Every finding on record at Desert Regional Medical Center D/P SNF

Based on observation and interview, the facility failed to ensure food was served at temperatures and with palatability consistent with resident preferences for four of 21 residents reviewed for food service (Residents 11, 18, 39, and 40).This failure resulted in residents receiving meals that were not served at expected temperatures and had the potential to diminish resident satisfaction with meals and adversely affect residents' enjoyment of dining and food intake.Findings: On June 8, 2026, at 10:08 a.m., an interview was conducted with Resident 11 in his room. Resident 11 stated the food was bland. On June 8, 2026, at 11:38 a.m., an interview was conducted with Resident 18 in his room. Resident 18 stated the chicken was bland and most meals were served cold. On June 9, 2026, at 9:12 a.m., an interview was conducted with Resident 39 in his room. Resident 39 stated the food needed to be warmer when it arrived. On June 9, 2026, at 9:21 a.m., an interview was conducted with Resident 40 in her room. Resident 40 stated all meals were lukewarm. On June 10, 2026, at 11:48 a.m. a test tray evaluation was conducted with Dietary Manager (DM 1) in the activities room. The contents of the test tray consisted of regular chopped texture diet meal which included: Chicken, mashed potatoes, green beans, cold desert (fruit pears), and cold beverage apple juice. The temperatures obtained in degrees Fahrenheit ( degrees F) were as follows: -Apple juice 53 degrees F -Cold pears chopped: 52 degrees F -Chicken chopped with chicken gravy: 116 degrees F -Mashed potatoes, 130 degrees F -Green beans chopped: 128 degrees F The food was found to be bland and lacking flavor. On June 10, 2026, at 11:52 a.m. an interview was conducted with DM 1. DM 1 stated cold food items should be maintained at 41 degrees F or below and hot food items at 135 degrees F or above; entrée and vegetables did not meet these standards, as well as the dessert and cold beverage were warmer than expected. DM 1 stated her expectation was for all food items to meet temperature parameters which they did not. DM 1 indicated possible contributors were tray line timing and distribution from kitchen to unit and delivery speeds. DM 1 emphasized that meals not meeting temperature standards could negatively impact resident satisfaction. On June 10, 2026, at 11:56 a.m., a follow up interview was conducted with Resident 18. Resident 18 stated lunch could be warmer. A review of the facility document titled, Daily Service Resident Taste and Temperature Log dated, June 12, 2026, indicated, .line check.holding temperature.hot entrees, vegetables > (greater than) 135 degrees F (Fahrenheit – a unit of measurement) .cold items < (less than) 41 degrees F. A review of the facility policy and procedure, titled, Patient Food Services, dated May 2025, indicated, .the test tray evaluation process provides food service management with a tool that measures the quality level of the meal service and identifies areas of substandard service requiring corrective action.when arriving on the unit, waits the normal amount of time from preparation of tray to when tray is recognized to be delivered to mimic the time of regular delivery practices.This time should be between 30 and 45 minutes of preparation.takes the point-of-service-temperatures.satisfactory point-of-service temperature is based on state requirements or account's standards.rates the quality control factors (appearance, taste, temperature, etc.

Based on interview and record review, the facility failed to notify the physician when blood glucose (sugar) levels were below 70 mg/dL (milligram per deciliter) as ordered by the physician, for two of three residents reviewed for notification of change (Residents 36 and 39). This failure had the potential to delay physician evaluation, treatment, and modification of medical interventions related to hypoglycemia (a blood sugar level below normal). Findings: 1. Resident 36's record was reviewed. Resident 36 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level). The care plan titled, Unstable Blood Glucose, dated June 6, 2026, indicated, .Diabetes Mellitus.blood glucose will be managed as per physicians' orders.interventions.report to physician any hypoglycemic reactions for intervention. The physician's order dated June 7, 2026, indicated, .Humalog (type of insulin) sliding scale (a numerical scale for administration of insulin).rapid acting for Diabetes Mellitus (DM) .for blood glucose < 70 mg/dL.initiate hypoglycemia management (low blood sugar) and call physician. Resident 36's blood sugar levels for the month of June 2026, were reviewed and indicated the following BS levels were below 70 mg/dL: - June 10, 2026, 63 mg/dL There was no documentation indicating Resident 36's physician had been notified of the blood glucose level below 70 mg/dL, as ordered. On June 10, 2026, at 3:20 p.m., a concurrent interview and record review were conducted with Registered Nurse 1 (RN 1). RN 1 stated when a resident's blood glucose levels below 70 mg/dL, the licensed nurse was expected to notify the physician in accordance with the physician orders. RN 1 stated on June 10, 2026, Resident 36's blood glucose level was 63 mg/dL. RN 1 stated there was no documentation indicating the physician had been notified regarding Resident 36's blood glucose level. RN 1 further stated she became aware of the low blood glucose level and should have notified the physician. On June 10, 2026, at 4:06 p.m., a concurrent interview and record review was conducted with Registered Nurse Supervisor (RNS 1). RNS 1 stated the licensed nurse should have notified the physician regarding Resident 36's low blood glucose level of 63 mg/dL in accordance with the physician's order and facility protocol. RNS stated she could not find documentation indicating the physician had been notified. 2. A review of Resident 39's record was conducted. Resident 39 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus. The care plan titled, Unstable Blood Glucose, dated June 7, 2026, indicated, .Diabetes Mellitus.blood glucose will be managed as per physicians' orders.interventions.report to physician any hypoglycemic reactions for intervention. The physician's order dated June 8, 2026, indicated, .Humalog (type of insulin) sliding scale (a numerical scale for administration of insulin) .rapid acting for Diabetes Mellitus (DM) .for blood glucose < 70 mg/dL.initiate hypoglycemia management (low blood sugar) and call physician. Resident 39's blood sugar levels for the month of June 2026, were reviewed and indicated the following blood sugar level was below 70 mg/dL: June 9, 2026, 61 mg/dL There was no documentation indicating Resident 39's physician had been notified of the blood glucose level below 70 mg/dl, as ordered. On June 11, 2026, at 9:43 a.m., a concurrent interview and record review was conducted with RN 2. RN 2 stated when a resident's blood glucose level is below 70 mg/dL, the licensed nurse should notify the physician. RN 2 stated, Resident 39's blood glucose level was 61 mg/dL on June 9, 2026. RN 2 stated there was no documentation the physician had been notified regarding the low blood glucose level. RN 2 stated it was important to notify the physician so the physician would be aware of the resident's condition and determine whether additional intervention was necessary. On June 11, 2026, at 12:55 p.m., a concurrent interview and record review were conducted with RNS 2. RNS 2 stated licensed nurses were required to follow physician orders and notify the physician for blood glucose levels below 70 mg/dl. RNS 2 stated physician notification should be documented, including when the physician was notified and any orders received. RNS 2 stated there was no documentation indicating the physician had been notified regarding Resident 's blood glucose level of 61 mg/dL. RNS 2 stated it was important to notify the physician to ensure the physician was aware of the event and could determine whether additional treatment or changes in management were needed. A review of the facility policy and procedure titled, Glucometer checks and insulin slide scale orders dated September 21, 2023, indicated, .Notify treating physician for blood glucose levels less than 70mg% .the following standardized Hypoglycemic treatment protocol shall be utilized with all insulin slide scale orders.treat blood sugar less than 70mg/dL and patient is alert and able to swallow, give 15 grams of fast acting carbohydrate (4oz fruit juice/non-diet soda, 8oz nonfat milk.cannot take PO (by mouth).treat blood sugar less than 70 mg/dL and patient cannot take PO, give 25ml of D50 (dextrose) as IV (intravascular) push (or 1 mg Glucagon SQ (subcutaneous) or IM (intramuscular) if no IV established. A review of the facility policy and procedure titled, Abnormal and irregular laboratory or diagnostic results, dated December 21, 2023, indicated, .abnormal/irregular results of diagnostic tests.we be communicated in a routine manner to the responsible physician.findings reported to the patients provider shall be appropriately addressed and documented in the patients medical chart.findings that are not critical but are regarded as abnormal/irregular shall be conveyed to the provider as soon as practical, generally within 24 hours or during physician rounds.

Based on interview and record review, the facility failed to develop a person-centered baseline care plan for one of three residents reviewed for unnecessary medications (Resident 39) when interventions related to anticoagulation therapy were not included in the resident's baseline care plan. This failure had the potential to result in staff not consistently implementing and monitoring interventions related to anticoagulation therapy (treatment with blood-thinning medication), including monitoring for adverse effects and changes in the resident's condition. Findings:A review of Resident 39's record was conducted. Resident 39 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (abnormal heart rhythm).The physician's order dated June 7, 2026, indicated, .apixaban (a blood thinner used to reduce the risk of blood clots and stroke in residents with atrial fibrillation) .Indication.atrial fibrillation.A review of Resident 39's baseline care plan indicated there were no care plan problems, goals, or interventions related to anticoagulation therapy. Additionally, there was no documented evidence that the physician's order for apixaban was incorporated into the baseline care plan.On June 11, 2026, at 9:43 a.m., a concurrent interview and record review were conducted with RN 2. RN 2 stated it was the licensed nurse's responsibility to initiate baseline care plans upon admission. RN 2 stated Resident 39's baseline care plan should have included anticoagulation therapy because the resident had an active physician order for apixaban RN 2 stated there was no baseline care plan initiated for anticoagulation therapy and that one should have been initiated. RN 2 stated it was important to initiate a baseline care plan for anticoagulation therapy to allow licensed nurses to address Resident 39's current needs by implementing interventions and to assist in meeting the resident's goals.On June 11, 2026, at 12:55 p.m., a concurrent interview and record review were conducted with RNS 2. RNS 2 stated the licensed nurse was responsible for initiating a baseline care plan upon admission. RNS 2 stated baseline care plans were developed upon admission based on the resident's history, current conditions, and physician orders. RNS 2 stated Resident 39's baseline care plan should have included anticoagulation therapy because the resident had an active physician order for apixaban. RNS 2 stated there was no baseline care plan initiated for anticoagulation therapy for Resident 39 and there should have been. RNS 2 stated it was important to initiate a baseline care plan for anticoagulation therapy to implement interventions with specific measures to meet the resident's desired goals.A review of the facility policy and procedure titled, Patient Care Plan, dated January 23, 2025, indicated, .plan of care is initiated upon the admission of a patient to include.Initial goals based on admission orders.physician orders.

Based on interview and record review, the facility failed to ensure physician ordered hypoglycemia management (treatment for low blood glucose [blood sugar]) was implemented and documented for two of three residents reviewed for diabetic management (Residents 36 and 39). This failure had the potential to result in inadequate management of hypoglycemic episodes (an episode of low blood glucose) and negatively affect residents' health and well-being. Findings: 1. Resident 36's record was reviewed. Resident 36 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level). The care plan titled, Unstable Blood Glucose, dated June 6, 2026, indicated, .Diabetes Mellitus.blood glucose (sugar) will be managed as per physicians' orders.interventions.report to physician any hypoglycemic reactions for intervention. The physician's order dated June 7, 2026, indicated, .Humalog (type of insulin) sliding scale (a numerical scale for administration of insulin) .rapid acting for Diabetes Mellitus (DM) .for blood glucose < 70 mg/dL.initiate hypoglycemia management (low blood sugar) and call physician. The physician's order dated June 9, 2026, indicated, .glucose Dextrose 4. 16g (grams, a unit of measurement) = (equals) 4 tabs (tablets) chew once PRN (as needed) for abnormal blood glucose: indication hypoglycemia for blood glucose less than 70 mg/dl symptomatic and if patient can tolerate PO (by mouth) . Resident 36's blood glucose levels for the month of June 2026, were reviewed and indicated the following blood glucose levels were below 70 mg/dL: - June 10, 2026, 63 mg/dL There was no documentation indicating Resident 36's was provided interventions to address the blood glucose level below 70 mg/dL or that hypoglycemia management was implemented in accordance with physician orders and facility protocol. June 10, 2026, at 3:20 p.m., a concurrent interview and record review were conducted with Registered Nurse 1 (RN 1). RN 1 stated when a resident experiences a blood glucose level below 70 mg/dl, the licensed nurse should implement hypoglycemia interventions, such as medication, juice, or snacks, in accordance with physician orders and facility protocol. RN 1 stated there was no documentation indicating what interventions had been provided for Resident 36's blood glucose level of 63 mg/dl. RN 1 stated the licensed nurse should have documented the interventions performed and the resident's response. RN 1 stated there was no documentation indicating the hypoglycemia protocol was followed for Resident 36 on June 10, 2026. June 10, 2026, at 4:06 p.m., a concurrent interview and record review was conducted with the Registered Nurse Supervisor (RNS 1). RNS 1 stated the licensed nurse should have documented the hypoglycemia management provided including medications, non-pharmacological interventions, and the resident's response. RNS 1 stated she was unable to locate documentation indicating what interventions were implemented to address Resident 36's blood glucose level of 63 mg/dL. RNS 1 stated facility protocol required documentation of interventions and follow-up related to hypoglycemic events. RNS 1 stated the nurse did not administer first-line medication like glucagon and did not document any hypoglycemic interventions. RNS 1 emphasized that proper documentation and reporting are required, and Resident 36 was at risk for continued hypoglycemia due to lack of appropriate intervention. 2. A review of Resident 39's record was conducted. Resident 39 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar level). The care plan titled, Unstable Blood Glucose, dated June 7, 2026, indicated, .Diabetes Mellitus.blood glucose will be managed as per physicians' orders.interventions.Oral medications.as ordered. The physician's order dated June 7, 2026, indicated, .Humalog (type of insulin) sliding scale (a numerical scale for administration of insulin) .rapid acting for Diabetes Mellitus (DM) .for blood glucose < 70 mg/dL.initiate hypoglycemia management (low blood sugar) and call physician. The physician's order dated June 7, 2026, indicated, .glucose Dextrose 4. 16g (grams, a unit of measurement) = (equals) 4 tabs (tablets) chew once PRN (as needed) for abnormal blood glucose: indication hypoglycemia for blood glucose less than 70 mg/dL symptomatic and if patient can tolerate PO (by mouth) . Resident 39's blood sugar levels for the month of June 2026, were reviewed and indicated the following blood sugar level was below 70 mg/dL: June 9, 2026, 61 mg/dl There was no documentation indicating Resident 39 was provided interventions to address the blood sugar level below 70 mg/dl or that hypoglycemia protocols were initiated and followed. On June 11, 2026, at 9:43 a.m., a concurrent interview and record review were conducted with RN 2. RN 2 stated it was the licensed nurse's responsibility to address blood glucose levels below 70 mg/dL by implementing the ordered medications or providing juice in accordance with the hypoglycemia protocol. RN 2 stated there was no documentation Resident 39 was provided interventions to address the blood glucose level below 70mg/dL or that the hypoglycemia protocol was implemented in accordance with physician orders on June 9, 2026. RN 2 stated it was important to follow physician orders and hypoglycemia protocols to appropriately manage symptoms and the resident's current condition. RN 2 further stated it was important to document the interventions provided to explain what was done for the resident. RN 2 stated licensed nurses should have followed the hypoglycemia protocol. On June 11, 2026, at 12:55 p.m., a concurrent interview and record review were conducted with RNS 2. RNS 2 stated there was no documented evidence indicating Resident 39's low blood glucose level on June 9, 2026, was treated in accordance with the physician's order and hypoglycemia protocol. RNS 2 stated the licensed nurse should have documented the interventions provided. RNS 2 stated it was important to follow physician orders and hypoglycemia protocols because they constituted the resident's medical treatment plan. RNS 2 further stated it was important to document the interventions implemented to reflect what was done to manage the low blood sugar level. RNS 2 stated the licensed nurses should have assessed the resident, implemented treatment, documented interventions, reassessed the resident, and documented outcomes. A review of the facility policy and procedure titled, Glucometer checks and insulin slide scale orders dated September 21, 2023, indicated, .Notify treating physician for blood glucose levels less than 70mg% .the following standardized Hypoglycemic treatment protocol shall be utilized with all insulin slide scale orders.treat blood sugar less than 70mg/dL and patient is alert and able to swallow, give 15 grams of fast acting carbohydrate (4oz fruit juice/non-diet soda, 8oz nonfat milk.cannot take PO (by mouth).treat blood sugar less than 70 mg/dL and patient cannot take PO, give 25ml of D50 (dextrose) as IV (intravascular) push (or 1 mg Glucagon SQ (subcutaneous) or IM (intramuscular) if no IV established.

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. One bag containing a yellow and orange colored liquid was stored in the walk-in refrigerator unlabeled and undated. 2. One package of small, round and brown dessert item was stored in the portable walk-in freezer unlabeled and undated. 3. One sandwich was stored in the resident's refrigerator inside the nourishment room unlabeled, undated, and readily available for use. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 23 residents who receive food in the facility. Findings: 1. On August 18, 2025, at 10:15 a.m., a concurrent observation and interview was conducted with the Dietary Services Supervisor (DSS) in the walk-in refrigerator. A bag with yellow and orange liquid was observed unlabeled and undated. The DSS stated the bag contained liquid eggs which usually came in two bags in a box and further stated, the bag must have been taken out of the box. The DSS verified the bag did not have a label or date. The DSS stated all items stored in the refrigerator should be labeled with the name of the item and received and/or use-by dates to prevent any food borne illness to the residents. 2. On August 18, 2025, at 10:28 a.m., a concurrent observation and interview was conducted with the DSS in the portable walk-in freezer. One package of small, round and brown dessert items was observed unlabeled and undated. The DSS stated the package contained cheesecake which normally came in a box and must have been taken out of the box. The DSS stated it should have had a label with received and/or use-by date. On August 20, 2025, at 11:50 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated staff were expected to label all items stored in the refrigerator and freezer with the appropriate name and use by dates to ensure food was safe to serve to the residents and avoid foodborne illness. 3. On August 20, 2025, at 8:50 a.m., a concurrent observation and interview of the resident nourishment refrigerator was conducted with a Certified Nursing Assistant (CNA) 2. CNA 2 stated the refrigerator was designated for storing residents' snacks, drinks, and outside food brought in by family. A plate with two halved sandwiches was observed stored in the refrigerator covered, but unlabeled and undated. CNA 2 stated the sandwich should have been labeled and dated. CNA 2 stated without a proper label, there was no way to determine if the sandwich was safe for consumption, which could lead to foodborne illness. On August 20, 2025, at 11:50 a.m., an interview was conducted with the RD. The RD stated staff were expected to label all items stored in the nourishment refrigerator with the appropriate name and use-by dates to ensure food was safe to serve and avoid food borne illness. On August 21, 2025, at 3:15 p.m., an interview was conducted with the DON. The DON stated staff were expected to place a label or a residents' sticker on all items stored in the nourishment refrigerator. The DON stated without proper labeling, there was potential for food borne illness if expired or unsafe food was served to residents. A review of the facility's policy and procedure titled, Food and Supply Storage, dated January 2025, indicated, .all food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety .of the food .label and date unused portions and open packages. A review of the facility's policy and procedure titled, Food from outside Sources, dated December 2023, indicated, .this policy applies to the Skilled Nursing Facility (SNF) at Desert Regional Medical Center (DRMC).it is the policy of the SNF to provide guidelines concerning safety and appropriateness of food items.food brought in from outside sources shall be labeled with the patient's information and dated with the date the item was received.the facility shall retain a refrigerator designated for patient food, and all perishable.items shall be stored and discarded consistent with the indications on the container, if noted.foods held in refrigerated or other storage areas shall be covered.stored appropriately.clearly labeled and dated.

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when multiple debris items were found on the ground outside of the designated container and not stored in the appropriate container. This failure had the potential to attract pests and cause infection control issues.Findings:On August 18, 2025, at 11:05 a.m., during a concurrent observation and interview with the Dietary Services Supervisor (DSS), in front of the dumpster storage area, multiple debris items including, wood scraps, pallets, and cardboard were observed on the ground and surrounding area. The DSS stated there should not be any debris, wood scraps, pallets, or carboard on the ground and around the dumpster compactor machine. The DSS stated these items could attract pests and could cause infection control issues.On August 20, 2025, at 12:15 p.m., during an interview with the Registered Dietitian (RD), the RD stated the dumpster compactor machine area should be kept clean and inspected daily to ensure no garbage, wood scraps, or cardboard boxes were left on the ground. The RD further stated this could result in pest infestation and infection control issues.On August 21, 2025, at 3:15 p.m., during an interview with the Director of Nursing (DON), the DON stated the dumpster compactor machine area should be kept clean and free of garbage, wood scraps, and cardboard boxes to prevent potential pest infestation and infection control issues.A review of the U.S FDA Food Code 2022, Section 5-501.115 , Maintaining Refuse Areas and Enclosures, indicated, .storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items, as specified under S 6-501.114, and clean.Section 5-501.116 (B), Cleaning Receptables, indicated, .soiled receptacles and waste handling units for refuse, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.

Based on observation, interview, and record review, the facility failed to ensure safe medication administration practices were implemented to meet the needs of the residents when: 1. One nurse was observed to not use the pill cutter to cut a medication tablet in half and instead, by hand to prepare and administer for one of four residents (Resident 10) 2. One nurse was observed to leave the resident's room before the resident finished one medication solution for one of four residents (Resident 42) 3. One blood pressure medication with hold parameters was administered not in accordance with the physician order and without clarification of the order for one of five residents reviewed (Resident 32) These failures had the potential for residents to receive inadequate medication therapy.1. On August 19, 2025, at 8:10 a.m., during a medication pass observation with RN 5, it was noted RN 5 prepared one of Resident 10's medication, citalopram (medication to treat mood disorder) 20 mg (milligram - unit of measurement) tablet, by breaking the tablet in half using gloved hands. Resident 10's medical record was reviewed on August 19, 2025, and the following was noted: The resident was a [AGE] year-old who was admitted to the facility on [DATE], with diagnoses including hip fracture and other fractures of left thigh bone; There was a physician order on August 2, 2025, for citalopram 20 mg, 1/2 tablet to be given to the resident daily for depression (mood disorder) manifested by verbalization of distress; There was a physician order on August 7, 2025, for pill cutter with the direction to use as directed; The medication administration record in the resident's medical record indicated citalopram 10 mg (1/2 tablet) was given daily. On August 19, 2025, at 11:20 a.m., during an interview, RN 5 acknowledged RN 5 used the gloved fingers to break the citalopram tablet in half and agreed the pill cutter should have been used. RN 5 stated the pill cutter was not available in the resident's medication cassette and normally it would be used to cut the pill in half. On August 21, 2025, 11:15 a.m., during an interview, the DON stated, to be accurate, the tablet should have been cut in half using the pill cutter. The facility's policy and procedure titled, Medication Administration, approved, 09/22/2022, was reviewed, and it indicated: .All medications shall be administered utilizing appropriate safe administration technique .to help prevent and/or reduce the occurrence of medication-related errors . 2. On August 19, 2025, at 8:30 a.m., during a medication pass observation with RN 5, it was noted RN 5 prepared one of Resident 42's medication, Healthylax (brand name: Miralax, medication to treat or prevent constipation) 17 gram powder packet, by mixing it with approximately 6 ounces of water in a cup. RN 5 gave the cup to Resident 42, who was observed to take the mixed medication solution in the cup using the straw and to place the cup on the bedside tray. RN 5 administered the rest of the morning medications to Resident 42. RN 5 instructed the resident to continue to sip the medication solution in the cup before leaving the resident's room. After RN 5 left the resident's room, it was observed the cup with the mixed solution on the bedside tray was still approximately half full. Resident 42's medical record was reviewed on August 19, 2025, and the following was noted: The resident was a [AGE] year-old, who was admitted to the facility on [DATE], with diagnoses including rib fracture; There was a physician order on August 13, 2025, for the generic for Miralax 17 gram powder packet to be given to the resident daily to prevent constipation;The medication administration record in the resident's medical record indicated the full dose of the generic for Miralax 17 gm was administered on August 19, 2025. On August 19, 2025, at 11:20 a.m., during an interview, RN 5 acknowledged RN 5 left the room before Resident 42 finished taking Healthylax. RN 4 stated RN 5 should have stayed until the administration of healthylax solution was completed. On August 21, 2025, at 11:15 a.m., during an interview, the DON agreed the Healthylax solutions should have been fully consumed by the resident before RN 5 left the resident's room. The facility's policy and procedure titled, Medication Administration, approved, 09/22/2022, was reviewed, and it indicated: .All medications .will be administered in a safe manner following The Five Rights .The correct dosage of the drug will be verified . 3. On August 19, 2025, Resident 32's medical record was reviewed, and the following was noted: The resident was a [AGE] year-old, who was admitted to the facility on [DATE], with diagnoses including elevated CK level (indication of muscle or heart damage) and troponin level (indication of damage to heart muscle); There was a physician order on August 9, 2025, for losartan (medication to treat high blood pressure) 50 mg with the direction to give the resident one tablet daily for hypertension (high blood pressure) and the parameter to hold the dose if systolic blood pressure (SBP) is less than 120 (top number in a blood pressure reading in millimeter of mercury, mmHg) or blood potassium level (a test to monitor conditions of kidney and heart, measured in millimoles per liter, mmol/L) is greater than 5; The blood pressure was measured and documented in the resident's medical record daily. However, the potassium level was obtained and documented on August 5 and August 18, 2025; The medication administration record in the resident's medical record indicated losartan 50 mg was documented as administered daily, except on August 12, 2025 for SBP of 115; There was corresponding documentation of SBP for each daily administration of losartan. There was no daily potassium level corresponding to the daily administration of losartan. On August 20, 2025, at 3:53 p.m., during an interview, Pharmacist 1 stated, after reviewing the potassium level being included in the parameters for losartan, it would be prudent to have the parameter associated with the blood pressure medication. Pharmacist 1 stated the potassium level was not expected to be ordered daily for nursing home residents. When asked how the nurse was expected to carry out the physician order with such parameter associated with losartan, Pharmacist 1 stated the losartan dose should be given according to the parameter based on the last blood potassium level available. Pharmacist 1 stated it would not make sense to have daily level of potassium available for residents in the nursing home. Pharmacist 1 stated Pharmacist 1 would not question and clarify the order with the physician regarding the parameter that included checking for potassium level, which is not available daily, prior to administering the daily losartan dose. On August 20, 2025, at 4:25 p.m., during an interview, the DON stated the DON had not seen a parameter that included checking for potassium level prior to administering the blood pressure medication. The DON stated the included parameter for the order would not be a wise practice by the provider. The DON stated if the potassium level was that important the DON would expect the physician to order more frequent levels of potassium. The DON stated the order should have been clarified. The facility's policy and procedures titled, Medication Regimen Review, (MRR) approved, 03/20/2025, was reviewed, and it indicated: .Irregularity refers to any event that is inconsistent with usual, proper, accepted, or right approaches to providing pharmaceutical services .A pharmacist performs a MRR at a minimum of once a month on all patients, and more frequently if necessary. This review .Includes a review of all clinical records .Specifies findings that are irregularities to generally accepted practice .

Based on interview and record review, the facility failed to ensure the physician's orders for fluid restriction were followed for two of two residents (Residents 29 and 40) reviewed for nutrition and hydration.These failures had the potential to:1. cause further electrolyte (minerals that help with water balance in the body) imbalance for Resident 29, and2. exacerbate heart failure for Resident 40.Findings: 1.A review of Resident 29's admission Facesheet, indicated Resident 29 was admitted on [DATE], with diagnoses which included acute kidney injury and hyponatremia (low salt levels in the body). A review of Resident 29's Minimum Data set (MDS - and assessment tool) dated July 23, 2025, indicated Resident 29 had a Brief Interview for Mental Status (BIMS - designed to quickly evaluate a resident's cognitive function) use score of 15 (cognitively intact). A review of Resident 29's Orders indicated restrict fluids, 1200 ml (unit of measurement) per 24 hours with order date of July 23, 2025. A review of Resident 29's care plan Fluid Maintenance Problem r/t., initiated on 7/23/25, indicated resident had an electrolyte imbalance and on fluid restrictions, 1200cc (unit of measurement).interventions.record I (input) and O (output).ensure nursing staff is aware of fluid restriction 1200ml. A review of Resident 29's Oral Intake Flowsheet for July and August 2025, indicated Resident 29's oral intake exceeded the 1,200 ml fluid restriction order on the following dates: - July 24, 2025 – 1,580ml - July 27, 2025 – 1,400ml - July 29, 2025 – 1,600ml - July 30,2025 – 1, 880ml - August 1, 2025 – 1,340ml - August 6, 2025 – 1,410ml - August 11, 2025 – 1, 540ml - August 13, 2025 – 2,100ml and; - August 18, 2025 – 1, 320ml On August 18, 2025, at 2:30 p.m., an observation outside of Resident 29's room, indicated a sign posted on the wall showing fluid restriction 1,200 ml. On August 18, 2025, at 2:32 p.m., during a concurrent observation and interview, Resident 29 was observed with a water pitcher on the bedside table. Resident 29 stated she was aware of her fluid restriction but was not sure how much she would drink from the pitcher. On August 19, 2025, at 11:54 a.m., during a concurrent observation and interview, Certified Nursing Assistant (CNA)1 stated she was aware of Resident 29's fluid restriction and stated she would fill the pitcher halfway, about 500 ml. CNA 1 stated she looked inside the pitcher and recorded the amount at the end of her shift, then informed the nurses. On August 19, 2025, at 2:15 p.m., during an interview with CNA 2, CNA 2 stated she provided a pitcher of water at the start of her shift, but for residents on fluid restriction she would give a cup of approximately 240 ml and refill as needed, reporting totals to the nurses. On August 20, 2025, at 1:17 p.m., during a concurrent record review of Resident 29's oral intake values and interview with Registered Nurse (RN) 1, RN 1 stated Resident 29 was being treated for hyponatremia and had an order for 1, 200 ml fluid restriction. RN 1 stated the oral intake exceeded the ordered amount on July 24, 27, 29, and 30, and August 1, 6, 11, 13, and 18, 2025. RN 1 stated it was important to closely monitor fluid intake to ensure compliance with physician orders to prevent further electrolyte imbalance. On August 21, 2025, at 3:27 p.m., during a concurrent record review of Resident 29's oral intake values and interview with the DON, the DON verified Resident 29's oral intake exceeded the 1,200 ml fluid restriction. The DON stated, staff were expected to measure and account for the total intake and report to the physician as needed. The DON further stated it was important to follow physician orders to ensure the resident's hydration status was monitored and electrolyte balance maintained. 2. A review of Resident 40's admission Facesheet indicated an admission date of August 14, 2025, with diagnoses which included congestive heart failure (CHF - a heart condition causing fluid buildup in the body). A review of Resident 40's Active Order Profile indicated a fluid restriction of 1500 ml per 24 hours, ordered on August 14, 2025. A review of Resident 40's Oral Intake indicated: -August 17, 2025: 2,200 ml -August 18, 2025: 2,460 ml On August 19, 2025, at 8:45 a.m., an observation was conducted outside of Resident 40's room, where a sign was posted on the wall indicating Fluid Restriction: 1,500 ml. On August 19, 2025, at 8:46 a.m., an interview was conducted with Resident 40. Resident 40 stated he was placed on fluid restriction due to difficulty breathing. On August 19, 2025, at 4:07 p.m., a concurrent interview and record review was conducted with CNA 4. CNA 4 stated he was aware Resident 40 was on a fluid restriction, and residents on fluid restriction should not be given more than 400 ml of water in the pitcher during the day. CNA 4 stated, Resident 40 exceeded the 1,500 ml fluid restriction on August 17 and August 18, 2025. CNA 4 stated it was important to follow physician orders to ensure Resident 40's condition did not worsen. On August 20, 2025, at 10:55 a.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 40 consumed more fluids than allowed according to the physician's orders for fluid restriction and staff should have followed the physician's orders. LVN 1 stated it was important to follow physician orders because excess fluids could cause fluid overload, worsening heart problems, and difficulty breathing. On August 21, 2025 at 1:15 p.m., an interview was conducted with the DON. The DON stated the staff expectation was to follow the physician's orders for fluid restriction. A review of the facility's policy and procedure titled, DES SNF – NUTRITION AND HYDRATION, dated January 23, 2025, indicated, .patients are provided and offered adequate nutrition and hydration, consistent with physician's orders.

Based on interview and record review, the facility failed to ensure for six of 11 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 5, 10, 29, 32 and 39) that: 1. Resident 5's AD was accessible in the resident's chart; and2. The facility followed up with Residents 1, 20, 29, 32 and 39 and/or Resident Representative (RP) regarding formulation of an AD.This failure had the potential to result in the ADs for Residents 1, 5, 10, 29, 32 and 39 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings: 1. On August 19, 2025, at 10:05 a.m., an interview was conducted with Resident 5. Resident 5 stated he could not recall if he had been given information about ADs and would like more information. A review of Resident 5's admission Facesheet indicated Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's Minimum Data Set (MDS - an assessment tool), dated July 19, 2025, indicated Resident 5 had a Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 15 (cognitively intact). A review of Resident 5's admission History Adult dated July 18, 2025, indicated he had an AD. A further review of Resident 5's records did not indicate that a copy of the resident's AD was accessible in his records. In addition, there was no documented evidence that Resident 5 and/or RP were followed up regarding the AD. On August 20, 2025, at 4:12 p.m., a concurrent interview and record review of Resident 5's admission History Adult form was conducted with the Director of Nursing (DON). The DON stated upon admission the licensed nurses were responsible for reviewing the admission packet with each resident and/or RP and verifying whether the resident had an AD. The DON stated, if the resident had an AD, a copy should be requested and made available in the facility. The DON further stated, since Resident 5's admission History Adult from indicated he had an AD, his expectation was for staff to obtain a copy and place it in the resident's chart. The DON stated, because a copy was not received, staff should have a narrative note during weekly follow-up indicating that the AD was being followed up. The DON stated, Resident 5's AD was not on file and stated there was a chance the facility would not be able to honor his wishes for care. 2. On August 19, 2025, at 10:12 a.m., an interview was conducted with Resident 10. Resident 10 stated he was not sure if he had an AD and would like more information. A review of Resident 10's admission Facesheet indicated Resident 10 was admitted to the facility on [DATE]. A review of Resident 10's MDS dated [DATE], indicated Resident 10 had a BIMS score of 14 (cognitively intact). A review of Resident 10's admission History Adult dated July 19, 2025, indicated he did not have an AD. A further review of Resident 10's records indicated there was no documented evidence that Resident 10 or RP were provided with follow-up information or education about the right to formulate an AD. On August 20, 2025, at 4:15 p.m., a concurrent interview and record review of Resident 10's admission History Adult form was conducted with the DON, the DON stated there was no documentation to indicate that AD resources were discussed with Resident 10 and/or his RP during weekly follow-up, or that follow-up information was provided. 3. On August 19, 2025, at 10:25 a.m., an interview was conducted with Resident 29. Resident 29 stated she was not sure if she had an AD or if she had been given information about it. A review of Resident 29's admission Facesheet indicated Resident 29 was admitted to the facility on [DATE]. A review of Resident 29's MDS dated [DATE], indicated Resident 29 had a BIMS score of 15 (cognitively intact). A review of Resident 129's admission History Adult dated July 23, 2025, indicated she did not have an AD. A further review of Resident 29's records indicated there was no documented evidence that Resident 29 or RP were provided with follow-up information or education about the right to formulate an AD. On August 20, 2025, at 4:19 p.m., a concurrent interview and record review of Resident 29's admission History Adult form was conducted with the DON. The DON stated there was no documentation indicating that Resident 29 and/or RP were provided with weekly follow-up regarding an AD. 4. On August 18, 2025 at 3:10 p.m. an interview was conducted with Resident 1. Resident 1 stated he does not remember if he was offered the opportunity to formulate an advance directive or if information was provided. Resident 1 stated he is unsure if he wants an advance directive at this time. A review of Resident 1's admission Facesheet indicated an admission date of July 14, 2025. A review of Resident 1's History and Physical dated July 17, 2025, indicated Resident 1's assessment included cognitive impairment (brain functioning that affects thinking). A review of Resident 1's admission History Adult, dated July 14, 2025, indicated Resident 1 did not have an advance directive. On August 20, 2025, at 4:27 p.m., a concurrent interview and record review of Resident 1's admission History Adult form was conducted with the DON. The DON stated there was no documented weekly follow up which indicated Resident 1 and/or RP were provided with follow up regarding AD. 5. A review of Resident 32's admission Facesheet indicated an admission date of July 30, 2025. A review of Resident 32's History and Physical dated August 2, 2025, indicated Resident 32's assessment included dementia (brain disorder that causes a decline in cognitive (thinking) abilities). A review of Resident 32's MDS indicated Resident 32 had a BIMS score of 14 (cognitively intact). A review of Resident 32's admission History Adult, dated July 31, 2025, indicated Resident 32 did not have an AD. On August 20, 2025, at 4:77 p.m., a concurrent interview and record review of Resident 32's admission History Adult form was conducted with the DON. The DON stated there was no documented weekly follow up which indicated Resident 32 and/or RP were provided with follow up regarding AD. 6. A review of Resident 39's admission Facesheet indicated and admission date of August 11, 2025. A review of Resident 39's History and Physical dated August 13, 2025, indicated Resident 39's assessment included post-traumatic stress disorder (PTSD – mental health condition that occurs after experiencing a traumatic event) secondary to MVA (motor vehicle accident) / trauma. A review of Resident 39's MDS indicated Resident 39 had a BIMS score of 15 (cognitively intact). A review of Resident 39's admission History Adult, dated August 11, 2025, indicated Resident 39 did not have an AD. On August 20, 2025, at 4:20 p.m., a concurrent interview and record review of Resident 39's admission History Adult form was conducted with the DON. The DON stated upon admission the licensed nurses were responsible for going over the admission packet with each resident and/or RP and verify if the resident had an AD. The DON stated, if they did not have one, a Social Service Director (SSD) consult would be initiated, and the SSD would follow up and provide information and education on how to formulate one. The DON stated there was no documented weekly follow up which indicated Resident 39 and/or RP were provided with follow up regarding AD. The DON further stated if there was no AD on file there was a potential for the facility to not be able to honor their wishes for care. A review of the facility's policy and procedure titled, Advance Directives, revised December 2023, indicated, .this policy.to outline criteria for use of advance directives in the SNF.on admission the nurse will assess and ask the patient or patient representative if he or she has established an advanced directive, and request a copy if available.along with patient preferences for treatment this shall be incorporated in the plan of care.in the event that the patient or patient's representative wishes to establish a new advance directive.the social worker will provide the advance directive document and coordinate with the.Ombudsman to be one of the witnesses.the interdisciplinary team on an ongoing basis will assess and incorporate the patient's changing preferences.

Based on observation, interview, and record review, the facility failed to provide food with appetizing taste according to residents' preferences for four of 23 sampled residents (Residents 10, 23, 40, and 41). This failure had the potential to decrease the nutritional intake and negatively affect the nutrition status of Residents 10, 23, 40 and 41. Findings: On August 18, 2025, the following interviews were conducted: - At 1:26 p.m., Resident 41 stated, chicken is like leather. - At 1:36 p.m., Resident 40 stated, chicken is dry and tough to chew. - At 1:40 p.m., Resident 10 stated, food not good, meat entrees taste dry and rubbery. - At 3:31 p.m., Resident 23 stated, food is hit miss, no taste, mushy texture. On August 20, 2025, at 12:15 p.m., during a concurrent observation and interview with the Registered Dietitian (RD), a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) of pork loin (pureed diet) and baked chicken (regular diet) was evaluated during meal service. The chicken was observed to be bland, dry and with gritty texture. The RD stated the chicken was dry, overcooked and lacked seasoning. The RD stated dietary staff were expected to follow standardized recipes and maintain proper temperature hold times to ensure food was flavorful and not dry or overcooked. The RD further stated unappetizing food could lead to residents refusing meals, which could contribute to malnutrition (a condition in which the body does not get the right amount of nutrients). A review of the facility's policy and procedure [NAME] - Essential Duties and Responsibilities, revised February 2014, indicated, .preparation of high-quality food items according to standardized recipes or instructions in an efficient manner.serve meals or prepare.using correct portioning.ensuring food is at the correct temperature and is attractive and tasty.

Based on interview and record review, the facility failed to follow its policy and procedure for the two-step tuberculosis (TB - an infectious disease which affects the lungs or other parts of the body) screening, a requirement for the annual health examinations, for two of eight staff members reviewed.This failure had the potential to place staff and vulnerable residents at risk for exposure to infection.Findings:On August 21, 2025, the facility's employee files were reviewed. Two employee files indicated the following: 1. Certified Nurse Assistant 4 (CNA 4) - No documentation was found indicating the annual tuberculosis screening was completed in 2022.2. Registered Nurse 2 (RN 2) - No documentation was found indicating the annual tuberculosis screening was completed in 2024.On August 21, 2025, at 10:20 a.m., a concurrent interview and record review was conducted with the Senior Human Resources Generalist (SHRG). The SHRG stated these two staff members did not complete their annual tuberculosis screenings timely. The SHRG stated there was no email communication for CNA 4 in 2022 or for RN 2 in 2024, regarding missed annual tuberculosis screenings and both were allowed to continue working. The SHRG stated it was important for staff to complete the annual tuberculosis screenings timely to prevent the risk of infection exposure and ensure resident safety. The SHRG further stated staff should not be allowed to work until their annual tuberculosis screenings were completed. On August 21, 2025, at 10:25 a.m., a concurrent interview and record review was conducted with the SHRG. The SHRG stated RN 2 was required to complete a two-step tuberculosis testing due to not completing a tuberculosis screening in 2024. The SHRG stated RN 2 did not complete the second step, which was scheduled on January 29, 2025. On August 21, 2025, at 3:41 p.m., a concurrent interview and record review was conducted with RN 2. RN 2 stated he did not complete the annual tuberculosis screening in 2024 and was not aware he was required to complete a two-step screening in January 2025. RN 2 stated he should have followed up on the January 30, 2025, email reminder to complete the second step. RN 2 stated tuberculosis screenings should be completed annually.On August 21, 2025, at 4:02 p.m., a concurrent interview and record review of the facility's policy and procedure titled, DES HR 46 ANNUAL HEALTH REVIEW, dated October 19, 2023. with the Human Resource Manager (HRM) was conducted. The HRM stated no policy outlining further action when staff fail to comply with the TB screening. The HRM stated staff should be removed from the schedule if they are not compliant, but this practice was not currently being implemented. The HRM stated the outcome of noncompliance could be potential exposure of residents, who are vulnerable population and staff.On August 21, 2025, at 4:38 p.m., a concurrent interview and record review with the Director of Nursing (DON) was conducted. The DON stated CNA 4 did not complete the annual tuberculosis screening in 2022, and RN 2 did not complete the annual tuberculosis screening in 2024 or the second step of the two-step tuberculosis screening in January 2025. The DON stated the risk of exposure was high and could have potentially transmitted a communicable disease to residents. A review of the facility's policy and procedures titled, DES HR 46 ANNUAL HEALTH REVIEW, dated October 19, 2023, indicated, .Employees need to complete their annual health review by the following dates.TB test must be completed yearly within month of hire.Annual Questionnaire, labs, and monitoring.Due on Anniversary of date of hire.If employees are not complete by the end of the month of hire (unless on LOA), a report is sent to Human Resources (HR) for further action per HR policy.If the employee remains non-compliant at 60 days, the matter will be referred to HR for appropriate action which may include suspension until completed or termination.

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan to address a physician-ordered fluid restriction for one of one resident (Resident 40) reviewed.This failure resulted in Resident 40's fluid restriction not being incorporated into the plan of care, which had the potential to exacerbate resident's congestive heart failure (a condition which causes fluid buildup in the body) and compromise his overall health status. Findings:On August 19, 2025 at 8:45 a.m., an observation was conducted outside of Resident 40's room. A sign indicating a fluid restriction of 1500 milliliters (ml) was posted on the wall. On August 19, 2025 at 8:46 a.m., an interview was conducted with Resident 40. Resident 40 stated he was placed on fluid restriction due to difficulty breathing. A review of Resident 40's admission Facesheet indicated an admission date of August 14, 2025. A review of Resident 40's History and Physical, dated August 16, 2025, indicated an assessment of systolic congested heart failure. A review of Resident 40's Active Order Profile indicated an order dated August 14, 2025, for fluid restriction of 1500 ml per 24 hours. On August 20, 2025 at 10:54 a.m., a concurrent interview and record review was conducted with LVN 1. LVN 1 stated Resident 40 has a history of congestive heart failure and a fluid restriction for the 1500 ml was ordered on August 14, 2025. LVN 1 stated licensed nurses are responsible for initiating care plans. LVN 1 stated, no care plan had been initiated for fluid restriction. LVN 1 stated a care plan for fluid restriction should have been initiated to ensure the plan of care was followed. On August 21, 2025 at 1:15 p.m., an interview with the Director of Nursing (DON) was conducted. The DON stated the expectation is that when a licensed nurse received an order, it should be care planned for continuity of care. A review of the facility's policy and procedures titled, DES SNF - PATIENT CARE PLAN, dated January 23, 2025, indicated, .develop and implement an effective and person-centered care plan that includes instructions.The plan of care is initiated upon the admission of the patient to include at a minimum.Physician orders.

Based on interview and record review, the facility failed to notify the resident ' s representative, of a transfer to the Emergency Department (ED) for further evaluation of agitation for one of three residents (Resident 1). This failure resulted in Resident 1 ' s Representative not being informed of the transfer to the ED, limiting their ability to participate in the resident's medical care decisions to the extent deemed possible. Findings: On January 9, 2025, an unannounced visit was made to the facility for a quality of care issue. A review of Resident 1 ' s, Face Sheet, undated, indicated, resident was admitted to the facility on [DATE], with an admitting diagnosis of a resistive organism fungemia (fungal infection in the blood). On January 9, 2024, at 3:00 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated, the document, Appointment of Personal Representative (APR), is part of the admission packet. The DON verified, this document allowed the resident to appoint a representative to be notified in case of an emergency or to make healthcare decisions on the resident's behalf if the resident is deemed confused or incapacitated. A review of Resident 1 ' s Appointment of Personal Representative, dated, December 13, 2024, untimed, indicated, . I do wish to appoint a Personal Representative . Further review of the document indicated Representative 1 was listed as resident ' s personal representative. A review of Resident 1 ' s Nursing Narrative, dated December 13, 2024, indicated, . (Resident 1) (transferred to) ED per (Doctor) . (resident) very restless/agitated . multiple attempts to crawl (Out of Bed) . Further review of Resident 1's nursing narrative revealed no documentation indicating that Resident 1's representative was notified of the transfer by RN 1. On January 9, 2025, at 5:15 p.m., a concurrent interview with the DON, and a review of Resident 1 ' s APR, Nursing Narratives, and Notification/Transfers, was conducted. The DON stated, if a resident is deemed too confused to notify their family or representative of a transfer, staff should notify the resident's appointed representative. The DON stated, the staff should document the notification in the resident ' s medical record under the Notification/Transfers section. The DON stated, Resident 1 was transferred to the ED on December 13, 2024, at 6:30 p.m., and notification of the transfer was not documented in Resident 1's medical record. On January 13, 2025, at 1:37 p.m., an interview was conducted with RN 1. RN 1 stated, the staff should notify the resident's appointed representative when the resident is unable to notify their family or representative. RN 1 stated, he would document the notification of the resident's representative in the Nursing Narrative note. RN 1 stated, he was Resident 1 ' s assigned nurse on the day the resident was transferred to the ED (December 13, 2024 at 6:30 p.m.). RN 1 stated, prior to the transfer, Resident 1 was combative, agitated, and confused. RN 1 stated, he received orders to transfer Resident 1 to the ED for further evaluation. RN 1 stated, he forgot to notify Resident 1 ' s Representative about the transfer to the ED. On January 14, 2024, at 10:30 a.m., an interview was conducted with the DON, who stated, RN 1 should have notified Resident 1 ' s Representative because resident was in no condition (restless & agitated) to notify their representative herself. A review of the facilities Policy & Procedure, Resident Rights, approved, April 23, 2021, indicated, . Policy: The patient has a right to . D. A patient who had not been adjudged incompetent by the state court: 1. Has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the patient ' s rights to the extent provided by state law . L. Be notified immediately on changes such as: 4. When there is a decision to transfer or discharge the patient . 7. The facility shall also contact the patient representative if the patient so chooses. If patient is deemed incompetent the representative shall be notified consistent with this or her authority .

Based on interviews and record reviews, the facility failed to ensure dementia (memory loss) training was provided to one of two sampled employees (CNA1). This failure had the potential to result in staff lacking the necessary skills to manage and care for residents with dementia effectively. Findings: On August 1, 2024, at 9:30 a.m., an unannounced visit was conducted to investigate an allegation of abuse. The personnel file for Certified Nursing Assistant (CNA) 1, who was hired in January 29, 2024, was reviewed. There was no documentation showing that CNA 1 had received dementia training. On August 1, 2024, at 12:38 p.m., a concurrent interview and review of CNA 1's personnel file were conducted with the Regulatory Manager (RM). The RM stated, CNAs are provided training for dementia annually. The RM stated, CNA 1 had not undergone this training. The RM stated, all CNAs should have dementia training for safety and to ensure they know how to care for and handle residents with dementia. On August 1, 2024, at 12:45 p.m., the Assistant Director of Nursing (ADON) was interviewed. The ADON stated the facility admits resident with dementia and all Skilled Nursing Facility staff should have dementia training. The ADON stated CNA 1 should have undergone dementia training. The ADON stated the purpose of the training is to ensure staff know how to take care for and handle residents with dementia effectively. A review of the facility policy and procedure titled, CERTIFIED NURSE ASSISTANT ORIENTATION AND IN-SERVICE TRAINING PROGRAM, dated December 21, 2023, indicated, .It is the policy of the SNF to .An orientation program is provided to each new CNA employee .The remaining eight (8) hours of the orientation program shall be presented within the next thirty-two (32) hours of employment .The topics shall include .Care of the cognitively impaired patients .Provide no fewer than twenty-four (24) hours of in-service training every calendar year .The content of the training program shall be an enhancement to the basic training program, consistent with the needs of the facility patients as determined by the facility staff .Included in the program is no fewer than five (5) hours of Dementia-specific training every calendar year .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner, in accordance with professional standards for food service safety, as evidenced by: 1. Rodent droppings and evidence of nesting (collection of clutter, trash, and debris) was found in the cooking line area of the kitchen, as well as an accumulation of grease and black grime and food, this had the potential to transmit disease to patients by contaminating food and food contact surfaces. In addition, a convection oven (oven that has fans to circulate air around food), a steamer, three ovens, one fryer and a broiler had an accumulation of grease and food grime build-up. This had the potential to attract pests and for microorganism (a microscopic organism, especially a bacterium, virus, or fungus) growth that could be inadvertently transferred to food. 2. The industrial stand mixer had crusted dry substances on the protection grate, the steam jacketed kettles had crusted yellow food inside the kettle, and the convection oven had black and yellow grime build-up and the side of the unit was rusted. This had the potential for microorganism growth and to attract pests. 3. Raw turkey was thawing and the juices were found to be dripping from storage boxes onto raw beef defrosting right next to it in the walk-in refrigerator. This cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) had the potential to cause foodborne illness (food poisoning-caused by food contaminated with bacteria, viruses, parasites, or toxins). 4. In the walk-in refrigerator designated for dairy, there were plastic risers that food was stacked on top of and underneath there was spilled milk and yellow crusty looking substance on the floor that appeared to be spilled eggs. This had the potential for microorganisms to grow and to attract pests. 5. Multiple drawers were missing under food prep tables, and food crumbs had accumulated in the tracks of the missing drawers. This had the potential for microorganisms to grow and to attract pests. 6. Two frozen vegetable patties were uncovered in the freezer. This had the potential for food to become contaminated and cause food-borne illness. 7. Hand hygiene was not performed by Dietary Aide 2 who was handling ready to eat food. This had the potential to cause food-borne illness. Rats are especially dangerous in healthcare facilities because these pests carry disease and spoil food with the bacteria and viruses they harbor in their saliva and droppings. This failure led to 15 out of 16 medically compromised residents who received food from the kitchen, to be at risk for food-borne illness from contaminated food. Findings: 1. During the initial tour of the kitchen and concurrent interview with the Executive Chef (Chef) on February 26, 2024, at 11:35 a.m., at the cooking line where food was prepared for the residents, there were rodent droppings and evidence of nesting identified under the fryer and oven range. The Chef stated, they had a rat problem and the kitchen is very old, equipment is not working, and it is very hard to clean. The Chef further stated, several failed attempts have been made to scrape off and remove the food and grime buildup. One of the fryers was out of service and had food and grime buildup. Three of the four ovens were out of service and the spaces between the three stoves which housed the gas lines had an accumulation of grease, trash, black food grime and rodent droppings and evidence of nesting. The floor under the equipment also had an accumulation of grease, food grime and trash. There were rat droppings, confirmed by the Chef and evidence of rodent nesting, small pieces of torn papers, and piles of trash under the ovens. A round greyish color food item was pulled out from the oven and the Chef stated, it was a hamburger patty. During a concurrent observation and interview with the Chef, on February 26, 2024, at 11:40 a.m., at the cooking line, the convection oven, the steamer, three ovens, two fryers and a broiler, had an accumulation of grease and food grime buildup. The knobs had a sticky brown residue, the inside of the convection oven had a black build-up, and the door of the oven was crusted with yellow and black grime. The steamer had yellow and black build-up. The non-functioning fryer was covered with a metal plate and underneath the cover there was oil and food grime buildup. The broiler above the stove top was crusted with black food grime and grease. During an interview on February 27, 2024, at 10:54 a.m., with the Service Technician (ST) from [Company Name] pest control company. ST stated rats have been an issue for a while, he was recently at the facility for an infestation. ST stated, he suspects the rats may be using the sewer lines in the kitchen to gain access and can come in through any holes in the kitchen. During an observation in the kitchen, on February 27, 2024, at 11:07 a.m., the back door of the dry storage room that leads to the loading dock had a gap under the door and the gasket (seals the gap between two surfaces) around the door was falling off. During an interview with the Clinical Nutrition Manager (CNM), on February 28, 2024, at 2:39 p.m., CNM stated if a space is accessible, it should be clean and free of rat droppings. During an interview with the Chief Administrative Officer (CAO), on February 29, 2024, at 3:17 p.m., he stated the rodent issue was never brought up in the daily safety huddle meetings. The CAO stated all the hospital upper management team gets together daily to talk about safety issues in the hospital/SNF. He stated that the Food and Nutrition Services Department staff do attend these meetings but never brought up the rat infestation in the kitchen. During a review of the [Company Name] summary of services report, dated February 16, 2024, indicated, Recommendation: Cracks or damage to wall allowing pest access. Please repair to prevent pest entry. A hole in wall in drink cage I (ST) pointed out to the Patient Service Manager (PSM)], Status: PENDING, Date: 11/30/2023. An accumulation of food products from damaged goods noted. Please remove food product to prevent attraction by pests. Main kitchen cooking line. Status: PENDING, Date: 04/06/2023. A review of an email, dated February 16, 2024, at 8:18 a.m., indicated the [Company Name] pest control company the facility's managers were notified regarding Large rat spotted in dish room and roaches spotted in cold production area basement kitchen. A review of the FANS (food and nutrition services) Pest Control Log indicated: -On January 12, 2024, a rodent was seen in the tray line area. -On January 24, 2024, roaches were seen in the tray line area. -On January 27, 2024, roached were seen in the tray line area. -On January 28, 2024, roaches were seen in the cold prep area and in the toaster. -On February 3, 2024, a rodent was seen in the kitchen. -On February 16, 2024, a rodent and roaches were seen in the dish room and cold prep areas. A review of the facilities policy titled Pest Control, dated January 2023, indicated The Food and Nutrition Services Department/Dining Services shall be free of all rodents and insects. Associates are instructed to report pest sightings to management . A review of the company's policy and procedures titled Sanitation and Infection Prevention and Control Program Overview, dated January 2023, indicated .Proper sanitation and infection control practices are observed in all phases of food production and service . During a review of the FDA Federal Food Code, dated 2022, 6-501.111 indicated, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under 7-202.12, 7-206.12, and 7-206.13; and (D) Eliminating harborage conditions. In addition, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, 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. During an observation of the cook's bulk preparation area, and concurrent interview with the Executive Chef (Chef), on February 26, 2024, at 11:19 a.m., there was an industrial stand mixer that had crusted food on the protection grate. Per Chef he agreed it was not from recent use. There was also yellow colored crusted food on the insides of two steam jacket kettles (uses steam heat to cook large amounts of food). The Chef stated the kettles should be cleaned after use and they were not currently in use. Next to the kettle was a convection oven, the side of the oven was a rust color, inside there was black and yellow grime build-up. Chef stated, there is only one oven they can use and do not have time to clean it because of the large volume of meals they have to prepare. During an interview with the Clinical Nutrition Manger (CNM) on February 28, 2024, at 2:39 p.m., the CNM stated that the cook's bulk preparation area equipment should be cleaned after every use and not have any crusted food on it. During a review of the facility policy titled Sanitation and Infection Prevention and Control Program Overview, dated January 2023, indicated Proper sanitation and infection control practices are observed in all phases of food production and service. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, 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. 3. During an observation in the walk-in refrigerator and concurrent interview with the Executive Chef (Chef) on February 26, 2024, at 11:01 a.m., there were multiple stacked boxes of raw beef defrosting. Next to the raw beef there were multiple stacked boxes of raw turkey defrosting, the raw turkey boxes were positioned and hung over the raw beef and juices from the turkey were seen dripping onto the boxes of raw beef. Chef stated, the box of turkey should not be defrosting on top of the beef due to possible cross contamination. A review of the facility's policy and procedure titled Food and Supply Storage, dated January 2023, indicated .Refrigerated storage .separate goods by category (meat, fish, poultry .if raw animal products are stored on the same rack, store them in the following order .whole cuts of beef, pork, ground meat and poultry . During a review of the FDA Federal Food Code, dated 2022, 3-302.11 indicated, Except when combined as ingredients, separating types of raw animal foods from each other such as beef, fish, lamb, pork, and poultry during storage, preparation, holding, and display by: (b) Arranging each type of food in equipment so that cross contamination of one type with another is prevented . In addition, It is important to separate foods in a ready-to-eat form from raw animal foods during storage, preparation, holding and display to prevent them from becoming contaminated by pathogens that may be present in or on the raw animal foods. With regard to the storage of different types of raw animal foods as specified under subparagraph 3-302.11(A)(2), it is the intent of this Code to require separation based on anticipated microbial load and raw animal food type (species). Separating different types of raw animal foods from one another during storage, preparation, holding and display will prevent cross-contamination from one to the other. The required separation is based on a succession of cooking temperatures as specified under S 3-401.11 which are based on thermal destruction data and anticipated microbial load. For example, to prevent cross-contamination, fish and pork, which are required to be cooked to an internal temperature of 145 F for 15 seconds, shall be stored above or away from raw poultry, which is required to be cooked to an internal temperature of 165 F (<1 second, instantaneous) due to its considerably higher anticipated microbial load. 4. During the initial tour of the kitchen an observation and concurrent interview was conducted with the Executive Chef (Chef), on February 26, 2024, at 11:12 a.m., in the walk-in refrigerator labeled number 22. There were plastic risers used to store milk and eggs, and under the risers there was spilled milk. In the back corner on the floor there was a yellow crusted looking substance that appeared to be spilled eggs. Chef stated spills should be clean up immediately. During an interview with the Clinical Nutrition Manager (CNM) on February 28, 2024, at 3:30 p.m., the CNM stated, that spills should be cleaned up as they occur. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, 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. 5. During an observation and concurrent interview was conducted with the Executive Chef (Chef), on February 26, 2024, at 11:12 a.m., multiple drawers were missing under food prep tables, in the cook's bulk preparation area, cooking line and cold food preparation area, the tracks used to hold the drawers had an accumulation of yellow food grime. Chef stated, the tracks of the drawer should be kept clean and not have an accumulation of food grime. During an interview with Dietary Aide (DA1), on February 27, 2024, at 10:38 a.m., DA1 stated that the drawers had been missing for years. During an interview with the Clinical Nutrition Manager (CNM), on February 28, 2024, at 2:39 p.m., CNM stated that the drawer tracks should be clean and free of food build-up. During a review of the FDA Federal Food Code, dated 2022, 4-602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, 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. 6. During the initial tour of the kitchen and concurrent interview with the Executive Chef (Chef) on February 26, 2024, at 10:51 a.m., There were two frozen vegetable patties, out of their packaging, in the freezer. The Chef stated all food should be covered. A review of the facility's policy and procedure titled Food and Supply Storage, dated January 2023, indicated .All food .used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption .wrap food tightly to prevent cross contamination . During a review of the FDA Federal Food Code, dated 2022, 3-301.11 indicated, (A) FOOD shall be protected from cross contamination by . (4) storing the food in packages, covered containers, or wrappings;. In addition, Food that is inadequately packaged or contained in damaged packaging could become contaminated by microbes, dust, or chemicals introduced by products or equipment stored in close proximity or by persons delivering, stocking, or opening packages or overwraps. Packaging must be appropriate for preventing the entry of microbes and other contaminants such as chemicals. These contaminants may be present on the outside of containers and may contaminate food if the packaging is inadequate or damaged, or when the packaging is opened. The removal of food product overwraps may also damage the package integrity of foods under the overwraps if proper care is not taken. 7. During an observation, on February 27, 2024, at 11:50 a.m., kitchen staff was plating meals for residents. Dietary Aide (DA2) was observed answering his phone, talking on the phone, and clipping the phone back on his pants while wearing gloves. DA2 did not change his gloves or wash his hands and continued to prepare resident meal trays. During an interview, on February 28, 2024, at 3:30 p.m., with the Director of Food and Nutrition Services (DFANS), and the Regional Supervisor (RS), was conducted. The RS stated, DA2 did not follow proper hand hygiene protocol, he should have performed hand hygiene and changed his gloves after answering his cell phone. During a review of the company's policy and procedures titled Sanitation and Infection Prevention and Control Program Overview, dated January 2023, indicated .Proper sanitation and infection control practices are observed in all phases of food production and service .proper hand hygiene .disposable glove use . On February 26, 2024, at 4:10 p.m., an immediate jeopardy (IJ) (immediate corrective action is necessary because the facility's noncompliance with one or more of those requirements has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a facility) was called under 483.60(i)(1)-Procure food from sources approved or considered satisfactory by federal, state or local authorities and 483.60(i)(2)-Store, prepare, distribute and serve food in accordance with professional standards for food service safety The facility was notified of the IJ under federal tag 812: The facility did not Store, prepare, distribute, and serve food in accordance with professional standards for food service safety when there was rodent droppings and evidence of nesting identified on the main cooking line in the kitchen, as well as the presence of excessive black grime and grease build-up and old food on the floor and kitchen equipment. A build-up of crumbs and black grime found on and under equipment and proper hand hygiene was not performed by one staff member handing ready to eat food. On February 26, 2024, the facility provided a Corrective Action Plan and indicated the following will be implemented immediately to address the sanitation issues in the kitchen: 1. All surface areas in the kitchen were cleaned. 2. All foods have been removed from the Skilled Nursing Facility (SNF). 3. An emergency request for pest control to come onsite and perform extermination services. 4. A restoration company will be working all night to perform deep cleaning of the kitchen and Evaluate any wall penetrations and perform repairs as needed. 5. All food preparation surfaces will be sanitized immediately before any food preparation. 6. The diet list for the 15 residents have been sent to the dietician. 7. Pre-packaged meals and beverages will be provided to residents on regular diets. 8. For residents on altered texture diets, the diets will be downgraded to pre-packaged purees and the residents will be provided with supplements. 9. After completion of the terminal clean, restoration, and extermination, we will have a third- party environmental company come onsite and perform an inspection. The IJ was lifted on February 29, 2024, at 4:30 p.m., after an acceptable corrective action plan was implemented and carried out, and verified through observation, interview, and record review.

Based on observation, interview, and record review, the facility failed to ensure the lunch menu served on February 27, 2024, met the nutritional need of 15 out of 16 residents in accordance with established national guidelines. This failure had the potential for residents not to receive the caloric intake needed, when the established menu was not followed, which could result in poor nutrition and further compromise the residents' medical status. Findings: An observation and concurrent interview were conducted on February 26, 2024, at 12:20 p.m., with Resident 227. Resident 227 stated, he should receive double-portions, and only received one scoop of potatoes today. Resident 227 stated, sometimes the facility messed up the order and he had to wait 45 minutes for the missing food. Resident 227 further stated, how was he supposed to gain weight if the facility kept messing up his food orders. An observation, on February 27, 2024, at 11:30 a.m., was conducted during the tray line. The Associate Patient Dining Staff (APDS) was portioning out food into each resident's styrofoam container. The APDS was serving meatloaf and broccoli, using tongs to pick up the broccoli. A serving of the meatloaf was weighed; it weighed 1.3 ounces, and the broccoli was approximately 1/4 of a cup. During a review of the kitchen's document titled Migrated Patient Menu, for lunch, on February 27, 2024, the menu indicated to serve 3 ounces of meatloaf and one cup of broccoli. During an interview on February 28, 2024, at 3:57 p.m., with the Clinical Nutrition Manager (CNM), the CNM stated, the menu should be followed for the serving sizes. A review of the facility's policy and procedure titled Menu Management, dated January 2023, indicated .Menus are managed to ensure patient meal selections are accurate for diet ordered .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests and rodents when: 1. There were rodent droppings and evidence of nesting found in the cooking line; 2. There was not a set schedule for the pest control company to service the kitchen; and 3. Recommendations made by the pest control company were never implemented. These failures created an environment attracting rodents and the potential contamination of food and kitchen equipment used to supply meals to 15 out of 16 vulnerable residents, who are put at risk for food-borne illness (caused by food contaminated with bacteria, viruses, parasites, and toxins). Findings: During the initial tour of the kitchen on February 26, 2024, at 11:35 a.m., at the cooking line where food was prepared for the residents, there were rodent droppings and evidence of nesting (collection of clutter, trash, and debris) identified inside a compartment between the stove and the fryer. The Executive Chef (Chef) stated, they have a rat problem, and staff was able to confirm, there were rat droppings and evidence of nesting. During an interview on February 27, 2024, at 10:54 a.m., with the Service Technician (ST), from [Name] pest control company, the ST stated, approximately three years ago he took over the contract with the facility. The ST stated, the rodents have been an issue for a while, he was out recently for an infestation in the facility. The ST stated, he suspects rats may be using the sewer lines in the kitchen to gain access and can come through any holes in the kitchen. During an observation on February 27, 2024, at 11:07 a.m., with the Director of Food and Nutrition Services (DFANS), in the kitchen, the back door of the dry storage room leads to a loading dock outside, and the door had a noted gap at the bottom and the gasket (seals the gap between two surfaces) around the door is falling off. The DFANS stated, the opening is wide enough for rodents to enter the kitchen. During an observation in the dry storage area of the kitchen, on February 28, 2024, at 11:53 a.m., inside the drink cage, where sodas are stored, there was a large area of damage to a corner wall. The area was covered with tape and plastic. The DFANS stated, it had been covered last night with the plastic and tape. The DFANS stated, the rodents will be able to chew through the plastic and tape, this will not deter the rodents. During an interview with the Food and Nutrition Services Manager (FNSM) on, February 28, 2024, at 3:57 p.m., the FNSM stated, the recommendation by the [Name] pest control company to patch the whole in the drink cage should have been done immediately. He stated that he never read the report from the [Company Name] until we asked for it. He stated a work order was never submitted to patch the whole in the drink cage and the accumulation of food product (that the [Company Name] recommended should be cleaned up) was never addressed. He stated, [Company Name] pest control services the whole hospital and was not routinely scheduled to service the kitchen, they only came when pests were identified. During an interview with the Clinical Nutrition Manager (CNM), on February 28, 2024, at 2:39 p.m., the CNM stated, all areas of the kitchen that are accessible should be cleaned, and free of old food and trash. The CNM stated, the back cook's bulk preparation area equipment should be cleaned after every use and should not have crusted food on it. During a review of the [Company Name] summary of services report, dated February 16, 2024, indicated, Recommendation: Cracks or damage to wall allowing pest access. Please repair to prevent pest entry. A hole in wall in drink cage I (ST) pointed out to the Patient Service Manager (PSM)], Status: PENDING, Date: 11/30/2023. An accumulation of food products from damaged goods noted. Please remove food product to prevent attraction by pests. Main kitchen cooking line. Status: PENDING, Date: 04/06/2023. During a review of the FDA Federal Food Code, dated 2022, 6-501.111 indicated, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: (A) Routinely inspecting incoming shipments of food and supplies; (B) Routinely inspecting the premises for evidence of pests; (C) Using methods, if pests are found, such as trapping devices or other means of pest control as specified under 7-202.12, 7-206.12, and 7-206.13; and (D) Eliminating harborage conditions. In addition, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. During a review of the facility's policy and procedure titled Pest Control, dated January 2023, indicated .The physical premises shall be in compliance with local regulations .Ensure that all holes and cracks in walls and floors where pests and rodents could gain entry are repaired/sealed .Ensure the exterior department doors including those leading to outside receiving areas and garbage have less than a 1/4 inch gap between the door and floor to prevent pest and rodent entry .Request a copy of the pest control service report; recommendations on the report are followed .

Based on observation, interview, and record review, the facility failed, for two employees observed, to ensure infection control policy and procedures for hand hygiene and personal protective equipment (PPE) were implemented when: 1. RN 2 did not perform hand hygiene before donning gloves on two occasions. In addition, RN 2 did not remove gloves after direct patient care and exited the room to enter another resident's room. 2. One Certified Nursing Assistant (CNA 1) did not perform hand hygiene upon entering and exiting a resident's room and after providing direct patient care. These failures had the potential to spread infection and compromise the overall health of residents residing in the facility. Findings: 1. During an observation on February 26, 2024, at 12:30 p.m., in Resident 74's room, RN 2 did not change gloves between providing care for two residents. In addition, RN 2 was observed to answer the telephone with the same gloved hands and entered Resident 77's room without performing hand hygiene. RN 2 entered the hallway and was observed to remove gloves without performing hand hygiene. RN 2 returned to Resident 74's room and donned new gloves without performing hand hygiene. During an observation on February 27, 2024, at 10:33 a.m., in Resident 74's room, RN 2 was observed to not perform hand hygiene or wear gloves while assisting a resident with a breakfast tray. RN 2 exited from the room and did not perform hand hygiene before entering Resident 79's room after obtaining a food item from the nourishment room. During an observation on February 27, 2024, at 10:45 a.m., RN 2 entered Resident 74's room and placed items on A bed and collected B bed's breakfast tray, exited the room, and reentered the room without performing hand hygiene. RN 2 was observed not wearing gloves. During an observation on February 27, 2024, at 11:56 a.m., in Resident 74's room, after a dressing change, RN 2 removed gloves, touched surfaces in the residents' room, exited the room, and touched medical equipment outside of the room. RN 2 did not perform hand hygiene before reentering the room. During an interview on February 27, 2024, at 12:05 p.m. with RN 2, RN 2 stated, she did not perform hand hygiene before entering and exiting resident's room, this morning. RN 2 stated, she should have performed hand hygiene before entering and exiting the residents' room, when collecting the meal tray, prior to handling medications, and when providing care. 2. During an observation on February 27, 2024, at 10:40 a.m., in Resident 77's room, CNA 1 was observed to assist Resident 77 with care without wearing gloves. CNA 1 exited Resident 77's room and entered Resident 78's room without performing hand hygiene. CNA 1 proceeded from Resident 78's room and entered Resident 77's room and did not perform hand hygiene before donning gloves. During an observation on February 27, 2024, at 10:56 a.m., in Resident 77's room, CNA 1 was observed to remove gloves after providing care to Resident 77. CNA 1 touched their face and hair, handled clean linens, and discarded resident's personal items without performing hand hygiene and donning gloves. During an interview on February 27, 2024, at 11:36 a.m. with CNA 1, CNA 1 stated, he should have washed his hands after removing his gloves after providing care to Resident 77. During an interview on February 28, 2024, at 9:35 a.m. with the Infection Preventionist (IP - responsible for dissemination of infection prevention information), the IP stated, staff should be performing hand hygiene by using alcohol-based hand gel (a gel containing alcohol used to kill or minimize many viruses, bacteria, and miccroorganisms on the hands) or washing hands with soap and water according to the facilities policy and procedure. During a review of policy and procedure titled DES IP 599 Hand Hygiene, dated February 16, 2023, indicated .B. Indications for hand hygiene and hand antisepsis .2. Before and after direct contact with patients; blood/body fluids or equipment and environmental items touched by patients, 3. Before entering occupied, clean, or empty rooms, 4. Before and after handling medication or food .7. Prior to donning gloves and after removing gloves .

Based on observation, interview, and record review, the facility failed to maintain essential kitchen equipment in a safe operating condition, as evidenced by multiple pieces of equipment out of service and not being clean or maintained. These failures led to harborage conditions in the kitchen that was attracting pest and the potential for cross contamination and foodborne illness in 15 out of 16 medically compromised residents who received food from the kitchen. Findings: During an observation in the bulk food preparation area and concurrent interview with the Executive Chef (Chef), on February 26, 2024, at 11:22 a.m., the double convection oven (oven that has fans to circulate air around food) had rust on the side and the inside had a build-up of food and yellow grime. The Chef stated, that they only have one working oven in the kitchen, all the other ovens are not working, because of the large volume of meals they prepare they do not have time to clean it. During a concurrent observation and interview with the Chef on February 26, 2024, at 11:35 a.m., at the cooking line where food is prepared for the residents, there were rodent droppings and evidence of nesting (collection of clutter, trash, and debris) noted in the compartment between the oven and the fryer. The fryer, 3 ovens and a broiler were not working. The Chef stated, the two steamers are not working, one is out of service and the other one leaks hot water, which leaves standing water in the kitchen. During further observation and a concurrent interview with the Chef on February 26, 2024, at 11:40 a.m. multiple drawers were missing under food prep tables, in the cook's bulk preparation area, cooking line, and cold food preparation area, the tracks used to hold the drawers had an accumulation of yellow food grime. The Chef stated, the tracks of the drawers should be kept clean and not have an accumulation of food grime. During an interview with Dietary Aide (DA1) on February 27, 2024, at 10:38 a.m., DA1 stated, the drawers under the preparation tables have been missing for years. During an interview with the Director of Biomedical Engineering (DBE) on February 27, 2024, at 10:39 a.m., he stated they do not currently have a plan for the broken equipment in the kitchen. A subsequent interview was conducted with the Director of Biomedical Engineering (DBE), on February 29, 2024, at 3:30 p.m., the DBE stated work orders go to the maintenance department, someone was assigned to confirm when the work was completed. The DBE stated, the Biomedical department was primarily responsible for the repairs of the medical equipment, the requested work orders should be completed in approximately 30 days. The DBE further stated, ideally the appropriate departments would be notified and follow up as indicated, but somehow the communication was not occurring, and work orders were not being completed nor followed through. A review of the facility's policy and Procedure titled Equipment Maintenance Program, dated January 2023, indicated .Proper maintenance of the physical plant and all equipment is the responsibility of the Director in cooperation with the Maintenance Department .with the maintenance department, plans in writing a program of preventative maintenance for all Food/Nutrition equipment requiring regular maintenance .Regular inspection/maintenance by maintenance department, periodic servicing by a service company contracted through the maintenance department .for equipment to be maintained by the department, incorporate maintenance tasks into the area and equipment cleaning frequency . During a review of the FDA Federal Food Code, dated 2022, 4-501.11 indicated, (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. In addition, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk.

Based on interview and record review, the facility failed to ensure the pharmacist recommendation to reduce the number of anticoagulants (medications to reduce or prevent blood from clotting) from two medications to single medication was acted upon by providing a rationale for not reducing the number of anticoagulants (medications that reduce or prevent blood from clotting), for one of five residents reviewed for unnecessary medications (Resident 76). This failure had the potential to result in adverse consequences related to anticoagulant therapy. Findings: During a review of the facility document titled Consultant Pharmacist's Recommendation to Inter-Disciplinary Team (IDT), dated February 25, 2024, indicated, .The resident has orders for Eliquis (Apixaban- anticoagulant) and Aspirin (anticoagulant) .Would monotherapy (single medication to treat a condition) be clinically feasible? . A review of Resident 76's record indicated Resident 76 was admitted to the facility on [DATE], with diagnoses which included peripheral vascular disease (a blood circulation problem) and heart failure (a heart that does not pump well enough). On February 29, 2024, at 10: 50 a.m., during a concurrent interview and review of Resident 76's Consultant Pharmacist's Recommendation with Registered Nurse (RN) 1, RN 1 stated, the physician did not document the reason if monotherapy was feasible. RN 1 stated there was no documented evidence the physician addressed the pharmacy recommendation. On February 29, 2024, at 9:24 a.m., during a concurrent interview and review of Resident 76's Consultant Pharmacist's Recommendation on February 25, 2024, with the Director of Nursing (DON), the DON stated, if there was a pharmacy recommendation, it should be acted upon immediately by the IDT. During a review of the facility policy and procedure titled, DES SNF- MEDICATION REGIMEN, dated April 23, 2021, indicated, .To ensure compliance with regulation surrounding drug therapies in the nursing facility .and to help reduce or potentially eliminate adverse drug reactions .Potential duplicate therapy .PROCEDURE: .Communicating the recommendation to the physician immediately, as soon as possible .the medical record will reflect the communication and the action taken .