration according to manufacturer's instructions. Water should be changed frequently. 3. Rinse dishes by submerging the utensils in clean water (170°F) for at least 30 seconds or use water (75°F) and 50 ppm (parts per million) hypochlorite (household bleach) or equivalent, . . METHOD 2 1. Compartment should be designated as follows: Compartment 1 - Wash Compartment 2 - Rinse and Sanitize .2. Pre-rinse dishes and utensils to remove food particles. 3. Wash dishes in hot water (110° - 120°F) in first compartment, in proper concentration according to manufacturer's instructions. Water must be changed frequently. 4. Rinse dishes in second compartment. Change water and sanitize dishes in second compartment. 5. Sanitation: a. Hot water Sanitation Method: 1) Sanitize dishes in second compartment. Empty and refill sink with clean hot water (170°F) for 30 seconds. 2) To immerse dishes in 170°F water, use a wire basket. 3) Water must be changed frequently to maintain water temperature. b. Chemical Sanitation Method Use 75° - 120°F water in compartment 2. Sanitize with one of two methods stated. 1) 50 parts per million (ppm)* hypochlorite (household bleach) or equivalent. 2) 12.5 ppm* Iodine 3) 220 ppm* Quaternary Ammonium (Quat) *Follow manufacturer's instruction to obtain proper solution. Further review of the facility's policy indicated DC 1 did not follow either method for hand washing dishes by failing to use the required chemical sanitizing solutions. An interview was conducted with the DS on December 30, 2015, at 4:37 p.m. She stated bleach was supposed to be used for the chemical sanitization process when hand washing dishes. 3. Observation of the kitchen on December 30, 2015, at 11:08 a.m., indicated DC 1 was observed putting a steam table pan and a cookie sheet on a shelf under the preparation table while the items were still wet. DC 1 then placed two serving spoons and a potato masher into a drawer on the preparation table while these items were still wet. In an interview with the DS on December 30, 2015, at 11:25 a.m., she confirmed these dishes were wet, and stated the dishes should be air dried prior to storing them away. Review of facility's undated policy titled, SANITATION AND INFECTION CONTROL, indicated the following: SUBJECT: DISHWASHING PROCEDURES (DISHMACHINE) PROCEDURES: .8 Allow rack of dishes /trays/utensils to air dry. If drying space is not ample for dishes to air dry, use utility carts .Do not rack and stack wet dishes or trays . 4. During observation of the kitchen and interview with the DS on December 30, 2015, at 4:43 p.m., the DS stated the dishwasher was a low temperature machine. DS 1 was asked to operate the dish washing machine and the following was observed: At 4:43 p.m., The wash cycle temperature was 90° F, and the rinse cycle was 96° F, as measured by the dishmachine water temperature gauge. At 4:46 p.m., the wash cycle temperature was 101° F, and the rinse cycle was 100° F. At 4:50 p.m., the wash cycle temperature was 104° F, and the rinse cycle was 109° F. In an interview with the DS at 4:56 p.m., she stated, The laundry shares water with dietary. The DS confirmed the water temperatures of the dishwasher were not reaching the required temperatures. At 4:58 p.m., the DS was observed to run another cycle through the dish washing machine. The water temperature was 100° F during washing, and 104° F during the rinse cycle. In a concurrent interview, the DS stated she needed to inform the maintenance department of the low temperatures. Review of the facility's policy titled SANITATION AND INFECTION CONTROL, dated 2012, indicated the following: SUBJECT: DISHWASHING PROCEDURES (DISHMACHINE) PROCEDURES, 3. Chemical low temperature dishwashing machines must maintain a water temperature of 120°F - 140° F. 5. During observation of the kitchen on December 30, 2015, at 5:05 p.m., the top of the dishwashing machine was observed to have brown sticky substance in multiple areas. Further observations revealed a cleaning wire brush (size of a tooth brush) with it's wire bristles flattened stored on top of the dishwashing machine. In a concurrent interview with the ADS, she stated the top portion of the dishwashing machine was supposed to be cleaned between shifts. She stated, DC 1 hasn't cleaned it yet. In addition, the ADS confirmed the bristles of the wire brush were flattened and stated the brush was used to clean and disinfect parts of the dishwashing machine. Review of a facility's form titled, Daily Cleaning Schedule Log, indicated dietary aides were to Clean dish machine, top, sides, under, empty basket . 6. During observation of the dry storage room on December 30, 2015, at 5:08 p.m., an upright freezer located in the storage room was observed to have a box of frozen cinnamon rolls inside. The top of the clear plastic inner lining of the box was covered with a white substance that had dripped on top of the box. In a concurrent interview with the DS, she stated the freezer was in a defrost mode awhile back, and the drippings were from melted ice cream. The DS further stated the cinnamon rolls were on the menu in the spring of this year (2015) and should be discarded. 7. During observation of the dry storage room on December 30, 2015, at 5:12 p.m., the lid of a white plastic barrel that contained dry oatmeal (1/3 full) was observed to have a date of March 2015. The lid of the barrel had a brown substance smeared on it. In a concurrent interview with the DS she confirmed there were brown smears on the lid and stated the lid should be cleaned. Review of the facility's policy titled, SANITATION AND INFECTION CONTROL, date 2012, indicated the following: SUBJECT: SANITIZING EQUIPMENT . .PROCEDURES: .2. All equipment should be sanitized to prevent the spread of disease and infection. 8. During observation of the dry storage room conducted on December 30, 2015, at 5:12 p.m., the cove (molding) at the bottom of the right wall had brown marks of an unknown substance on it. Further observation revealed the left bottom wall was missing approximately two feet of coving and exposing the plaster which had the potential for entry of insects. In an concurrent interview with the DS, she confirmed the cove was soiled and part of it was missing from the wall. She further stated the cove should be cleaned and she would notify maintenance to install a new cove on the bottom of the left wall. 9. During observation of the kitchen on December 30, 2015, at 5:30 p.m., the food temperature log (trayline log) for the week of December 20, 2015, thru December 26, 2015, was reviewed. On December 21, 2015, the lunch meal food temperatures were recorded by DC 1 and documented as follows: Lunch Meat/Entree Regular 180° F Ground 170° F Pureed (blended) 180° F Starch Regular 180° F Ground 180° F Vegetable Regular 180° F Pureed 180° F Desert/Fruit Regular 40° F Pureed 40° F Milk 40° F On December 22, 2015, the lunch meal food temperatures were recorded by DC 1 and documented as follows: Meat/Entree Regular 190° F Ground 180° F Pureed 180° F Starch Regular 180° F Ground 180° F Vegetable Regular 180° F Pureed 180° F Desert/Fruit Regular 40° F Pureed 40° F Milk 40° F On December 26, 2015, the lunch meal food temperatures were recorded by DC 1 and documented as follows: Meat/Entree Regular 180° Ground 170° Pureed 180° Starch Regular 180° Ground 180° Vegetables Regular 180° Pureed 180° Desert/Fruit Regular 40° Pureed 40° Milk 40° In an interview with the DS, and ADS on December 30, 2015, at 5:32 p.m., they were asked why the recorded temperatures for different foods and different consistencies were exactly the same without any variation. The DS and Assistant DS were not able to explain why. 10. During observation of the kitchen on December 30, 2015, at 5:39 p.m., the table mounted can opener had a large amount of built-up brown and black crusted food particles around the cutting blade. In a concurrent interview with DC 1, she was asked what she had recently opened with the can opener. She stated, Applesauce. DC 1 acknowledged the can opener blade was dirty. Review of the facility's policy titled, SANITATION AND INFECTION CONTROL, dated 2012, indicated the following documentation: SUBJECT: SANITIZING EQUIPMENT . PROCEDURES: .4. All kitchen equipment and surfaces which come in contact with food will be cleaned and sanitized after each use . 11. During observation of the kitchen on December 30, 2015, at 5:48 p.m., the following were observed: a. The corner tiles of the kitchen floor had crusted white and black granules sticking to the tiles. The floors also had build-up of a thick black substance on them. b. Spider webs were observed on the walls of the Dietary Supervisor's office. c. Brown stains were noted around the light switch covers. In a concurrent interview with the DS she stated, Dietary staff should cleaning the wall and floors. An interview was conducted with the Administrator on December 30, 2015, at 6:04 p.m. The Administrator stated he had not been in the kitchen recently, and the facility's Registered Dietician came to the facility twice a month. On December 31, 2015, at 10:20 a.m., a third visit was made to the facility. During an interview with the Maintenance Supervisor (MS) on December 31, 2015, at 10:27 a.m., he stated the hot water heater that supplied the kitchen stopped working about three weeks ago and was being replaced. The MS stated the freezer in the dry storage room had stopped working approximately two months ago. The MS further stated he was not aware that the cove floor molding needed to be replaced. Review of the facility's updated [MEDICATION NAME] Outbreak Log on December 31, 2015, indicated eight more residents (Residents 9, 10, 11, 12, 13, 14, 15, and 16) became ill starting December 29, 2015, with the following symptoms: a. Resident 9 had symptoms of diarrhea and was treated with [MEDICATION NAME]. b. Resident 10 had symptoms of diarrhea. c. Resident 11 had symptoms of diarrhea. d. Resident 12 had symptoms of diarrhea. e. Resident 13 had symptoms of diarrhea. f. Resident 14 had symptoms of diarrhea. g. Resident 15 had symptoms of diarrhea. h. Resident 16 had symptoms of vomiting. On December 31, 2015, at 12:35 p.m., an Immediate Jeopardy was called in the presence of the Administrator regarding the facility's unsafe dietary practices and high probability for the development of foodborne illness to the residents. The Administrator provided an immediate corrective action plan on December 31, 2015, at 2:35 p.m., including but not limited to performing a deep cleaning of the kitchen, conducting inservices to dietary staff, performing needed repairs, and consulting with the facility's Registered Dietician. The immediate Jeopardy was removed in the presence of the Administrator on December 31, 2015, at 2:35 p.m., after the facility's immediate plan of action was put into place to ensure safe food handling practices within the dietary department.