Every finding on record at Creekview Skilled Nursing

Based on observation, interview and record review the facility failed to administer and/or clarify doctor's order for Furosemide (commonly known as Lasix, which is used to remove excess fluids in the body) medication when one of 17 sampled residents (Resident 2) had pitting edema (swelling due to fluid buildup, where pressing the swollen area leaves an indentation or a pit) in both legs for 17 days. Resident 2 had a primary diagnosis of heart failure (a chronic condition in which heart does not pump blood effectively). This failure placed Resident 2 at risk for further increased edema, increased discomfort, skin breakdown, complications related to heart failure such as fluid accumulation in the lungs, shortness of breath, upto and including death. Findings: During a record review of Resident 2's Admission Record (a record with resident's basic information) printed on 2/27/25, the record indicated Resident 2 was admitted to the facility on [DATE]. During a record review of Resident 2's Minimum Data Set (MDS, an assessment used to guide resident's care) dated 12/2/24, the assessment indicated Resident 2's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's mental status) score was zero (0) out of 15, indicating Resident 2's mental statis was severely impaired. The MDS assessment indicated Resident 2 had a diagnoses of heart failure, hypertension (high blood pressure), non-Alzheimer's Dementia (memory loss), and asthma (breathing difficulty). During an observation on 2/24/25 at 9:51 a.m., Resident 2 was sitting up in wheelchair in her room. Resident 2's both lower legs were exposed. Resident 2's both legs and both feet were swollen. During a concurrent observation and interview on 2/25/25, at 10:00 a.m., with Certified Nursing Assistant (CNA 1), Resident 2 was lying in her bed, with non-skid socks on both feet. CNA 1 removed the socks and stated Resident 2 always had swelling in her legs but was worse that day. During a concurrent observation and interview on 2/25/25, at 10:15 a.m., with Registered Nurse (RN 1), in Resident 2's room, Resident 2 was sitting up in a wheelchair. RN 1 put on gloves and pressed Resident 2's both legs. Resident 2 had an indentation (a pit) left on both legs after RN 1 pressed them. RN 1 stated it was 3+ (5-6 millimeter of deep indentation which rebounds in upto 60 seconds) pitting edema on Resident 2's both legs. RN 1 stated Resident 2 always edema in her legs but she did not notice that edema had increased to 3+. RN 1 stated Resident 2's Furosemide medication was discontinued recently. During a concurrent interview and record review on 2/25/25, on 12:22 p.m., with Director of Nursing (DON), Resident 2's Electronic Health Record (EHR) for Physician Orders and Medication Administration Record (MAR) for 02/2025 were reviewed. The DON stated Resident 2 was taking 60 milligrams (mg) of Furosemide by mouth every day since 2/23/24 until it was discontinued on 2/9/25. The DON stated Resident 2 had a new order to receive 20 mg of Furosemide by mouth as needed for edema since 2/9/25. The DON stated MAR indicated Resident 2 continued to have +2 edema (3-4 millimeter of indentation that bounds in 15 seconds or less) throughout the month until 2/24/25, however she did not receive any Furosemide since 2/9/25. The DON stated nurses should be administering as needed dosage of Furosemide 20 mg to Resident 2 for +2 edema. During an interview on 2/26/25, at 11:00 a.m., the DON stated administering Lasix to Resident 2 was important to avoid increasing leg/feet edema, discomfort, skin breakdown, worsening of her heart condition, and shortness of breath. The DON then stated the new order for Furosemide dated 2/9/25, did not have clear parameters to indicate at what level of pitting edema, Resident 2 was to receive Furosemide. The DON then stated; however, facility did not contact and/or clarify the order with Resident 2's doctor until the afternoon of 2/25/25.

Based on observation, staff interviews, and review of facility documents, the facility failed to comply with Federal regulations related to the oversight of food service operations when the facility did not have a full-time Registered Dietitian and/or a full-time Director of Food Services in accordance with California Code, Health and Safety Code - HSC S 1265.4 The lack of a full-time, qualified supervision over Food and Nutrition services had the potential to result in inadequate supervision leading to food borne illness for 45 residents who received food from the kitchen out of a facility census of 51. Findings: During the Federal re-certification survey from 4/10/23 - 4/13/23, it was noted that Food and Nutrition services provided meals not only to skilled nursing residents but also to a separately licensed, affiliated assisted living facility and memory care units. Review of the organizational structure of the community identified that the Skilled Nursing Facility was part of a continuing care community that included independent and assisted living levels of care. According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. In an interview on 4/10/23 at 9:54 a.m., the Food and Nutrition Services Director (FNSD) stated she was the full-time supervisor for the entire kitchen which included food service for the skilled nursing facility and assisted living. In an interview on 4/11/23 at 9:21 a.m., the Registered Dietitian (RD) confirmed she was not full-time, and she worked part time 2 to 3 days a week. In an interview on 4/12/23 at 10:19 a.m. the Administrator confirmed FNSD was the supervisor of Food and Nutrition Services which included skilled nursing, assisted living, and memory care. Review of the undated organizational chart which showed the organization of Food and Nutrition Staff, showed the FNSD reported to ADM and all Food and Nutrition staff were under the FNSD.

Based on observation interview and record review, the facility failed to ensure infection control practices were implemented when the following was noted for eight of eight residents: 1. An unlabeled bedpan and basin were observed in the shared bathroom of Residents 14 and 34. A yellow basin labeled for Resident 34 was on the floor in the Resident's shared bathroom. 2. Resident 34's feeding pump had tannish-brown residue in the tubing channel and flaky, light brown residue on the base of the pole. 3. Resident 17's wheelchair had torn armrests and dried, flaky reddish-brown matter and white staining on the seat and in the metal frame. 4. The facility did not have appropriate isolation precaution signage for four of four sampled residents (2, 21, 100 and 349). 5. Certified Nurse Assistant 1 (CNA 1) and Certified Nurse Assistant 2 (CNA 2) did not perform hand hygiene and or change gloves during peri-care for Resident 8. These failures placed the facility's residents at risk for healthcare-associated infections. Findings 47382 1. During a review of facility's Admission Record for Resident 14, dated 4/12/23, Resident 14 was readmitted ,d+[DATE] after a hospitalization . During a review of Resident 14's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section G showed Resident 14 required extensive assistance by staff for personal hygiene and toileting. Section H showed Resident 14 was incontinent of bowel and bladder. During a review of facility's Admission Record for Resident 34, dated 4/12/23, Resident 34 was admitted ,d+[DATE]. During a review of Resident 34's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section G showed Resident 34 was totally dependent on two or more staff for personal hygiene and toileting. Section H showed Resident 34 was incontinent of bowel and bladder. During an observation on 4/10/23, at 10:50 a.m., in Resident 14 and 34's shared bathroom, a gray unlabeled bedpan and gray unlabeled basin were sitting in the rack on the wall between the toilet and the sink. A yellow basin was sitting on the floor. During a concurrent observation and interview on 4/10/23, at 1:13 p.m., with Licensed Vocational Nurse 3 (LVN3), in Resident 14 and 34's shared bathroom, LVN 3 stated the basins were used for bed baths. LVN 3 discarded the unlabeled bedpan. LVN 3 a discarded the gray basin, LVN3 stated was unlabeled and could not determine which resident it was used for. LVN 3 took the labeled basin from the floor and placed it in the holder on the wall. LVN 3 stated should discard it and then threw it away. LVN 3 stated unlabeled basins and bedpans could not be used on more than one resident because it was an infection control risk, as well as with the basins touching the floor. LVN 3 also stated it could cause UTI or other infections if germs on basins touched the residents. During a review of the facility's policy and procedure titled Cleaning and Disinfecting of Resident Care Items and Equipment dated 11/23/21, indicated only equipment that is designated reusable shall be used by more than one resident and single resident-use items, which are cleaned/disinfected between uses by a single resident and disposed of afterwards, include bedpans. 2. During an observation on 4/10/23, at 10:53a.m., in Resident 34's room, observed a tannish-brown residue in the tubing channel Resident 34's feeding pump. Also observed dry, flaky, beige residue on the base of the feeding pump pole. During a concurrent observation and interview on 4/10/23, at 1:13 p.m., with LVN 3, in Resident 34's room, LVN 3 stated the feeding pump residue was from the feeding formula. LVN 3 stated the nursing staff cleaned feeding pump once a week with a Sani-Cloth (a disposable pre-moistened disinfecting wipe). LVN 3 stated nursing was responsible for wiping down the equipment and housekeeping cleaned the feeding pump poles. 3. During a review of facility's Admission Record for Resident 17, dated 4/12/23, Resident 17 was admitted ,d+[DATE]. During a review of Resident 17's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section G showed Resident 17 normally used a wheelchair and was completely dependent upon staff to move about the facility. During an observation on 4/11/23, at 10:48 a.m., in the activity room, Resident 17's wheelchair had a tannish-brown flaky residue along the edge of the seat and on the metal frame. Resident 17's wheelchair also had white stains along the edge of the seat. The wheelchair arm pads were cracked and peeling on the outer edges of both armrests. During a concurrent observation and interview on 4/11/23, at 10:52 a.m., with LVN 3, in the activity room, LVN 3 stated the residue on Resident 17's wheelchair appeared to be old food. LVN 3 used her finger and flaked off some of the tannish-brown residue. LVN 3 stated environmental services (EVS) is responsible for cleaning the chairs. LVN 3 stated the armrests should be changed and were an infection risk for the resident. During a review of the facility's policy and procedure titled Cleaning and Disinfecting of Resident Care Items and Equipment dated 11/23/21, indicated Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations . The policy identified durable medical equipment as reusable items. During a review of CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities - Guideline for Disinfection and Sterilization in Healthcare Facilities, dated 2008, the Cleaning of Patient-Care Devices indicated clean medical devices as soon as practical after use (e.g., at the point of use) because soiled materials become dried onto the instruments. Dried or baked materials on the instrument make the removal process more difficult and the disinfection or sterilization process less effective or ineffective. It also indicated, inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization. Discard or repair equipment that no longer functions as intended or cannot be properly cleaned and disinfected or sterilized. 47400 4. During a concurrent observation, and interview on 04/10/23, at 10:30 a.m., with Infection Preventionist (IP 2) the Resident 21 and 100's room had a signage Yellow Gowns outside by the door. IP 2 stated Resident 21 and Resident 100 were recently admitted with MDRO (Multidrug-resistant organisms Bacteria that resist treatment with more than one antibiotic and are found mainly in hospitals and long-term care facilities). IP 2 stated both residents were placed on Enhanced Precautions. (an infection control intervention to reduce transmission of MDROs in nursing homes). IP 2 stated the signage stating, yellow gowns was unclear and confusing and it should be labeled as Enhanced precautions instead. During a concurrent observation, and interview on 04/10/2023, at 10:32 a.m., with IP 2 the Resident 2's room had a signage Contact Precautions outside by the door. (intended to prevent direct or indirect transmission of infection with the resident or the resident's environment). ). IP 2 stated Resident 2 was recently readmitted with a with a Feeding Tube (a flexible plastic tube placed into stomach or bowel to provide nutrition). IP 2 stated the signage outside Resident 2's room was incorrect as it should state Enhanced Precautions. During a concurrent observation, and interview, on 04/10/2023, at 10:34 a.m., with IP 2, Resident 349's room had a signage STOP. Visitors: Please report to the Charge Nurse before entering the room. IP 2 stated that Resident 2 should also be on enhanced precautions he was a recent readmitted after a surgery. IP 2 also stated signage outside the room was incorrect and misleading; and should state Enhanced Precautions. During an interview on 04/10/23 at 11:15 a.m., with the Director of Nursing (DON), DON stated No sign or incorrect sign means that staff have no way of knowing of the resident's condition. The DON stated, The sign is important as it helps prevent the spread of infections. During an interview on 04/11/23 at 09:48 a.m., with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated he gets a report at the beginning of his shift for only his assigned residents, but answers call-lights throughout the facility. CNA 5 stated that he relied on the signage outside the room to guide him for providing care, and that he did not check with the assigned nurse every time prior to answering call lights throughout the facility. During a record review of facility's Policy and Procedures titled, Enhanced Standard Precautions Guidelines policy dated 10/24/2022, showed Upon admission identify residents at high risk for Multi-Drug resistant organisms (MDRO) colonization's and transmission .Document the decision for Enhanced Standard or Transmission-Based precautions, and room placement or roommate selection, Ensure that the appropriate instructions are provided to all Healthcare Personnel (HCP) who will be providing care, Communicate and educate all HCP about the reason for choosing a single-bed room or roommate selection. 5. During an observation on 4/12/23, at 10:09 a.m., in Resident 8's room, Certified Nursing Assistant (CNA)1 and CNA 2 provided peri-care to Resident 8 while she was lying in supine position in bed. CNA 1 at first, wiped a wooden nightstand with sanitizing wipes on the right side of Resident 8's bed. Without removing the gloves and or performing hand hygiene, CNA 1 uncovered Resident 8's legs, pulled the hospital gown up and removed Resident 8's incontinent brief. CNA 2 was on the left side of Resident 8's bed at that time and assisted to remove Resident 8's incontinent brief. CNA 1 then opened a wooden closet on Resident 8's right side of the bed, picked up a spray bottle, sprayed it on Resident 8's peri area and closed the closet. CNA 1 stated it was a peri care spray. CNA 2 then wiped Resident 8's front peri area with cleaning wipes. CNA 1 and CNA 2 moved Resident 8 towards CNA 2, on the left side of Resident 8's body. CNA 1 opened the wooden closet again, picked up the peri spray, sprayed on Resident 8's bottom, put it back in the closet and closed the closet. CNA 1 then wiped Resident 8's bottom with cleaning wipes. CNA 1 again opened the wooden closet, got incontinent pad (also known as chucks), closed the closet, put the incontinent pad under Resident 8's bottom and put on a new incontinent brief. Without removing the gloves and/or performing hand hygiene, CNA 1 and CNA 2 repositioned Resident 8 back to supine position, pulled her up, put a pillow under her neck. CNA 2 continued to fix Resident 8's hair, wheeled Resident 8's bedside table closer her bed, used bed control to sit Resident 8 up, picked up a chocolates bag and put it inside the wooden closet, closed the closet, touched Resident 8's call bell, and then removed her gloves. During an interview on 4/12/23, at 10:22 a.m., CNA 1 stated she thought she changed her gloves after wiping the nightstand and prior to starting Resident 8's peri care. CNA 1 sated she should have had the peri spray out until the end of the procedure, so it was readily available throughout the care. During an interview on 4/12/23, at 10:25 a.m., CNA 2 stated she was supposed to change her gloves after peri care and prior to touching Resident 8's belongings for infection control. During an interview on 4/13/23, at 8:43 a.m., Infection Preventionist (IP)1 stated staff was expected to wash their hands and/or use alcohol based hand rubs (hand sanitizer) in between gloves changes; remove their contaminated gloves after cleaning resident's peri area and prior to touching resident's belongings and/or surroundings. IP1 also stated following infection control practices was important to minimize the spread of infections. During a record review of facility's Policy and Procedures titled Hand Washing and Hand Hygiene dated 9/30/22 showed, This facility considers hand hygiene the primary means to prevent the spread of infections . Employees shall wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: .Before and after assisting a resident with personal care .after removing gloves .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food safely when: 1. Meat was not thawed according to storage guideline dates; 2. kitchen staff did not follow appropriate hand hygiene and glove use procedures when going between and handling dirty dishes and clean dishes; 3. Three out of 5 storage bins for bulk dry goods had crumbling plastic liners; 4. Four out of 12 pairs of tongs and 1 ladle had cracked handles; 5. 2 of 2 Ice machines in the kitchen and nourishment room had rough, discolored surfaces on ceiling of the ice bin where ice was stored; and 6. Food in resident's refrigerator was undated for one out of 2 residents (Resident 14) and food was kept more than 3 days for one out of 2 residents (Resident 351). These failures has the potential of placing the 45 residents who received food from the kitchen at risk for foodborne illnesses out of a census of 51. Findings: 1. During a concurrent observation and interview on 04/10/23, at 09:54 a.m., with Sous Chef (SC) and Food and Nutrition Services Director (FNSD), in the walk-in refrigerator, one box of boneless chicken thighs with a delivery date of 4/3/23 was on the bottom shelf and noted to be soft (thawed). SC confirmed delivery label on chicken thighs was 4/3/23. There was also a case of boneless chicken breast with a label showing received 4/6 the chicken was soft (thawed), a closed case of beef tenderloin showing a receive date of 4/6, a 7-pound package of pork butt with a receive date of 4/6; a package of Italian ground sausage with a receive date of 4/6, and an opened package of raw Italian sausage in a plastic container with a hand written date on the container showing 4/7/23 - 4/17/23. FNSD stated the date on the opened Italian sausage was incorrect and should be dated 4/7/23-4/10/23. SC confirmed the delivery dates on the chicken breast, beef tenderloin, pork butt, and Italian sausage was 4/6. He stated all of the meat was delivered fresh and not frozen and was put directly into the FNSD stated kitchen gets foods delivery two times a week, Tuesdays and Fridays. During a concurrent observation and interview on 4/10/23 at 11:47 a.m., the meat delivery invoice was reviewed with FNSD. The invoice showed the fresh meat observed in the refrigerator with delivery dates of 4/6 was delivered on 4/7/23 and the meat was delivered fresh not frozen, including the boneless chicken breast, beef tenderloin, and pork butt. During a concurrent interview and record review on 04/10/23, at 1:19 p.m., with Food and Nutrition Services Director (FNSD), Refrigerated Storage Chart, dated May 2016, was reviewed. The Refrigerated Storage Chart indicated meats may be left in distributer packaging for refrigerator storage and fresh chicken (raw) can be stored up to two days, and fresh ground meat and stew meat can be stored for one to two days. During an interview on 04/12/23, at 12:15 p.m., with Registered Dietician (RD), RD stated her expectations for thawing meat, for example chicken, if the meat comes in fresh, it should go into the refrigerator and be used within 1-2 days. During a review of facility's policy and procedure titled, Food Storage, dated 04/06/23, indicated [ .]4. Hamburger and fresh chicken should be cooked within one to two days of purchase .[ .]. 2. During a concurrent observation and interview on 04/11/23 at 10:00 a.m., in the kitchen, with the FNSD and Utility Worker (UW), UW loaded used dishes and trays from the resident breakfast into the dishwashing machine. Then UW removed the cleaned dishes and trays from the clean dishes and trays from the dishwashing machine without changing gloves or washing hands in between handling the dirty and clean dishes and trays. FNSD stated UW should have removed her gloves and washed hands when going from dirty dishes to clean dishes. FNSD stated her expectation is also for staff to wash hands before glove changes. During a review of facility's policy and procedure titled Handwashing and Glove Use, dated 04/15/2020, showed hands must be washed following contact with any unsanitary surface. When gloves are used, handwashing must occur prior to putting on gloves and whenever gloves are changed. Gloves must be changed as often as hands need to be washed. Gloves may only be used for one task. Review of the document titled Dishwashing Procedure revised 8/31/2018, showed when two people are in the dish room, on the dirty side, and one on the clean side. If one person does both (dirty and clean side), they must wash their hands between dirty and clean areas. 3. During a concurrent observation and interview on 04/10/23 at 10:27 a.m., in the kitchen, with FNSD, three bulk dry good storage containers were filled and labeled thickener, sugar, and panko (breadcrumbs). Each container was lined with a white plastic bag. Portions of the bags on the internal space of the containers were torn, cracked, and crumbling. FNSD confirmed portions of the bags were torn, cracked, and crumbling. A review of the FDA Food Code, dated 2022, indicated Food packages shall be in good condition and protect the integrity of the contacts so that the food is not exposed to adulteration or potential contaminants. Federal Food Safety Code also indicated food shall be protected from contamination by storing the food in a clean location that is not exposed to dust or other contaminants. 4. During a concurrent observation and interview on 04/10/23, at 10:25 a.m., in the kitchen, with Food and Nutrition Services Director (FNSD), serving utensils were observed in a clean storage area. There were four pairs of tongs and one ladle with handles with a plastic coating. The coating on handles were cracked, uneven, and rough. FNSD confirmed handles that were cracked could be hard to clean effectively. A review of the FDA Food Code, dated 2022, indicated Contact Surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 5. On 04/11/23, at 9:11 a.m., in the kitchen, the ice machine was observed with the Maintenance Supervisor (MS 1). The ceiling of the interior ice storage bin had a rough, yellow/brown discolored surface surrounding the ice chute (where formed ice entered into the ice bin). MS 1 confirmed there was a rough, discolored surface on the ceiling inside the ice machine bin. During an observation on 04/11/23, at 9:21 a.m., in the nourishment room, the ice machine was observed with MS 1. The ceiling of the interior ice storage bin had a rough, yellow/brown discolored surface surrounding the ice chute. MS 1 confirmed there was a rough, discolored surface. A review of the FDA Food Code, dated 2022, indicated Nonfood-contact surfaces that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbable, and smooth material. 6. During a concurrent observation and interview with the Infection Preventionist 1 (IP 1) on 04/10/23, at 12:18 p.m., in the Resident Nourishment Room located at the nursing station, showed a freezer/refrigerator with food stored inside. There was one opened jar with purple liquid with a hand written label that showed smoothie with Resident 14's name. There were also 2 plastic reusable containers inside a plastic bag. The reusable containers had a hand written label on the lids which showed 4/4/23 and Resident 351's name. The reusable containers contained cooked food which resembled mashed potatoes with butter in one container and 3 meatballs with sauce in the other container. IP 1 confirmed there was no date on the smoothie jar to show when it was placed in the refrigerator. She also confirmed food could only be stored for 3 days. She stated the NOC (night) shift was responsible for discarding food after 3 days. The procedure posted on the refrigerator door showed all food brought by family will be thrown after 48 hours. During an interview on 04/11/23, at 9:14 a.m., with FNSD, FNSD stated either she or the nurses will remove food from the resident's refrigerator every 3 days. During a review of facility's policy and procedure titled Food From Outside Sources, dated 2020, the policy indicated 4 .Perishable food should be sealed and dated with a use-by date and placed in refrigeration .

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were competent in job duties related to: 1. using the three compartment sink; 2. testing the sanitizer liquid in the red sanitization bucket; and 3. cleaning the juice machine. These failures have the potential for improper cleaning and sanitization which could lead to increased risk for food-borne illness for 45 residents who received food from the kitchen out of a facility census of 51. Findings: 1. During a concurrent observation and interview on 04/11/23, at 09:37 a.m., with Utility Worker (UW) and the Food and Nutrition Services Director (FNSD) in the kitchen dishwashing area, FNSD stated the 3-compartment sink is a back-up for washing dishes if the dish machine did not work. She stated UW was a dishwasher and would be responsible for cleaning dishes in the 3-compartment sink if needed. UW stood in front of the 3-compartment sink and spoke to how she would clean dishes and utensils in the sink. On the wall, above the 3-compartment sink, was a sign with directions on sink use. UW stated if dishwasher was not working, she would use three compartment sink. UW stated she would wash in sink number one, rinse in sink number two, then soak in sanitizer solution for 15 seconds in sink number three. The sign above the sink indicated soaking in sanitizer solution for 1 minute. A review of facility's Utility Worker's Job Description dated May 2020, showed the Utility Worker performs a number of kitchen duties including dishwashing and pot/pan washing. During an interview on 04/12/23, at 02:05 p.m., with Registered Dietician (RD), RD stated when using three compartment sink, kitchen equipment should be soaked in sanitizer solution for 1 minute per the sanitizer manufacturer's guidelines. During a review of document titled Warewashing Solutions [brand name of quaternary ammonium sanitizer], dated 2017, indicated in the directions [ .]2. Expose all surfaces of equipment, ware, or utensils to the sanitizing solution for not less than one minute.[ .] 2.During a concurrent observation and interview on 04/11/23, at 09:50 a.m., with Cook 2 and FNSD in the kitchen, Cook 2 stated he was responsible for filling red buckets with sanitizer solution. He demonstrated how he filled up the bucket and stated one of the steps was to test the solution strength with a sanitizer-testing strip. He was observed testing the sanitizing solution in a red sanitization bucket. Cook 2 was observed removing a test strip from a quaternary ammonium (a type of sanitizer) test strip container and then held the test strip in the solution for 17 seconds. He compared the color of the test strip against the color chart inside the test strip container and stated the strip showed a strength of 200 ppm (parts per million; concentration of sanitizer in water). Cook 2 stated he should have held the test strip for 15 seconds. Another test strip was held in the solution for 10 seconds and compared to the color chart. FNSD confirmed when the test strip was held in the solution for 10 seconds, the strip showed the solute was 150 ppm. A review of the manufacturer's instruction insert located inside the quaternary ammonia test strip container indicated Dip paper in quat solution .for 10 seconds. Review of the document titled Sanitation Buckets dated 2019, showed all surfaces and equipment should be washed and then sanitized with a sanitizing solution. Sanitizing buckets must be established with appropriate sanitizing solution concentration, then the concentration range is to be tested . 3. A review of facility's Diet Aid job description dated August 2016, indicated principle duties for a Diet Aid includes [ .]Maintains station equipment and work area in a safe and sanitary conditions.[ .] During an interview on 04/12/23 at 09:20 a.m, with Dietary Aid (DA2) and Food Nutrition Services Director (FNSD), DA 2 stated the juice machine was cleaned every PM (afternoon/evening) shift, she sometimes works PM shift and was responsible for cleaning the juice machine. DA 2 stood in front of the juice machine and described her cleaning process. She stated she takes the nozzles off, cleans them with a brush and quaternary ammonium (a sanitizer solution), then reattaches the nozzles. FNSD stated the person cleaning the juice machine also soaked the nozzles in sanitizer solution overnight, then reattached the nozzles in the morning. FNSD stated there are no written instructions on how to clean the machine. During a concurrent observation and interview on 04/12/23, at 02:05 p.m., in the kitchen at the juice machine, with FNSD and Registered Dietician (RD), written instructions were observed inside the cover of the juice machine. FNSD stated written instructions are located inside the cover. A review of the machine cleaning instructions showed the daily cleaning included a water flush which showed to hold the flush button for 6-8 seconds. The daily cleaning instructions also showed to remove the rubber nozzle covers and Lift out rubber nozzle cover. Clean nozzle and nozzle cover with hot water, then sanitize, and rinse. FNSD confirmed when DA 2 was describing how she cleaned the juice machine, she did not describe using the water flush and she did not use hot water to clean the nozzles as described on the cleaning instructions.

Based on observation, interview, and record review, the facility failed to store and label medication in accordance with standards of practice by failing to date three open bottles of medications (sodium chloride, milk of magnesia and bismuth subsalicylate), and one open container of blood sugar test strip for two of three medication carts inspected. This failure had the potential to result in medications and test strip used to not be effective. Findings: During a concurrent observation and interview of medication cart 3 on 4/11/23, at 10:40 a.m., with LVN 2, LVN 2 pulled from medication cart drawer one bottle of sodium chloride (salt - an essential compound a body uses to function) and one container of blood sugar test strip (the strip work with glucose meters to read blood sugar levels) had no open date. LVN 2 stated, the standard practice was to date the bottles right away. During an interview on 4/12/23, at 1:45 p.m., with the Director of Nursing (DON), DON stated, medication bottles including blood sugar test strip should be labeled immediately with open date because medications can go bad within certain time they were open. During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated 12/2012, the P&P indicated, 9.When opening a multi-dose container, the date opened shall be recorded on the container.

Based on observation, interview, and record review, the facility failed to reconcile controlled substances (a drug subject to special handling, storage, and disposal because of its potential for abuse or addiction) for one of 51 residents (Resident 37). This failure had the potential for the loss or diversion of controlled substances. Findings: During a concurrent observation and record review on 4/11/23, at 11:17 a.m., with RN 1, Resident 37's Controlled Drug Record (CDR) for morphine sulfate (a controlled medication used for moderate to severe pain) 0.25 ml (milliliters - a unit of measurement), dated 4/4/23, was reviewed. The CDR indicated as follows: 4/4/23; PM; 0.25ml; 16 ml remaining. An observation of morphine bottle container showed, 14 ml remaining. During a subsequent interview with RN 1, RN 1 stated the amount remaining in the morphine bottle did not match the CDR. RN 1 further added, she did not do narcotic count with the going off duty nurse. During an interview on 4/12/23, at 1:27 p.m., with the Director Of Nursing (DON), DON confirmed Resident 37's morphine bottle did not match the CDR. DON also stated, going off duty nurse and coming on duty nurse were expected do narcotic count to ensure narcotics remaining in the pack/container are accurate. During a review of Resident 37's admission record dated 4/12/23, the admission record indicated Resident 37 was admitted to the facility 11/22 with multiple diagnoses that included Personal History of Malignant Neoplasm of breast (cancer). The admission record also indicated, Resident 37 was on Palliative Care (medical care treatment for people with serious illness). During a review of Resident 37's Order Summary Report, dated 4/12/23, the order summary report indicated a physician's order for Morphine Sulfate (concentrate) Solution 20 mg/ml Give 0.25 ml by mouth every 4 hours as needed . During a review of the facility's policy and procedures (P&P) titled, Controlled Substances, dated 12/2012, the P&P indicated, 9. Nursing staff must count controlled medications at end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

Based on interview and record review, the facility failed to implement its COVID-19 [Coronavirus disease] Vaccination policy and procedures to ensure two of two sampled Residents (46 and 249) were fully vaccinated for Coronavirus Disease-19 (an acute respiratory illness with fever, cough, and capable of progressing up to and including death). This failure resulted in Residents 46 and 249 to be unaware of the risks and benefits associated with the COVID-19 vaccine. Findings During a review of the Resident 46's Admission Record printed on 04/13/23, the record showed Resident 46 was admitted to the facility 03/23. During a review of the Resident 249's Admission Record printed on 04/13/23, the record showed Resident 249 was admitted to the facility 02/23. During an interview and record review on 04/12/23, at 09:56 a.m., the Director Nursing (DON) was asked to provide a list of unvaccinated residents. DON stated Resident 46, Resident 249 were unvaccinated, and they did not have a pending and/ or granted exemptions for COVID-19 vaccination. The DON stated facility expected all resident's vaccination status to be checked upon admission, and if a resident was unvaccinated, the staff were to offer a COVID-19 vaccination along with an explanation of the risks and benefits of the vaccination. During a concurrent interview and record review on 04/12/23, at 10:14 a.m., with Infection Preventionist (IP 1), Clinical Records for residents 46 and 249 from 02/23/23 through 04/12/23 were reviewed. IP stated they were unable to locate COVID-19 vaccination record, documentation that vaccination was offered, or documentation that an explanation of risks and benefits of vaccination was provided to Resident 46 and 249. During a record Review of the Minimum Data Set (MDS-an assessment used to guide care) dated 03/02/23, the assessment showed Resident 249 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating intact mental status. During an interview on 04/13/23 at 11:19 a.m., Resident 249 stated that the facility did not offer COVID-19 vaccination nor provide them with information about the risks and benefits of the COVID-19 vaccine. During a record review of facility's undated policy titled COVID-19 VACCINATION showed, Education on the vaccine shall be provided in a manner that is easily understood and in advance of each vaccination dose. This information will include the U.S Food and Drug Administration (FDA) Emergency Use Authorization (WUA) fact sheet, benefits and side effects for each dose needed. Vaccines will be offered as available unless contradicted .If the vaccine is unavailable, the facility shall provide information on obtaining vaccination opportunities (e.g., health department or local pharmacy).

Based on observation, interview, and record review, the facility failed to ensure menu was followed when one of 51 residents (Resident 4) was given pureed broccoli instead of minced and moist broccoli. This failure has the potential for one of 51 residents to not get the type of food texture as indicated on the planned menu which could compromise the resident's intake of food and nutritional status. Findings: A review of the cook spreadsheet menu titled Daily Spreadsheet dated for 4/11/23, and used for lunch, the spreadsheet indicated a minced and moist diet receives minced and moist (food cut into very small pieces, less than 1/8 inch pieces; minimal chewing is required) seasoned broccoli florets. A review of Resident 4's diet card, dated 04/12/23, indicated [ .]3) Minced and most or mashed chilled steamed vegetables [ .]. During a concurrent observation and interview on 04/11/23, at 11:46 a.m., at tray line, Dietary Aide (DA 1) was looked at tray tickets and called out diets to Cook 1. Cook 1 then placed hot food on resident plates according to the diet DA 1 called out. Cook 1 was observed serving one scoop of pureed (food that is blended into smooth texture that does not require chewing) broccoli to Resident 4's tray. When the surveyor asked DA 1 if Resident 4 was supposed to receive pureed broccoli, DA 1 stated Resident 4 received the incorrect broccoli texture, that it should have been minced and moist instead of puree but did not notify Cook 1 that the incorrect texture was provided to the resident. When Cook 1 was questioned, she stated minced and moist diet should get pureed broccoli and did not consult menu spreadsheet which was available for reference. During a review of facility's policy and procedures titled Trayline Setup and Service, dated 07/02/18, indicted [ .]5. According to the diet called, the main plate is served .therapeutic spreadsheets are posted on trayline and are followed. [ .].

Based on observation, interview and record review, the facility failed to ensure dignity and maintain privacy for one of three sampled residents (Resident 14), when Resident 14's uncovered care instructions were posted above the bed visible to anyone entering the room. This failure resulted in a lack of dignity and privacy for Resident 14. Findings During a review of facility's Admission Record for Resident 14, dated 4/12/23, Resident 14 was readmitted ,d+[DATE]. During a review of Resident 14's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 2 out of 15, indicating severely impaired mental status. During an observation on 4/10/23, at 10:47 a.m., in Resident 14's room, care instructions labeled Strict Aspiration Precautions were posted on the wall above the head of Resident 14's bed. The instructions were not covered and stated, Diet Texture: thin liquids/minced and moist. OK for bread at breakfast and dessert, Upright in chair for ALL meals, in dining room when possible, Oral care x3 daily, No straws, Small cup-sip/tsp-sip, Single bites, Slow pace, Alternate liquids and solids, Check mouth for residual food and remove it as needed, Remain upright for 30 minutes after a meal. During a concurrent observation and interview on 4/10/23, at 1:05 p.m., with Licensed Vocational Nurse 3 (LVN 3), in Resident 14's room, LVN3 stated the precautions above Resident 14's bed was not covered because it was a reminder to nursing staff, particularly for new direct care staff. LVN 3 stated care instructions should be covered to provide privacy from visitors. During a review of the facility's Policy and Procedure (P&P) titled Quality of Life, dated October 2009, the P&P indicated, residents shall be treated with dignity and respect at all times and Signs indicating the resident's clinical status or care needs shall not be openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible (e.g., taped to the inside of the closet door).

Based on interview and record reviews, the facility failed to obtain a Physician's Order to perform a laboratory test for novel Coronavirus disease, commonly known as COVID-19 (a mild to severe respiratory illness) for two of three randomly sampled residents (Resident 1 and Resident 2). This failure had the potential to result in the attending physician not being aware of Resident 1 and Resident 2's plan of care and health condition; which could potentially delay the prompt care and treatment for [REDACTED]. Findings: During a record review of Resident 1's Admission Record dated 1/20/21, the Admission Record indicated Resident 1 was admitted to the facility on [DATE]. During an interview and record review, on 1/26/21 at 11:00 a.m. with the Director of Nursing (DON), Resident 1's COVID-19 lab results dated 11/13/20 and 11/23/20 were reviewed. The lab results indicated Resident 1 was tested for COVID-19 on 11/13/20 and 11/23/20. During an interview and record review, on 1/26/21, at 11:00 a.m., with the DON, Resident 1's Physician's Order Summary Report from 11/01/20 through 12/31/20 was reviewed. The DON stated Resident 1 did not have a physician's order to perform COVID-19 lab test on 11/13/20 and 11/23/20. During a review of Resident 2's Admission Record dated 12/15/20, the Admission Record indicated Resident 2 was admitted to the facility on [DATE]. During an interview and record review, on 1/26/21, at 11:05 a.m., with the DON, Resident 2's COVID-19 test results dated 11/13/2020, 11/17/2020, 11/20/2020, 11/23/2020, 12/1/2020 and 12/4/2020 were reviewed. The COVID-19 test results indicated Resident 2 was tested for COVID-19 on those dates. During an interview and record review, on 1/26/21, at 11:05 a.m., with the DON, Resident 2's Physician Order Summary Report from 10/26/2020 through 12/11/2020 was reviewed. The DON stated Resident 2 did not have physician's orders for COVID-19 lab test completed on 11/13/2020, 11/17/2020, 11/20/2020, 11/23/2020, 12/1/2020, and 12/4/2020. During an interview, on 1/26/2021, at 11:05 a.m., with the DON, the DON stated a Physician's Order must be obtained prior to a lab test. During a review of the facility's Policy and Procedure (P&P) titled, COVID-19 Testing Plan-Residents and Staff in Skilled Nursing, dated 5/28/20, the P&P indicated, Residents with suspected COVID-19 or other respiratory illness shall be tested for COVID-19, influenza and pneumonia per physician's orders .

Based on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions when: 1. Two male dietary staff did not cover their beards while working in the kitchen; and 2. Two ice machines (one in the kitchen and one in the front Nursing Station) had brownish/black substances in the ice bins. This failure resulted in all 54 residents of the facility receiving food prepared under conditions not meeting professional standards and had the potential to cause food-borne illnesses. Findings: 1. During a dietary observation with the Director of Dietary Services (DDS) and concurrent interviews with Kitchen Utility Staff 1 (KU 1) and Cook 3 on 11/13/19 at 11:20 a.m., KU 1 was in the kitchen with his hairnet on but his overgrown beard was uncovered. KU 1 indicated the DDS did not tell him to wear a beard guard, and stated, I don't cook, but I work inside the kitchen. I know I should cover my beard or just shave it. Cook 3 was observed walking around in the kitchen with his beard uncovered. Cook 3 indicated this was the first time he had grown a beard but stated, I understand it should be covered. The facility's Personal Hygiene/Safety/Food Handling policy, dated 3/5/19, indicated, Beards or any body hair that may be exposed (i.e., arms) must be covered. 2. During a dietary observation and concurrent interview with DDS, the Administrator-in-Training (AIT), and KU 1 on 11/13/19 at 11:25 a.m., the kitchen ice machine had a blackish substance in the ice bin. The DDS stated she had wiped the ice bin two days earlier (11/11/19), and it was clean. DDS and AIT agreed the black substance came from the ice machine. KU 1 indicated the ice machine was cleaned on 11/4/19. During an observation of the front Nursing Station ice machine and concurrent interview with the Director of Nursing (DON) on 11/13/19 at 12:30 p.m., there was brownish/black substance and reddish brown splatters in the ice bin and DON stated, That is dirty. A review of the facility's Ice Machine Cleaning Schedule policy, dated 1/10/19, instructed staff to, Wash inside of machine with approved detergent and hot water. Rinse with clean water. Then use sanitizing solution and clean cloth to sanitize. Make sure the door liner, door gasket and door frame are free of scale and/or mild .Allow to air dry. A review of the facility's Ice Machine & Filter Cleaning Log indicated both ice machines were cleaned on 11/4/19. A review of the facility's Ice Machine Service policy, dated 9/19/19, indicated it is the facility's policy, to maintain and service the ice machine and ice bin in a matter to obtain a clean and functioning system.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 144) received appropriate medical care when oxygen was administered to Resident 144 without a physician's order. This failure placed Resident 144 at risk for a delay in identifying or treating any adverse effects from oxygen therapy. Findings: A review of Resident 144's Admission Record indicated Resident 144 was admitted to the facility for hospice care with multiple diagnoses, including acute [MEDICAL CONDITION] with [MEDICAL CONDITION] (a low oxygen level), acute respiratory distress, and [MEDICAL CONDITION] that had spread to the bone. During an observation and concurrent interview with Resident 144 on 11/12/19 at 11:50 a.m., Resident 144 was wearing a nasal cannula (tubing that fits in the nares) and receiving oxygen at 4 liters per minute. Resident 144 stated he had been receiving oxygen since he was admitted to the facility at the beginning of the month. A review of the Order Summary Report in Resident 144's medical record indicated there was no physician's order for oxygen administration. During an interview with the Director of Nursing (DON) on 11/13/19 at 9:00 a.m., DON stated she could not find an order for [REDACTED]. A review of the facility's Oxygen Management policy, dated 10/28/19, indicated, Oxygen therapy is administered to the resident only upon the written order of a licensed physician or in the event of an emergency until a physician order can be received.

Based on interview and record review, for one of 14 sampled residents (Resident 43) the facility failed to provide appropriate treatment and services to a resident with an indwelling catheter (a tube inserted into the body that drains the urine into an external bag) when facility staff failed to monitor the resident's intake (the measurement of fluids taken into the body) and the output (the measurement of fluids expelled from the body). This failure had the potential to negatively impact Resident 43's existing urinary conditions. FINDINGS: A review of Patient 43's Admission Record indicated Resident 43 was admitted with multiple diagnoses, including [MEDICAL CONDITION] (an enlarged prostate gland that can cause urinary symptoms such as blocking the flow of urine out of the bladder) with lower urinary tract symptoms, a urinary tract infection, retention of urine (the inability to completely empty the bladder of urine), and a flaccid neuropathic bladder (impairment of the bladder function due to nerve damage). A review of Patient 43's Minimum Data Set (MDS, an assessment tool used to guide care), dated 10/26/19, indicated Resident 43 had a Brief Interview for Mental Status (BIMS, a tool used to assess mental function) score of 8, meaning Resident 43 had mild cognitive impairment. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 11/14/19 at 9:30 a.m., LVN 1 stated Patient 43 was admitted with an indwelling urinary catheter. LVN 1 indicated Patient 43's fluid intake and output were not being monitored nor recorded. During a concurrent interview and record review with the Director of Nursing (DON) on 11/14/19 at 12:35 p.m., DON was unable to show evidence Patient 43's fluid intake and output were being monitored. DON stated Resident 43's intake and output should have been monitored and documented in Patient 43's chart. A review of Patient 43's care plan, dated 10/24/19, indicated a nursing intervention for Resident 43's indwelling catheter was to observe and document intake and output as per facility policy. A review of the facility's Intake and Output Protocol policy, dated 9/17/19, indicated, Fluid intake and output is recorded for each patient .with an indwelling catheter.

Based on observation, interview and record review, the facility failed to ensure that one (Resident 31) of 14 sampled residents received an accurate assessment, plan of care, and interventions for limited range of motion for a three week period. This deficient practice had the potential for Resident 31 to suffer from worsening and decreased movement in her left arm due to a lack of planning to provide treatment and interventions. Findings: Review of Admission Record dated 10/24/18 showed Resident 31 was admitted to facility on 9/28/18. By observation on 10/22/18 at 10:30 a.m., Resident 31 was lying in bed, writing with her right hand, with her left arm folded at chest level. By further observation, Resident 31 was not able to move her left arm. In an interview on 10/22/18 at 10:32 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 31 was not able to use her left arm. LVN 1 stated she was unaware whether Resident 31 had an order for [REDACTED]. LVN 1 did not return with an answer. In a follow up observation and concurrent interview on 10/24/18 at 8:43 a.m., Certified Nursing Assistant (CNA 3) asked Resident 31 to move her left arm. By observation, it was difficult for Resident 31 to move her left arm. CNA 3 then stated, It's gonna hurt her. In an interview on 10/24/18 at 8:45 a.m., CNA 2 stated Resident 31 had been unable to use her left arm since her admission. In a concurrent interview and record review on 10/24/18 at 8:48 a.m., the Minimal Data Set Coordinator (MDSC) stated and confirmed that Resident 31's Admission MDS dated on 10/5/18 showed that Resident 31 had, No impairment in her upper extremity. During an observation and interview on 10/24/18 at 8:56 a.m., MDSC tried to move Resident 31's left arm which again was difficult to move. MDSC stated, Yes there is limitation and should be coded in (Resident 31's) the MDS assessment. In a follow up interview and record review on 10/24/18 at 8:57 a.m., MDSC confirmed Resident 31 did not receive an assessment for her left arm limitations upon admission. MDSC pointed out that a Nursing Weekly Summary dated on 10/18/18 showed, Contracture /limited range of motion in Arm, however there was no additional information regarding whether a physician's orders [REDACTED]. MDSC stated Resident 31 did not have a specific plan of care to address treatment for [REDACTED].

Based on observation, interview and record review, the facility failed to accurately assess one (Resident 31) of 14 sampled residents. For Resident 31, the Minimal Data Set (MDS- An assessment tool used to direct care) inaccurately reflected that Resident 31 did not have limitation in the range of motion for her arm. This deficient practice resulted in an inaccurate reflection of Resident 31's clinical condition which had the potential to effect her health care outcomes. Findings: Review of Admission Record dated 10/24/18 showed Resident 31 was admitted to facility on 9/28/18 for Palliative care. By observation on 10/22/18 at 10:30 a.m., Resident 31 was lying in bed, writing with her right hand, with her left arm folded at chest level. By further observation, Resident 31 was not able to move her left arm. In an interview on 10/22/18 at 10:32 a.m., Licensed Vocational Nurse (LVN 1) stated Resident 31 was not able to use her left arm. During another observation and concurrent interview on 10/24/18 at 8:43 a.m., Certified Nursing Assistant (CNA 3) asked Resident 31 to move her left arm which was difficult to move. CNA 3 stated, It's gonna hurt her. In an interview on 10/24/18 at 8:45 a.m., CNA 2 stated Resident 31 had not been able to use her left arm since admission. In a concurrent interview and record review on 10/24/18 at 8:48 a.m., the Minimal Data Set Coordinator (MDSC) stated and confirmed that Resident 31's Admission MDS assessment dated on 10/5/18 showed that Resident 31 had, No impairment in her upper extremity. During an observation and interview on 10/24/18 at 8:56 a.m., MDSC tried to move Resident 31's left arm which again was difficult to move. MDSC stated, Yes there is limitation and should be coded in (Resident 31's) the MDS assessment.

Based on observation, interview, and record review, the facility failed to promote the dignity of one (Resident 17) of 14 sampled residents, when staff stood over her while feeding. This deficient practice had the potential to effect the self worth of Resident 17. Findings: Review of the medical record showed Resident 17 was admitted to the facility on [DATE]. Further review of Resident 17's last comprehensive Minimum Data Set (MDS - an assessment tool used to direct health care needs) dated 12/8/17 indicated Resident 17 was dependent on staff for eating. By observation on 10/22/18 at 12:00 p.m., Certified Nursing Assistant (CNA 1) was standing up while feeding Resident 17 in the dining room. In an interview on 10/22/18 at 12:02 p.m., CNA 1 stated she knows she is supposed to sit down while feeding residents. In an interview on 10/23/18 at 8:31 a.m., the Director of Nursing (DON) stated it is standard practice that all staff must sit down to feed residents. Review of the facility Policy and Procedure titled, Dignity, dated 1/23/15, showed, It is the policy of the facility to promote the dignity of each resident in a manner and an environment that enhances his/her self esteem and self worth. Review of the facility Policy and Procedure titled, Dining and Meal Service dated 1/20/15, showed, The dining experience will be person centered with the purpose of enhancing each inidividual resident's quality of life and being supportive of each individual's needs during dining.

Based on interview and record review the facility failed to provide copies of 11 of 11 sampled residents' (Residents 1 through 11) Notice of Transfer or Discharge to the State Long-Term Care Ombudsman's (SLTCO) office (an advocate for nursing home residents) after Residents 1 through 11 were notified of their pending discharge from the facility. This failure resulted in Residents 1 through 11 not being afforded the advocacy services of the Ombudsman regarding their transfer or discharge rights. Findings: Review of the discharge Minimum Data Sets (MDS - An assessment tool used to guide care) of Residents 1 through 11 indicated the following: MDS dated [DATE] indicated Resident 1 was admitted to the facility on [DATE] and was discharged to the community on 6/3/18. MDS dated [DATE] showed Resident 2 was admitted to the facility on [DATE] and was discharged to a nursing home on 5/14/18. MDS dated [DATE] indicated Resident 3 was admitted to the facility on [DATE] and was discharged to the community on 7/3/18. MDS dated [DATE] showed Resident 4 was admitted to the facility on [DATE] and was discharged to the community on 3/21/18. MDS dated [DATE] indicated Resident 5 was admitted to the facility on [DATE] and was discharged to the community on 3/22/18. MDS dated [DATE] showed Resident 6 was admitted to the facility on [DATE] and was discharged to the community on 3/23/18. MDS dated [DATE] indicated Resident 7 was admitted to the facility on [DATE] and was discharged to the community on 3/21/18. MDS dated [DATE] showed Resident 8 was admitted to the facility on [DATE] and was discharged to the community on 4/6/18. MDS dated [DATE] indicated Resident 9 was admitted to the facility on [DATE] and was discharged to the community on 4/9/18. MDS dated [DATE] showed Resident 10 was admitted to the facility on [DATE] and was discharged to the community on 4/18/18. MDS dated [DATE] indicated Resident 11 was admitted to the facility on [DATE] and was discharged to the community on 5/1/18. During a telephone interview on 7/3/18 at 11:48 a.m., the State Long-Term Care Ombudsman (SLTCO) stated the SLTCO had not received notification of transfer or discharge from this facility for Residents 1 through 11. The SLTCO further stated the SLTCO had not received a list of resident discharges from this facility since (MONTH) (YEAR). During an interview on 7/3/18 at 3:41 p.m., the Social Worker (SW) stated after the physician has signed an order for [REDACTED]. During an interview on 7/3/18 at 4:38 p.m., the Assistant Director of Nursing (ADON) stated the residents and families are notified at least a week before discharges occur. ADON further stated all communications regarding discharges are done by the SW. During an interview on 7/3/18 at 4:48 p.m., the Assistant Administrator (AAdmin) stated the discharge process starts on day one of admission and discharges are communicated to residents and families a week in advance or more. During an interview on 7/3/18 at 4:50 p.m., the Administrator (Admin) stated discharge planning begins at admission and the SW notifies the residents and families. During a telephone interview on 7/9/18 at 10:18 a.m., the Director of Nursing (DON) stated, The general notification to Ombudsman is being done by the SW per our Administrator. During a telephone interview on 7/12/18 at 10:15 a.m., the SW stated, I will only notify them (Ombudsman) if the resident is leaving against medical advice. The SW acknowledged the Notice of Transfer or Discharge for Residents 1 through 11 were not sent to the Ombudsman. Review of the SW's document sent to the SLTCO titled Patient Choice Discharges/AMA Discharges, did not show the names of Residents 1 through 11. Review of the facility's Policy and Procedure titled, Discharge Planning, last revised on (MONTH) 15, (YEAR), showed no statement regarding notifying the SLTCO.

Based on observation, interview and document review, the facility failed to maintain clean equipment and environment, label food items, practice hand sanitation, and store food under sanitary conditions. This failure had the potential to cause food contamination and food borne illness in residents. Findings: 1. During the initial kitchen tour, an observation and concurrent interview on 11/6/17 at 6:55 a.m. with the Dietary Director (DD), Dietary Aide ( DA) 1 and the Cook the following was observed: a. The steamer had brown substance around the rim. b. The soup maker had a black substance on it c Inside the oven there was a buildup of black substance. The glass doors in the oven had brown substance on them. The DA 1 stated they were suppose to clean the oven after each use. d. The trash can had brown substance on the lid and down the side e. Cart with bakeware, bottom shelf had brown substance around the rim. g. The ice machine had green substance around the opening where the ice dropped. The filters were covered with black dust. A sign posted on the ice machine indicated filters were to be cleaned twice a month. The DM stated maintenance cleaned the ice machine on 10/31/17. The DD stated the dust looks like it had been there longer than a week. In an interview on 11/7/17 at 8:46 a.m. with the Maintenance Supervisor (MS), the MS verified dust was inside the ice machine and that it was dirty with dust balls. Review of the facility policy titled, Cleaning Schedules, dated 3/2014, indicated the dietary staff shall maintain the sanitation of the Dietary Department Review of the facility policy titled, Cleaning of Ice Machine, dated 8/03/16, indicated the ice machine and related equipment will be cleaned on a regular basis to maintain a clean sanitary condition. Review of the facility Dietary Cleaning List, not dated, indicated the oven, steamer, carts and microwave were to be cleaned weekly. 2. On 11/6/17 at 7:15 a.m. during an observation and concurrent interview with the DD, the following was observed in the breakfast/lunch refrigerator: a. Extra salad with brown lettuce was not covered and it did not have a date. b. There was no label or date on the cracker tray. c. Large white container with white powder, no label or date. d. Large white container with bags of sugar and a brown substance on the bottom of the container. e. Large white container with rice without a date or use by date. f. Large white container with panko without date or use by date. In the hall, near the breakfast lunch refrigerator, on a cart, the bread tray had two loves of country wheat bread without an open or use by date. The DD stated the procedure was to completely cover and label food. The DD stated the cracker tray should be dated and labeled. On 11/6/17, during an observation and concurrent interview with the DD. the following was observed: In the vegetable refrigerator: a. Three trays of chicken were not covered. c. Pastrami had a date, but not a use by date. d. Thawed pork without a use by date. In the snack refrigerator: a. [MEDICATION NAME] in a cup without date or use by date. b. Container of milk with the date of 10/5 and a use by date of 10/19. c. 14 thawed shakes without a use by date. d. One half sandwich without a date. Review of the facility policy titled, Trayline Refrigerated Leftover Storage, dated, 01/01/2014, indicated sandwiches were not to be saved. Review of the facility policy titled, Refrigerated Storage Chart, dated 5/16, indicated open milk was good for 3-5 days. The facility policy,Dry Storage Chart, dated 5/12/2016, recommended storage for open bread was one day. In the dry food area, the following observations were made with the DD: a. Open walnuts and pine nuts without a use by date. b. A box of potatoes sitting on the floor. 3. On 11/7/17 at 8:45 a.m., the following observations were made with the DD: a. Cayenne pepper 14 oz. with powdery substance on the container. b. White pepper 14 oz. with a powdery substance on the container. c. Kitchen Bouquet container with brown liquid going down the sides and expired. d. Wild Honey with sticky substance on the outside of the container. e. Clear container with red and white onions had brown substance around the top rim. Review of the facility, Dry Storage Chart, dated 5/12/16, indicated kitchen bouquet should not be stored open any longer than 6 to 9 months. The facility policy titled, Food Storage, dated 8/9/17 indicated all products should be inspected for safety and quality and dated upon receipt and when they are prepared. Use by dates on all foods stored in the refrigerators and use dates according to the timetable in the Dry Refrigerated and Freeze Storage Leftovers should be dated according to the Leftovers policy. Remember to cover label and date. 4. On 11/8/17 at 11:40 a.m. an observation and concurrent interview, the DA 2 took a cart from the kitchen to the dinning room. Upon return, the DA 2 returned to the tray line without washing his hands. In an interview with DA 2, he stated he was suppose to wash his hands prior to touching the tray. The facility policy titled, Handwashing, dated 2/20/14 indicated hands must be washed prior to beginning work, after using the restrooms, after smoking, when working with different food substances and following contact with any unsanitary surface .

Based on observation and interview, the facility failed to ensure hearing devices were provided for 2 (Resident 5 and 11) of 10 sampled and 2 non-sampled residents. This failure risked residents not hearing adequately and being unable to participate in activities and maintaining relationships. Findings: Record review of the document titled, Admission Record, showed the facility admitted Resident 5 on 1/9/17. Review of the Annual Minimum Data Set (MDS), Resident Assessment and Care Screening, dated 10/19/17, showed Resident 5 had difficulty in some environments (e.g. when people speak softly of setting is noisy). Review of the Care Plan, showed Resident 5 had a communication problem hearing deficit, the intervention included to ensure hearing aid (right ear) was in place. During an observation on 11/7/17 at 1:45 p.m., Resident 5's was in the activity room, watching television, had no hearing aid in ears. In an interview on 11/7/17 at 2 :15 p.m., Certified Nursing Assistant (CNA 5), stated Resident 5 was admitted with hearing aid, she thought the son might have taken the hearing aid home. 2. Record review of the Admission Record, showed the facility admitted Resident 11 on 11/2/16. Review of the MDS, dated [DATE], showed Resident 11 had clear speech, was able to express her ideas and wants and understood what others said to her. 0n 11/7/17 at 11:20 a.m., during an interview, Resident 11 stated one of her hearing aids was missing. Resident 11 stated she could not hear properly with one hearing aid and preferred to use both hearing aids. Resident 11 stated she had notified the staff about her missing hearing aid. In an interview on 11/7/17 at 1:36 p.m., the Social Service Director (SS) stated she was not aware of the missing hearing aid. In an interview on 11/7/17 at 2:00 p.m., CNA 6 stated Resident 11 had one hearing aid and the battery was not working . In an interview on 11/8/17 at 9:00 a.m., Licensed Vocational Nurse (LVN) 2, stated Resident 11's daughter said she reported the loss of hearing aid to the S'S last month.

Based on observation, interview and record review the facility failed to to prevent a second fall for one (Resident 1) of three sampled residents by not implementing fall prevention interventions after the first fall. This failure resulted in a second fall and a fracture of Resident 1's left hip requiring hospitalization and surgery. Findings: During a review on 1/20/17 of the clinical record, the Nurses Notes, dated 12/13/16 at 3:34 p.m., indicated Resident 1 was found lying on the floor at 2:50 p.m Resident 1 complained of right hip pain and was sent to the hospital. Review of the Nursing Progress Notes, dated 12/15/16 at 6:50 a.m., showed a plan of care note indicating Resident 1 had a right hip fracture as a result of that fall. This plan of care note indicated the facility's Interdisciplinary Team (IDT-disciplines, such as nursing and physical therapy) reviewed and updated interventions related to the fall when Resident 1 was readmitted to the facility. A review of Resident 1's care plan showed Resident 1 was at high fall risk since her admission in October 2016. After the fall, 12/13/16, the care plan was updated on 12/13/16 to include use of a bed sensor pad electronic alarm (alarm sounds when pressure on the sensor pad was removed). No additional updates were made to the fall care plan. Resident 1 returned to the facility on [DATE]. The Minimum Data Set (an assessment tool), dated 12/25/16, showed Resident 1 had a Brief Interview for Mental Status score of 5 which indicated a severe impairment of her mental status. A review of the progress notes for Resident 1 showed she had a second fall on 1/14/17 at 8:12 a.m. when she was found lying on the floor her left side, complaining of a lot of pain. Nurse progress notes, dated 1/14/17, at 4:56 p.m., indicated Resident 1 was transferred to the hospital at 3:15 p.m. and had surgery to repair the left hip fracture. During an interview with the Occupational Therapist (OT) on 1/20/17, at 11:20 a.m., she stated Resident 1 had a strong personality and wanted to go the bathroom independently. OT stated before the first fall on 12/13/16, Resident 1 was able to get in and out of bed independently and walk with a cane in her room. OT stated Resident 1 was not able to walk independently at the time of her second fall. During an observation on 1/20/17 at 11:50 a.m., Resident 1 was observed sitting in a wheelchair in her room. Resident 1 was pressing the call light button to get assistance from the staff. The staff responded to the call light in 10 minutes. During an interview with Certified Nursing Assistant 1 (CNA 1) on 1/20/17 at 12:20 p.m., she stated Resident 1 returned to her previous bed after her hospitalization for her first fall. CNA 1 stated Resident 1 was moved to a room closer to the nurse's station and placed in the first bed so the staff could observe her better on 1/20/17. During an observation on 1/20/17 at 12:35 p.m. the bed where Resident 1 stayed after her fall on 12/13/16. Resident 1 had been in the second bed of the room. The second bed was not fully visible from the hall. There was a permanent divider between the two beds that consisted of closets and drawers to store residents' belongings. During a interview on 1/20/17 at 12:30 p.m., with the Administrator (Admin), she stated there were no additional updates to the plan of care after the first fall, because she did not think Resident 1 would fall again. The Admin acknowledged there was no documentation of an IDT meeting to plan interventions after the first fall. The facility policy and procedure titled, Fall Intervention Policy and Procedure, dated 7/25/16, indicated that following a fall the facility should review and update causative factors, interventions, care plan and fall assessment. Staff will make appropriate interventions upon completion of the report to minimize reoccurrence of a fall.