Every finding on record at Fountains, The

Based on interview, and record review, the facility failed to ensure one of three residents (Resident 1) sampled for resident's right was treated with dignity and respect when Resident 2 reported that Certified Nurses Assistance (CNA) A was rude and impatiently spoke to Resident 1 in a Disrespectful manner, and denied them assistance to the bathroom when requested.These actions resulted in Resident 1 experiencing feelings of upset, disrespect, and intimidation.Findings:During a review of the undated facility policy titled, Prevention, Identification, and Reporting of Abuse indicated, It is the policy of the facility that abuse, neglect, abandonment, isolation, financial abuse shall not be tolerated in this facility at any time. Each resident has the right to be free from verbal, sexual, physical, mental, neglect, financial exploitation, and involuntary seclusion. Residents must not be subject to abuse by anyone, including, but not limited to facility staff. Verbal abuse is defined as any use of oral, written, or gestured communications, or sounds, that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation.On 11/4/2025 at 2:49 pm the California Department of Public Health (CDPH) received a facility reported incident alleging Resident 2 observed CNA A verbally abusing Resident 1 on 11/3/2025 and 11/4/2025.A review of Resident 1's admission record, dated 10/13/2025, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of pneumonia, acute respiratory failure with hypoxemia (low oxygen levels), shortness of breath with activity, generalized muscle weakness, and difficulty in walking. A review of Resident 1's care plans dated 10/18/2025, indicated Resident 1 was to assist with use of the bedpan or to the toilet every shift, and will be assisted by staff to transfer in and out of bed and to walk due to fall risk. A review of Resident 1's most recent Minimum Data Set (MDS, resident assessment) dated 11/4/2025, indicated in the Cognitive Function Section that Resident 1's Brief Interview for Mental Status (BIMS, cognitive assessment) score was 14 indicating minimal cognitive impairment. Functional Abilities Section indicated Resident 1 requires supervision and touching assistance with toileting and walking.A review of Resident 2's admission record, indicated Resident 2 was admitted on [DATE] for post-operative orthopedic care (a phase of medical management after bone or joint surgery, focusing on preventing complications). A review of Resident 2's MDS, dated [DATE], indicated Resident 2's BIMS score was 15, indicating normal thinking and memory. Resident 2 makes their own decisions.During an interview with Resident 2 on 11/25/2025 at 4:14 pm, Resident 2 stated they observed CNA A Verbally abusing Resident 1 two days in a row. Resident 2 stated on 11/3/2025 their roommate, Resident 1, had a hard night and was crying and there were lots of tissues on the floor. Resident 2 stated CNA A scolded Resident 1 for Being messy and brought a trash can to the bedside telling Resident 1 to clean up their mess. Resident 2 also stated that the next morning (11/4/2025) CNA A was doing vital signs and woke Resident 1. Resident 2 stated CNA A said to Resident 1, No, I am here to do your vital signs. You always do this. I have a job to do. No, you will wait when Resident 1 requested assistance to go to the bathroom. Resident 2 stated that CNA A left the room and did not come back. Resident 2 stated that the way CNA A talked to Resident 1 was Upsetting and disrespectful. Resident 2 stated CNA A did not take Resident 1 to the bathroom until much later when Resident 2 called for help. Resident 2 stated that later that day CNA A came by their room and pounded on her chest saying, Thank you directed at Resident 2. Resident 2 stated they felt they were being threatened. Resident 2 stated they reported these incidents to Resident 1's family member.During an interview on 12/2/2025 at 10:10 am, Resident 1's Family member stated Resident 2 reported the incident to them on 11/4/2024 and they reported it to the facility. Family member stated they had not witnessed the incident however described Resident 2 as 100% legit (believable). During an interview on 12/2/2025 at 10:12 am, Resident 1 stated they remembered CNA A yelling at them stating, Why do you always do this to me when they requested to be changed. Resident 1 verbalized that she was upset. Resident 1 stated following the two incidents she observed CNA A coming back to her room and telling Resident 2 I will remember you. Resident 1 stated they felt that CNA A's statement was meant to intimidate Resident 2 for reporting the two incidents.During an interview with CNA A on 12/3/2025 at 11:02 am, CNA A stated on the morning of 11/4/2025 around 6:30 am, they went to Resident 1 and Resident 2's room to do vital signs. CNA A stated they started vital signs on Resident 1 and Resident 1 requested to go to the bathroom. CNA A stated they left Resident 1's room to get vital signs on the other residents they were assigned to and came back to Resident 1's room to find them asleep. CNA A stated Resident 2 used their call light to request assistance back from the bathroom and at this time they helped Resident 1 to the bathroom.

Based on observation, interview, record review, and review of the Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to accurately code the Minimum Data Set (MDS) for 2 (Resident #7 and Resident #47) of 2 residents reviewed for Preadmission Screening and Record Review (PASRR) requirements and 1 (Resident #16) of 3 residents reviewed for dental concerns. Findings included: 1. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, revealed, A1500: Preadmission Screening and Resident Review (PASRR) included Steps for Assessment, which included, 2. Review the Level I PASRR form to determine whether a Level II PASRR was required. 3. Review the PASRR report provided by the State if Level II screening was required. The manual revealed, Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID [intellectual disability]/DD [developmental disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. A Resident Face Sheet indicated the facility admitted Resident #47 on 07/07/2022. According to the Resident Face Sheet, the resident had a medical history that included diagnoses bipolar disorder, unspecified dementia with psychotic disturbance, unspecified dementia with mood disturbance, and depression. An annual MDS, with an Assessment Reference Date (ARD) of 07/10/2024, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Per the MDS, the resident had active diagnoses of bipolar disorder, unspecified dementia with psychotic disturbance, unspecified dementia with mood disturbance, and depression. The MDS indicated Resident #47 was not considered by the state level II PASRR process to have a serious mental illness. Resident #47's Care Plan revealed a problem statement initiated 07/08/2022 and revised 02/25/2025, that indicated the resident had a diagnosis of bipolar disorder manifested by a history of paranoia. The Care Plan indicated the resident was taking antipsychotic medication. The Care Plan included a problem statement initiated 07/08/2022 and revised 02/25/2025 that indicated the resident had a diagnosis of depression and was taking antidepressant medication. Resident #47's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 07/07/2022, revealed the screening result was Positive and indicated the resident had a suspected mental illness. A letter from the State of California Health and Human Services Agency, Department of Health Care Services, PASRR Section, to Resident #47, dated 09/29/2022, indicated that Resident #47 had a Level II evaluation completed on 09/09/2022, and indicated that a determination report was included with the letter. Resident #47's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 09/29/2022, revealed that there were specialized services recommended to address the resident's mental health needs, including mental health rehabilitation activities, psychotherapy/counseling, neuropsychology consultation, and psychiatric consultation and follow-up care. The Social Services Director (SSD) was interviewed on 03/19/2025 at 3:04 PM. She stated that the MDS Coordinator was responsible for coding the section of the MDS that captured a resident's Level II PASRR status. During an interview on 03/20/2025 at 8:12 AM, the MDS Coordinator stated the MDS was to be coded accurately to reflect the resident status and the care provided. She stated the information about the Level II PASRR result was retrieved from the Level II PASRR determination letter. The MDS Coordinator reviewed the Level II PASRR and determination letter for Resident #47 and stated if the resident's MDS did not reflect that the resident had a Level II evaluation, then it was inaccurate. During an interview on 03/20/2025 at 11:10 AM, the Director of Nursing (DON) stated she expected all resident MDS assessments to be completed accurately to reflect the needs of the resident. She stated she expected the PASRR Level II evaluation to be captured on the MDS accurately. During an interview on 03/20/2025 at 11:34 AM, the Administrator stated he expected all MDS assessments to be completed accurately, capturing everything that could be coded to assess the resident appropriately. He stated he expected a Level II PASRR evaluation to be coded accurately on the MDS. On 03/19/2025 at 8:33 AM, the MDS Coordinator stated the facility did not have a policy regarding MDS accuracy, noting the facility followed the RAI manual. 22445 2. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed, A1500: Preadmission Screening and Resident Review (PASRR) included Steps for Assessment, which included, 2. Review the Level I PASRR form to determine whether a Level II PASRR was required. 3. Review the PASRR report provided by the State if Level II screening was required. The manual revealed, Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID [intellectual disability]/DD [developmental disability] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. A Resident Face Sheet revealed the facility admitted Resident #7 on 01/21/2022. The Resident Face Sheet revealed Resident #7 had a medical history that included diagnoses of unspecified schizophrenia and major depressive disorder. An annual MDS, with an Assessment Reference Date (ARD) of 01/24/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #7 had received antidepressant medication and antipsychotic medication during the assessment timeframe. The MDS indicated Resident #7 was not considered by the state level II PASRR process to have a serious mental illness. Resident #7's Care Plan included a problem area initiated on 01/30/2025 that indicated the resident verbalized feelings of depression and was at risk for a psychosocial well-being decline. The Care Plan included a problem area initiated 01/19/2024, that indicated Resident #7 had episodes of confabulation evidenced by spontaneous fabrications of false memories or events such as people talking about the resident or staff having aggressive chatter about the resident. Interventions directed staff to monitor for increased delusions and report those to the physician (initiated 02/06/2024). The Care Plan included a problem area initiated 02/17/2023, that revealed Resident #7 had auditory hallucinations and complained of hearing high pitched electric razor sounds. The Care Plan included a problem area initiated 01/22/2022, that revealed the resident required antipsychotic medication due to auditory hallucinations and suicidal ideation. Resident #7's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 01/21/2022, revealed the screening result was Positive and indicated that the resident had a suspected mental illness. A letter from the State of California Health and Human Services Agency, Department of Health Care Services, PASRR Section, to Resident #7, dated 05/18/2022, indicated that Resident #7 had a Level II evaluation completed on 05/13/2022, and indicated that a determination report was included with the letter. Resident #7's Preadmission Screening and Resident Review (PASRR) Individualized Determination Report, dated 05/18/2022, revealed that there were specialized services recommended to address the resident's mental health needs, including mental health rehabilitation activities, psychotherapy/counseling, neuropsychology consultation, psychiatry consultation and follow-up care, and behavior monitoring. The Social Services Director (SSD) was interviewed on 03/19/2025 at 3:04 PM. She stated that the MDS Coordinator was responsible for coding the section of the MDS that captured a resident's Level II PASRR status. During an interview on 03/20/2025 at 8:12 AM, the MDS Coordinator stated the MDS was to be coded accurately to reflect the resident status, and the care provided. She stated the information about the Level II PASRR result was retrieved from the Level II PASRR determination letter. During an interview on 03/20/2025 at 11:10 AM, the Director of Nursing (DON) stated she expected all resident MDS assessments to be completed accurately to reflect the needs of the resident. She stated she expected the PASRR Level II evaluation to be captured on the MDS accurately. During an interview on 03/20/2025 at 11:34 AM, the Administrator stated he expected all MDS assessments to be completed accurately, capturing everything that could be coded to assess the resident appropriately. He stated he expected a Level II PASRR evaluation to be coded accurately on the MDS. On 03/19/2025 at 8:33 AM, the MDS Coordinator stated the facility did not have a policy regarding MDS accuracy, noting the facility followed the RAI manual. 3. The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2024, revealed, Section L: Oral/Dental Status included Check L0200D, obvious or likely cavity or broken natural teeth: if any cavity or broken tooth is seen. A Resident Face Sheet revealed the facility admitted Resident #16 on 03/09/2022. The Resident Face Sheet revealed Resident #16 had a medical history that included diagnoses of cerebral infarction without residual deficits (stroke without lasting effects) and type 2 diabetes mellitus. An annual MDS, with an Assessment Reference Date (ARD) of 03/09/2025, indicated Resident #16 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed it was not coded to reflect that Resident #16 had obvious or likely cavities or broken natural teeth. The MDS indicated that Section L was completed by Licensed Vocational Nurse (LVN) #6. Resident #16's Care Plan included a problem area initiated 03/14/2022 and revised 03/11/2025, that indicated the resident had their natural teeth and required routine dental care. The Care Plan indicated the facility staff monitored for any dental issues that may arise. An observation on 03/17/25 10:28 AM revealed Resident #16 had broken front teeth. LVN #2 was interviewed on 03/19/2025 at 10:47 AM. LVN #2 stated she thought Resident #16 had a broken front tooth. She then confirmed the tooth was broken by going to the resident's room and observing the resident. LVN #2 stated Resident #16's family member had reported to her the resident had fallen at home about three years prior and broken the tooth. Certified Nursing Assistant (CNA) #5 was interviewed on 03/19/2025 at 11:32 AM. CNA #5 stated Resident #16 had a broken top tooth. CNA #5 stated that the tooth was broken when the facility admitted the resident. During an interview on 03/20/2025 at 8:12 AM, the MDS Coordinator stated the MDS was to be coded accurately to reflect the resident status, and the care provided. The MDS Coordinator stated she completed the dental/oral portion of the MDS and stated that to get the information about a resident's dental status, staff assessed the resident and she spoke with the nurses and CNAs. LVN #6 was interviewed on 03/20/2025 at 8:28 AM. She stated she got the oral/dental information for residents from the CNAs and assessed the resident's mouth. She stated if Resident #16 had a broken front tooth, then the MDS for the resident was not accurate. LVN #6 stated an inaccurate MDS may necessitate a revision to the care plan if the broken tooth was causing problems. She stated there was no policy for coding the MDS, and the MDS nurses followed the instructions in the RAI manual. LVN #6 assessed Resident #16 at that time and confirmed the resident had a broken tooth. During an interview on 03/20/2025 at 11:10 AM, the Director of Nursing (DON) stated she expected all resident MDS assessments to be completed accurately to reflect the needs of the resident. The DON stated she expected the MDS nurse to assess the residents for broken teeth or any other dental issues. She stated that if the resident had dental issues, she expected social services staff to be notified and dental care to be provided if needed. The DON stated she expected the MDS nurse to assess Resident #16 for broken teeth and to enter the correct information on the MDS. The Administrator was interviewed on 03/20/2025 at 11:34 AM. The Administrator stated he expected 100% accuracy on the MDS assessments. He stated if Resident #16 had broken teeth, then he expected that to be captured on the MDS. On 03/19/2025 at 8:33 AM, the MDS Coordinator stated the facility did not have a policy regarding MDS accuracy, noting the facility followed the RAI manual.

Based on record review, interview, and facility policy review, the facility failed to ensure staff immediately reported an allegation of abuse for 1 of 1 incident of alleged resident-to-resident abuse. Specifically, Resident #123 alleged to a certified nursing assistant (CNA) that Resident #115 kicked them and the CNA failed to immediately report the allegation. Findings included: A facility policy titled, Policy: Prevention, Identification and Reporting of Abuse- [facility's initials], revised 12/18/2019, indicated, Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The policy revealed, 7. Reporting included a. All mandated reporters are required by law to report incidents of known or suspected abuse in two ways: 1) by telephone immediately or as soon as practically possible, to the local ombudsman or local law enforcement agency and 2) by written report, Department of Social Services Form (SOC Form 341), 'Report of Suspected Dependent Adult/Elder Abuse' sent within two (2) working days and c. The first responder of first staff member informed will be responsible for informing the immediate supervisor and initiating an incident report. A Resident Face Sheet indicated the facility admitted Resident #123 on 11/19/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; and unspecified anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/21/2025, revealed Resident #123 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. Resident #123's Care Plan included a problem statement, initiated 02/22/2025 and revised 03/05/2025, that indicated the resident had confabulation episodes. Interventions directed staff to ask specific questions about factual information to minimize delusional/confabulating content (initiated 02/22/2025). A Resident Face Sheet indicated the facility admitted Resident #115 on 03/09/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of unspecified dementia, unspecified severity, with mood disturbance; and anxiety disorder. A quarterly MDS, with an ARD of 12/12/2024, revealed Resident #115 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. Resident #115's Care Plan included a problem statement, initiated 03/13/2024 and edited 12/16/2024, that indicated the resident required dementia and cognition care. Interventions directed staff to develop and implement a structured schedule with cognitive stimulation to keep the resident engaged (initiated 03/13/2024) and establish consistent daily routines and rituals to provide structure and predictability for the resident (initiated 03/13/2024). During an interview on 03/17/2025 at 1:52 PM, Resident #123 stated they (Resident #123) were kicked in the foot six times that day by another resident. The resident stated that CNAs saw the incident occur. Resident #123 was unable to provide any names of individuals associated with the alleged event. During an interview on 03/17/2025 at 3:45 PM, the Administrator was notified of Resident #123's allegation by a surveyor. The Administrator stated he was not aware of an allegation of abuse from Resident #123. During an interview on 03/19/2025 at 10:03 AM, CNA #4 stated she was working as a restorative nursing assistant on 03/17/2025 from 6:00 AM to 2:30 PM. CNA #4 stated she was at the nurses' station when Resident #123 verbalized that Resident #115 had kicked them (Resident #123). CNA #4 stated she did not report the allegation from Resident #123 because she did not see Resident #115 kick Resident #123. During an interview on 03/19/2025 at 11:55 AM, CNA #4 stated it was around 9:00 AM on 03/17/2025 when Resident #123 alleged they were kicked by Resident #115. She stated she did not notice if any other staff were present during the date and time in question. During a telephone interview on 03/20/2025 at 4:13 PM, CNA #4 stated she did not report Resident #123's allegation because Resident #123 was very confused. During an interview on 03/20/2025 at 5:59 PM, the Director of Nursing (DON) stated no staff members had reported hearing an allegation of abuse from Resident #123. During an interview on 03/20/2025 at 1:59 PM, the Administrator stated he expected allegations of abuse to be reported immediately.

Based on observation, interview, record review, and facility policy review, the facility failed to provide toenail care for 1 (Resident #7) of 4 residents reviewed for activities of daily living (ADLs). Findings included: A facility policy titled, Resident Care- Nursing Responsibilities- [facility's initials], revised 04/02/2019, indicated, 10. Residents shall be provided with good personal hygiene, including care of the skin, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, cleaning glasses, hearing aids and cleaning/cutting of fingernails and toenails. NOTE: Residents with diabetes shall have nail cutting performed by a licensed nurse or the podiatrist. A Resident Face Sheet revealed the facility admitted Resident #7 on 01/21/2022. The Resident Face Sheet revealed Resident #7 had a medical history that included diagnoses of Parkinson's disease without dyskinesia, unspecified schizophrenia, and other chronic pain. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/24/2025, indicated Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #7 had did not reject evaluation or care during the assessment timeframe. The MDS indicated Resident #7 required supervision or touching assistance from staff for completion of personal hygiene tasks and was dependent on staff for putting on and taking off footwear. Resident #7's Care Plan included a problem area initiated 01/19/2024 and revised 02/25/2025, that indicated Resident #7 was at risk for impaired physical mobility, injury from tremors, and involuntary muscle movements due to Parkinson's disease. Interventions directed staff to evaluate the resident's ability to accomplish ADLs and provide required assistance as needed (initiated 01/22/2022). Resident #7's Active Orders revealed an order for podiatry consultations and treatment to be provided as indicated, with an order date of 01/21/2022. Resident #7's Podiatric Evaluation & Treatment Form, dated 01/04/2025, revealed the podiatrist noted Resident #7's toenails to be painful, elongated, and mycotic (a fungal infection that caused the nail to be thick, fragile, and separate from the nail bed). The record revealed the dead tissue was removed from the resident's nails, the dystrophic nails (nail deformity such as thickening or unusual curves) were trimmed, and nail avulsion (removal of part or all of a nail from the nail bed) was completed. An interview was held with Resident #7 on 03/17/2025 at 1:36 PM. Resident #7 stated one of their biggest concerns was the irregularity of podiatry services. The resident stated their toenails needed to be clipped. The resident was unable to remember the last time podiatry had visited. An observation was made on 03/19/2025 at 10:14 AM, accompanied by Registered Nurse (RN) #1. The three middle toenails on Resident #7's left foot had curled under the end of the toe and were touching the bottom of the resident's toes. Resident #7 stated their feet hurt but was unable to specify the type of pain or the area of the feet that were hurting. Resident #7 stated that, about two weeks prior, someone had tried to trim the toenails but was only able to get a little off the nails. Resident #7's toenails were thick and white in color. RN #1 stated the podiatrist came to the facility approximately every three months, and if anyone needed podiatry services in between visits, staff notified the social worker. RN #1 confirmed that Resident #7's toenails had curved under the toes and touched the skin on the bottom of the toes. RN #1 stated that a few months prior, the resident's toenails had curved under, and a note had been placed in a communication book for the provider. RN#7 stated that when the podiatrist had trimmed the toenails, the podiatrist had done a good job. RN #1 opined that, if Resident #7's toenails were trimmed, it may partially relieve some of the resident's foot pain. Licensed Vocational Nurse (LVN) #2 was interviewed on 03/19/2025 at 10:53 AM. She stated she had last seen Resident #7's feet the week prior when she assisted the resident with donning socks. LVN #2 stated she had not noticed the condition of the resident's toenails. The LVN stated no other staff had reported that Resident #7's toenails were curved under the resident's toes, touching the bottom of the resident's toes. LVN #2 stated Resident #7 had no complaints about toe pain. Certified Nursing Assistant (CNA) #3 was interviewed on 03/19/2025 at 11:13 AM. CNA #3 stated she was assigned to provide care to Resident #7 that day. CNA #3 stated Resident #7 required assistance with ADLs and was totally dependent on staff for donning socks and shoes. CNA #3 stated she had seen the resident's feet earlier in the day and described Resident #7's feet as hard and crusty, and looking like the feet had fungus. CNA #3 stated Resident #7's toenails needed to be trimmed, but she was unable to trim the toenails because the nails were so thick. CNA #3 stated she had seen Resident #7's feet on 03/18/2025 also but had not reported the condition of the resident's toenails to anyone because she knew the resident was on the podiatry list. CNA #3 stated she was unsure how frequently the podiatry services were available in the facility. The Social Services Director (SSD) was interviewed on 03/19/2025 at 3:04 PM. The SSD stated she relied on floor staff, conversations with residents and family members, and progress notes to get information about any issues affecting residents. The SSD stated the podiatrist was in the facility twice year. She stated that if a resident required a podiatry visit in between the in-house podiatry visits, the resident received toenail care from the licensed nurse or was taken to a community podiatrist. The SSD stated no one had mentioned that Resident #7 needed podiatry services. When the SSD was given description of the resident's toenails curling under and touching the bottom side of the toe, she stated nursing staff should have reported that to her. The Director of Nursing (DON) was interviewed on 03/20/2025 at 11:21 AM. The DON stated if Resident #7's toenails were curving under and touching the bottom of the toes, she expected the staff bathing the resident to alert the nurse and plan for the resident to receive care. The DON stated that although Resident #7 had seen the podiatrist in 01/2025, if the resident's toenails curled under now and were possibly causing the resident discomfort, she expected the staff to notify the SSD to make arrangements for care to be provided. The Administrator was interviewed on 03/20/2025 at 11:34 AM. The Administrator stated if staff observed a resident's toenails curling under and touching the toes, he expected staff to notify the SSD so a podiatrist visit could be scheduled. The Administrator stated that he expected an appointment to be made for podiatry, even if a resident had seen the podiatrist in 01/2025.

Based on interview and record review, the facility failed to provide an environment free from accidents and hazards by not developing and implementing a plan of care to prevent wandering/Elopement (leaving a healthcare facility without permission or notice) for one of four sampled residents (Resident 4) when: 1. Resident 4 exited the facility unsupervised and was found on the sidewalk near the roadway outside the facility premises. The facility ' s failure to develop a plan of care to prevent leaving the facility unsupervised which resulted in Resident 4 to leave the facility and put him at risk for harm and injury. Findings: A record review of facility policy titled Resident Care - Wandering/Elopement, revised 06/25/20 indicated under policy compliance under prevention that all residents shall be assessed by the interdisciplinary team regarding the risk of wandering on admission, quarterly, and when behavior changes. If the resident is at risk of wandering from the facility an alert device shall be considered, if it is determined that an alert device is needed nursing personnel shall attach the device to the resident. If the resident is in imminent danger of leaving the staff shall provide one to one staffing if available. The care plan will be updated to include interventions to prevent wandering included but not limited to an alert bracelet, assignment to a room away from exits that are commonly utilized if a room is available at that time, sign on the residence room, and engagement and group activities. A record review of hospital Clinical Note dated 01/01/25 at 04:05 am, Registered Nursed document that Resident 4 was agitated, trying to crawl out of bed, yelling, and required a sitter at the bedside. A record review of an admission record, indicated that Resident 4 was admitted on [DATE] with diagnoses that included but not limited to a psychotic disorder (a mental disorder that causes abnormal thinking and perceptions) with delusions and adjustment order with anxiety. A record review of Elopement Evaluation dated 01/02/25 at 8:36pm, indicated Resident 4 to be non-ambulatory (unable to walk) and unable to perform independent wheelchair locomotion (to move from one place to another). Additionally, that Resident 4 had no history of wandering or displayed any behaviors that would indicate an attempt to leave, with an elopement risk score of 0 (no risk). A record review of Admission Observation dated 01/02/25 at 8:47pm indicated Resident 4 had a mood disorder, hallucinations, and used a cane as a mobility device. A record review of a Minimum Data Set (resident assessment) dated 01/09/25, Section GG Functional Abilities, indicated that Resident 4 was able, with supervision or touching assistance, to walk 10 feet A record review of Resident 4 Progress Notes dated 01/12/25 at 04:07am indicated that two Certified Nurse Assistants (CNA ' s) went to get the Resident 4 who had left the building and was opening the gate. The CNAs were trying to prevent the resident from entering the street/traffic, local law enforcement was called for help as the resident was fighting to get away, police officers arrived and assisted returning Resident 4 to the facility. A record review of Resident 4 Progress Notes dated 1/12/25 at 12 am indicated that Resident 4 was found in the parking lot and the and the family was notified. The family stated that he gets hallucinations and starts walking and takes off when he gets them. the family was informed that the plan was to put a wander guard device (a wearable device that triggers an alarm when approaching a restricted area or doorway) on Resident 4. Family stated, I thought they put one on his ankle earlier when he did this. A record review titled General Order dated 1/12/25 at 12:57 am, indicated Resident 4 was to have an Ankle Wander Guard related to elopement. A record review of Resident 4 ' s care plans dated 01/12/2025 indicated a new care plan was initiated post elopement for wandering/elopement risk related to strong desire to go home, Cognitive Loss, Parkinson ' s Disease due to history of attempts to leave facility unattended., Wandering into other residents ' rooms, and impaired safety awareness. A record review of admission 48-hour Baseline Person-Centered Care Planning dated1/02/25 at 8:40 pm, indicated that Resident 4 ' s family was present at the time of the care plan meeting. An interview with Registered Nurse (RN B) on 03/03/25 at 12:15 pm, RN B stated Resident 4 had requested to go home with family and was observed following them to the door when the family would leave. RN B explained she was aware that Resident 4 was an elopement risk 4 days after his admit, due to observing him hanging around the front door of the facility and overheard statements he made to his family about wanting to go home. RN B confirmed the behavior and statements made by Resident 4 would make him an elopement risk and should have been reassessed for it. During an interview with Director of Nursing (DON) on 03/03/25 at 1225, DON stated that Resident 4 had a recent room transfer which placed him in a room one door from the exit door. DON explained that on the evening of January 11th at about 6pm Resident 4 attempted to leave the facility by following family to the door after a visit. [NAME] stated at about 11pm Resident 4 again attempted to leave the facility, this time through the exit door near his room. DON agreed that he should have had a Wander Guard device on after the first attempt. DON confirmed no care conference was done during the admission and usually the goal was to have it done within the first 5 days of admission where families usually participate in plan of care. An interview with Licensed Nurse (LN C) on 03/03/25 at 3:50 pm, Resident 4 was confused and ran out of the building, the CNAs were able to stop him, but he was kicking and hitting them. LN C stated that behaviors such as a resident moving around the building or looking for a way out, would prompt a reassessment of the risk for elopement. An interview with Certified Nurse Assistant (CNA A) on 03/05/24 at 2:41 pm, Resident 4 ran from bed out of the facility. CNA A and another CNA were able to stop the resident at the sidewalk, outside of the gate to the facility. They feared the resident would be hit by a car and called law enforcement for assistance. An interview with a family member (FM) of Resident 4 on 03/06/25 at 1135 am, Resident 4 had tried to leave the building earlier in the evening, prior to the elopement. FM discussed that prior to this incident staff would keep an extra eye on him to keep him from leaving the facility. Fm stated that Resident 4 ' s past psychosis and elopement behavior were discussed during his admit, and that it is why he was there.

Based on observation, interview, and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when: 1. The facility did not have a qualified food and nutrition professional working full time in the kitchen for approximately six months prior to survey when the Food Service Manager was on leave of absence. 2. The Registered Dietitian (RD) did not conduct regular audits of the Food and Nutrition Services to ensure food safety and sanitation systems, practices and meal service requirements were in place and followed. 3. The facility's therapeutic menus and diet manual were not reviewed and signed off by the facility's Registered Dietitian and did not include all diets routinely ordered by providers at the facility. 4. There was not an adequate or effective system in place to ensure staff training and competency in skills and knowledge required for food safety and sanitation. These failures had to potential to result in non-compliance with physician ordered diets, inadequate provision of nutrients, promote foodborne illness, and to negatively affect overall health for residents living in the facility. Findings: During an interview with the Food Service Director (FSD) over all hospital affiliated food service entities on 4/17/23 at 9:45 am, he stated he was employed by the contracted food services company they had been responsible for the facility's food services for the past two years. Review of a document containing the food service contractor logo and titled Position Profile, Position Title: Registered Dietitian II, signed by the RD on 11/22/21 was provided by the Interim Food Service Manager (IFSM) and Clinical Nutrition Manager (CDM). It showed the RD was responsible for providing comprehensive nutrition assessments and care planning for patients and residents with special needs, upheld the company's business practices, mission and values, and contributed to account revenue and profit through implementation of services. Technical duties and responsibilities included individualized nutrition assessments and care planning for residents, directing dietary care of residents, collaborates and communicates with culinary and clinical departments on established processes, special diets and menu requests .Ensures compliance with all federal, state and local regulations as well as (food and nutrition services [FANS] contractor)/ client policies and procedures. The job description did not include the requirement for the facility RD's regular oversight of the Food and Nutrition Services if the Food Service Manager was not a full-time Registered Dietitian. Review of an untitled, undated document provided by the IFSM and CDM showed Job Title General Manager 3 - Food. Position summary showed Directs all contract management service operations at a single account/unit .Hires and trains personnel, provides team leadership, controls unit financials, directs daily food operations for quality and safety standards, supervises day to day activities .monitors operating standards .establishes a safe work environment. Qualifications included a bachelor's degree, management experience, with RD, CDM or DTR (Diet Technician Registered) required. 1. The facility did not have a qualified food and nutrition professional working full time in the kitchen for approximately six months prior to survey when the Food Service Manager was on leave of absence. During an interview with the Registered Dietitian (RD) and Interim Food Service Manager (IFSM) on 4/17/23 at 9:30 am, they stated all food service staff including the RD and IFSM were employees of the contracted food services company. The IFSM stated she was new to the job, had been there for about a month, but previously worked for the FANS contractor at the hospital in a different capacity. The RD stated she worked as the facility's RD for approximately 16 months. During an interview with the FSD on 04/17/23 at 10:30 am he stated the (FANS contractor) did have a general manager over the facility's food service, but he had been on leave of absence, just resigned, with last day 4/21/23. During an interview on 4/19/23 at 8:55 am, the CDM and IFSM stated the previous Food Service Manager had been on leave of absence and worked intermittently for 6 months prior to his April 2023 resignation, and they were unable to replace him sooner due to his protected status. They reported many documents including in-service training were missing from the FANS office after he left. Review of the State Operations Manual (SOM) S483.60(a) Staffing showed the facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Review of the SOM S483.60(a)(2) showed if a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. Review of the SOM S483.60(a)(1)-(2) showed Full-time meant working 35 or more hours a week. 2. The facility's Registered Dietitian did not provide adequate or effective oversight of the Food and Nutrition Services to ensure food safety and sanitation systems, practices and meal service requirements were in place and followed (Cross Reference F812, F805, F802). During multiple observations between 4/17/23 at 9:30 am and 4/19/23 at 5:00 pm, multiple staff did not adequately restrain their hair, and did not practice hand hygiene or glove use according to facility policy and professional standards of practice. In addition, various food preparation areas and equipment in the kitchen and in nursing food pantries were not sanitary. Staff did not practice or document ambient food cooling, did not follow food storage guidelines, did not check chlorine or quat sanitizer concentration properly, and did not clean fixed equipment according to professional standards of practice. The dish machine rinse and final rinse temperatures for did not display on the machine and DW 2 confirmed they had not been visible on the screen for quite a while. On 4/18/23 at 9:45 am a review of documents titled Dishwashing/Ware washing Machine Temperature Log, dated April 2023 for breakfast, lunch and dinner meal periods showed temperature requirements for high temperature machines, but did not show the required temperatures for the low temperature machine the facility used. The logs showed staff continued to log temperatures on the dish machine temperature log. There was no indication the RD or ITSM had reviewed the logs. During an interview with the IFSM, RD and CNM on 4/19/23 at 3:30 pm the IFSM stated she had never run the dish machine and was unable to answer questions about it. She confirmed to clean fixed equipment staff should wash with soapy water, rinse with clean water, then sanitize and air dry. She stated she did not know how often the meal carts were cleaned but they should be sanitized between meals. In further interview, the RD stated she did quarterly kitchen audits. The IFSM stated she and the RD had completed one kitchen audit together, then the FSD reviewed it, saw what needed to be done, and determined what the action plan should be implemented. The surveyor requested the kitchen audits performed by the RD during the past year. Kitchen audits completed by the RD were provided by the CDM and showed the RD performed audits semi-annually (twice) instead of quarterly (four times) in the past year as previously stated. They were dated 4/18/22 and 9/29/22. The kitchen audit dated 4/18/22 was titled Kitchen Observation and showed deficiencies with food labeling and dating, tray line temperature logs, dishwasher temperatures, testing quat sanitizer need correct strips, appropriate chemical test strips - see notes, if the facility had and followed a cleaning schedule - [NAME] working on. The nursing unit refrigerators were not observed. It showed food preparation equipment was clean and there was no evidence of pests. It also showed the facility menus met the needs of the residents with note to see separate audit. The words see notes was written next to 14 topics of concern, yet no notes were provided with the audit to provide further explanation. The kitchen audit conducted 9/29/22 used a different format, was titled (Facility) Kitchen Sanitation/Food Storage Audit and included the RD's name. It cited deficiencies for a dusty refrigerator, and lack of documented corrective action when refrigerator temps were outside the acceptable range. The RD documented that all other aspects of the food services were acceptable including all hair is completely covered with hair net, dish machine temps were correct, equipment and work areas were clean, handwashing and glove use were correct. 3. The facility's therapeutic menus and diet manual were not reviewed and signed off by the facility's Registered Dietitian and did not include all diets routinely ordered by providers at the facility (Cross Reference F803). Resident complaints and a review of lunch tray tickets dated 4/17/23 showed inconsistent practices in provision of fortified (high calorie, high protein) diets. Fortified diets are generally ordered for residents experiencing weight loss, or poor meal intakes, or with extra nutritional needs such as for wound healing. A review of the facility diet manual signed by the hospital CDM 1/25/22 (but not signed by the facility RD) showed it did not contain any guidance for fortified diets. The diet manual also showed unmodified consistent carbohydrate diets should receive 5 to 6 servings of carbohydrate each meal. The lunch meal on 4/17/23 contained approximately eight servings of carbohydrate (Cross Reference F803). During an interview on 4/19/23 at 3:30 pm regarding fortified diets, the RD agreed there was no tool or guide for cooks/staff to follow, to know if they were providing the correct food and portions for the fortified diet. She confirmed there were no guidelines for the fortified diet in the facility's diet manual. I am not making any adjustments for fortified diets, and I am not checking calories. When asked how they would know if a resident was getting the correct food and portions (for example with fortified diets) on their trays per doctor's orders, the CNM stated they would know by resident weight changes (Cross Reference F803). Resident complaints regarding too much curry on the menu prompted a review of vegetarian tray tickets for the five-week cycle showed vegetarian residents were served the same three curry recipes for 37% of their lunch and dinner meals. There was no vegetarian menu available for vegetarian residents to review if desired. 4. There was not an adequate or effective system in place to ensure staff training and competency in skills and knowledge required for food safety and sanitation (Cross Reference F802, F812, F805). During multiple observations, interviews and record reviews in the kitchen during the survey the kitchen areas and equipment were not sanitary, adequate hair restraint was not ensured, staff hand hygiene and glove use did not comply with professional standards of practice, risk of cross contamination was not minimized, food was not stored properly, staff did not know how to monitor the dish machine for proper function or how to test chlorine or quat sanitizer concentration, or clean fixed equipment correctly. They did not know what size texture modified foods should be, and they did not monitor food cooling for TCS foods (Cross Reference F802, F812, F805). . Review of training checklists showed some of these topics were listed in a broad sense such as HACCP System and Potentially Hazardous Foods in training, but it is unknown what details of those topics were taught, not taught, or if the staff was competent in those required skills. Other topics such as ambient food cooling was not covered in policy, training checklists, or staff practice.

Based on observation, interview, and record review the facility failed to ensure its staff were trained and competent to perform their duties according to professional standards of practice when: 1. There was no evidence training occurred for Food and Nutrition Services (FANS) staff with longevity at the facility, and there was no evidence of evaluation of competency for any FANS staff. 2. Staff did not perform hand hygiene or change gloves between tasks. 3. Staff did not adequately restrain hair or facial hair. 4. There was an overall lack of sanitation in the kitchen and nursing food pantries. 5. Equipment was not cleaned according to professional standards of practice. 6. Staff did not check temperatures or perform cooling logs for TCS (Time and temperature Control for Food Safety) foods prepared at ambient temperature. 7. Staff did not recognize when the dish washer did not function correctly and did not describe or perform the correct process for checking chlorine concentration. 8. Staff did not describe or perform the correct process for checking quat sanitizer or its use in cleaning fixed equipment. 9. Staff did not chop meat according to diet manual standards. 10. Food was not stored, labeled, and dated correctly. These failures had the potential to result in foodborne illness for all residents receiving meals from the facility, and the potential to cause residents requiring chopped food to choke, have decreased meal intakes, or inability to self-feed. Findings: During an interview with the Registered Dietitian (RD) and Interim Food Service Manager (IFSM) on [DATE] at 9:30 am, they stated all food service staff including the RD and IFSM were employees of the contracted food services company. During an interview with the Food Service Director (FSD) over all hospital affiliated food service entities on [DATE] at 9:45 am, he stated he was employed by the contracted food services company they had been responsible for the facility's food services for the past two years. Review of a facility document titled Policy: Competencies of Food and Nutrition Support Staff, revised [DATE] showed support staff would be trained using on-the-job training and monthly in-services provided by the Food Service Manager or the RD. A competency checklist will be reviewed for each support staff member (cooks, food service workers, utility workers, etc.) to ensure they are competent in all required areas for the preparation and service of palatable, attractive meals and maintenance of sanitary standards. Review of a facility document titled Policy: In-service Training, revised [DATE] showed The Food & Nutrition Services Department conducts competency (in-service) training on an ongoing basis for all full-time and part-time employees for all shifts .A record of each class will be kept on file for a minimum of 3 years. A Competency Training Manual shall be established with current data on the schedule/frequency of classes, topics and lesson plans, records of participation and evaluation. Review of an untitled Food and Nutrition Services (FANS) Staff Schedule dated [DATE] through [DATE] defined five positions in the kitchen: Manager, Lead Worker, Cooks, Diet Aids, Dishwashers. It identified 14 current staff, one staff as Manager, one staff as Lead Worker, five staff as Cooks, four as Diet Aids and three as Dishwashers. Seven documents provided by the IFSM titled Position Profile, [DATE] contained the food service contractor's logo and individual subtitles for positions Cook 1, Dietetic Clerk, Food Prep Helper, Trayline Attendant, Utility Worker, Healthcare Host/Hostess, and Cashier/Food Service Worker. Only one of seven position titles (Cook) aligned with the titles identified on the schedule or with how staff identified themselves when introducing themselves during survey. Only pages one and three were provided for 7 of 7 job descriptions, with the contents of page 2 unknown. Further review of the seven job descriptions showed they all required Complies with all (food service contractor) HACCP (Hazard Analysis Critical Control Points - Food safety practices) policies and procedures; clean and sanitize workstations and equipment following all (food service contractor), client and regulatory rules and procedures; attend allergy and foodborne illness in-service training. The Cook's Position Profile also showed Prepares food in accordance with current applicable federal, state and corporate standards, guidelines and regulations to ensure high-quality food service is provided .Prepares foods under direct supervision or instruction by operating a variety of equipment (in food preparation). 1. There was no evidence of training for Food and Nutrition Services (FANS) staff with longevity at the facility, and there was no evidence of evaluation of competency for any FANS staff. During an interview with the Food Service Director (FSD) over all hospital-affiliated food services on [DATE] at 8:55 PM he stated food safety, and health and safety were monthly in-service topics pre-determined by the food service contractor. New staff completed facility/Human Resources (HR) orientation requirements before starting to train in the kitchen. TOPS - Teach our People Safety was the food service contractor's in-service program. Orientation took about 4 hours. Staff sat down and received some verbal training and some video trainings. It included topics such as acknowledgement of the Employee Handbook, safety shoes requirement, uniforms. The HR portion was done in the first ,d+[DATE] minutes. Then staff started their kitchen training. They shadowed and trained with another staff for ,d+[DATE] weeks (depending on individual employee needs) and started participating in the work as they progressed. Then staff were put into their roles. The FSD stated managers knew staff competency by watching them. He further stated there were no staff competency forms or documentation of staff competency. On [DATE] at 9:14 am staff training and competency checklists were requested for seven FANS staff including four Cooks, one Diet Aide (DA), and two Dishwashers (DW). The Clinical Nutrition Manager (CNM) provided documents for four staff (Cook 2, Cook 4, DA 3, and DW 2), but stated they had no evidence of training or competency for the other three staff (Cook 1, Cook 3, DW 3) who had been at the facility for a long time. There were no documents provided that indicated any staff in the FANS department were evaluated for competency. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster - Include in every employee's file as of hire date showed places to insert the employee's name, hire date/position, and trainer(s), and an Employee Sign-off signature and date. All positions (Cook, Diet Aide, Dishwasher) had the same training checklists. The checklists showed handwashing, correct use of gloves, personal hygiene, HACCP system/potentially hazardous foods, critical control points, preventing cross contamination, thermometers use and calibration, food allergens, temperature logs, food temperatures, food cooling, hot and cold food holding must be covered during the first 10 days of starting a position. The showed handling service-ware and utensils, receiving and storing food, cleaning and sanitizing must be covered in training within 60 days of working in a food handling position. During an interview with the Clinical Nutrition Manager (CNM) and IFSM on [DATE] at 8:55 am they stated they had minimal in-service documentation available. They stated the previous Food Service Manager had been on leave of absence, was intermittently at work for six months prior to his resignation in [DATE], and they learned after he left that information was absent regarding in-services completed prior to 2023. 2. Staff did not perform hand hygiene or change gloves between tasks (Cross Reference F812). A review of the facility's policy titled Disposable Glove Use dated [DATE], the policy indicated, All personnel shall wash their hands each time before gloves are put on. Gloves shall be discarded after each use and if they are soiled, torn or contaminated. During multiple observations in the kitchen between [DATE] at 9:30 am and [DATE] at 5:00 pm, staff (Cook 2, Cook 3, DA 3, DA 4) were observed to touch multiple potentially contaminated surfaces (trash can, refrigerator handles, stove knobs, soiled dishes) with their gloves on, and return to food preparation activities without changing their gloves or washing their hands. During multiple observations in the kitchen between [DATE] at 9:30 am and [DATE] at 5:00 pm, multiple staff (Cook 2, Cook 4, DW 2, DA 3, DA 4) did not wash their hands before donning gloves, or between doffing soiled gloves and donning new gloves. During an observation in the kitchen on [DATE] at 11:44 am, five kitchen staff assembled resident's lunch trays on tray line. When a dietary aide rang a bell, five of five staff doffed (took off) their gloves, donned (put on) new gloves, and continued to prepare residents food trays. The did not wash their hands prior to donning new gloves. During an interview on [DATE] at 3:40 PM, with the Registered Dietitian (RD) and the Interim Food Service Manager (IFSM), the RD indicated that kitchen staff were to change their gloves every 30 minutes, and staff were supposed to wash their hands when they changed their gloves. During an interview on [DATE] at 2:05 PM, Cook 2 stated he did not always have time to wash his hands between glove changes. Review of a policy titled Food Safety revised [DATE] showed Employees must wash hands before beginning/returning to work or when necessary, during work .and maintain good hygienic practices. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster for Cook 2 ([DATE]), Cook 4 ([DATE]), DA 3 ([DATE]), and DW 2 ([DATE]) showed they were trained in handwashing procedures and correct use of gloves, but there was no evidence staff competency was evaluated, and staff practice did not follow food safety standards of practice. 3. Staff did not adequately restrain hair or facial hair (Cross Reference F812). Review of a policy titled Food Safety revised [DATE] showed Employees wear approved hair restraints .Men with beards and/or mustaches must wear appropriate beard restraints. A review of the facility's kitchen audit tool titled Fountains Kitchen Sanitation/Food Storage Audit dated ,d+[DATE] and completed by the RD indicated Hair is covered completely with hair net. During multiple observations in the kitchen between [DATE] at 9:30 am and [DATE] at 5:00 pm, Cook 2 and Cook 3 did not wear beard nets to cover their beards and mustaches, but intermittently wore surgical masks with their mustaches still exposed. Cook 4 wore a hair net but had hair hanging out and the hairnet did not cover the lower two inches of her hair in the back. During an interview on [DATE] at 3:30 pm with the IFSM, CNM and RD, the IFSM stated their hairnets policy stated there should be no loose hair, and hair, including hair buns should be fully covered. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster for Cook 2 ([DATE]), Cook 4 ([DATE]), DA 3 ([DATE]), and DW 2 ([DATE]) showed the topic personal hygiene and defined subtopics regarding jewelry, nail polish and fingernail hygiene, but did not list hair restraint requirements as part of training. 4. There was an overall lack of sanitation in the kitchen and nursing food pantries (Cross Reference F812). During multiple observations in the kitchen between [DATE] at 9:30 am and [DATE] at 5:00 pm the kitchen and its equipment were not sanitary. Multiple pieces of equipment had an accumulation of grime, food debris or food residue including the blender and food processor bases, knife rack, knives, food scale and serving utensils. The range and ovens had black grime and food debris on their surfaces and knobs. There was food splatter on the walls. The cook's white cutting boards on the steam table and in the corner near the oven had deep black knife cuts that could be a potential haven for microbial growth. The plate warmer was soiled with brown grime and food crumbs. The Coffee Room equipment storage and supply shelves dusty, the floor had black grime and food debris under the cabinet, and an ant crawling on the floor. The hood above the dish machine had a buildup of black grime and dust. There was further potential for cross contamination in relation to kitchen sanitation practices when cooks placed rinsed wet blender and food processor containers back on their bases, ready for use when they had not been washed and sanitized after use, and when cooks stacked soiled dishes in the food preparation sinks and counters where food was concurrently handled. During observations of the three, nursing unit resident food pantries on [DATE] at 4:20 pm, they contained soiled dishes in the sink, soiled refrigerators. Food and food supply cabinets were soiled with food debris, sticky substances, and dead ants. In concurrent interviews the RD confirmed these spaces were dirty. Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for Cook 2 ([DATE]), Cook 4 ([DATE]), DA 3 ([DATE]), and DW 2 ([DATE]) showed Within 60 Days they were trained on Cleaning and Sanitizing, and Cleaning and Sanitizing Food Contact Surfaces, Optional: Inspector HACCP video You Call That Clean? There was no evidence provided regarding staff competency in cleaning, and the kitchen and food pantries were found to be unsanitary. 5. Equipment was not cleaned according to professional standards of practice (Cross Reference F812). Review of the 2022 FDA Food Code ,d+[DATE].15 and ,d+[DATE].16 showed a distinct 3-step process to clean fixed equipment including washing with detergent to remove all food residue and other contaminants, rinsing with clean water to remove abrasives and cleaning chemicals, and sanitizing to ensure microorganisms are reduced to a safe level. During an observation and concurrent interview with DA 3 on [DATE] at 10:00 am she used a rag to wipe down resident meal carts with sanitizer solution. In a concurrent interview she stated the process to clean the carts was to wipe them down with sanitizer, especially the top and bottom rungs the trays sit on because sometimes things spill on them. She stated I wish we could deep clean them better because some of the crevices and corners looked dirty. During an interview with Cook 4 on [DATE] at 10:08 am she stated she cleaned her area at the end of her shift including tray line. She stated she wiped off the food, wiped everything down with a sanitizer cloth, then dried off all the surfaces including inside of the wells with a clean new disposable cloth to ensure everything was dry and ready for the next shift. During an interview on [DATE] 3:30 PM, the IFSM stated to clean fixed equipment, staff should wash with soapy water, rinse with clean water, then sanitize and air dry. She did not know how often the meal carts were cleaned but they should be sanitized between meals. A review of AM Dishwasher Cleaning Logs dated [DATE] - [DATE] included assignments to sweep and mop dry storage, carts area and coffee room daily; clean and sanitize meal carts after each meal; clean coffee room shelves on Monday, and wash hood in dish room on Friday. A review of their Kitchen Audit tool titled Kitchen sanitation/Food storage Audit dated ,d+[DATE], indicated the cook's work area, worktables and prep areas were to be clean, cutting boards clean with no deep knife marks, food processors clean, range, oven, grill clean and grease free, cutlery/rack clean and dry vegetable prep sink clean and work and prep tables clean and sanitized properly. Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for Cook 2 ([DATE]), Cook 4 ([DATE]), DA 3 ([DATE]), and DW 2 ([DATE]) showed Within 60 Days they were trained on Cleaning and Sanitizing, and Cleaning and Sanitizing Food Contact Surfaces, Optional: Inspector HACCP video You Call That Clean? There was no evidence provided regarding staff competency in cleaning, and the kitchen and food pantries were found to be unsanitary. 6. Staff did not check temperatures or perform cooling logs for TCS (Time and temperature Control for Food Safety) foods prepared at ambient temperature (Cross Reference F812). The 2022 FDA Food Code ,d+[DATE].15(B) showed Time/temperature control for safety food shall be cooled within 4 hours to 41 F (degrees Fahrenheit) or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Further review of the 2022 FDA Food Code Annex 3, ,d+[DATE].15 showed Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for food safety foods has been consistently identified as one of the leading contributing factors to foodborne illness. During an interview with Diet Aide 1 (DA 1) on [DATE] at 10:35 am she stated she worked at the facility for [AGE] years. In an additional interview with Diet Aide 1 (DA 1) on [DATE] at 9:45 am she stated she prepared sandwiches for residents, including egg salad, tuna salad, or chicken salad. She explained she made tuna salad using tuna from the dry storage room, added mayonnaise and pickle relish from the refrigerator. She made egg salad using purchased pre-cooked hard-boiled eggs, pickle relish, mustard, mayonnaise, and pepper. DA 1 added she preferred to put the ingredients together ahead of time and put it in the refrigerator so the flavors could meld. She stated she did not take the temperature when she made the egg/tuna/chicken salad but took the temperature before she made the sandwiches to make sure it was cold for the residents. DA 1 stated it should be less than 40 F, and she did not keep a temperature log. Review of a policy titled Food Safety revised [DATE] showed All TCS foods must meet the following temperature requirements during storage, preparation, display, service and transportation .HACCP temperature logs for potentially hazardous foods and for refrigerators and freezers are completed and kept on file for 12 months. The policy did not direct staff to monitor the temperature of TCS foods such as egg salad, tuna salad and chicken salad from ingredients at ambient temperature. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster for DA 3 dated [DATE] showed she had been trained by DA 1. It included the topic cooling foods, but it did not identify monitoring food cooling for TCS foods made with ambient temperature ingredients. This presented a compounded problem when the facility's food cooling policy did not describe ambient food cooling, the training checklist did not include ambient food cooling, and the trainer, DA 1, did not monitor ambient food temperature cooling with foods such as tuna so was unlikely to teach that to new staff. 7. Staff did not recognize when the dishwasher was not functioning correctly, did not describe or perform the correct process for checking chlorine concentration (Cross Reference F812). The function of the dishwashing machine is vital in protection of residents from the spread of disease. If dishes aren't properly cleaned and sanitized microbes can spread from one person to the next through contaminated dishes. During an observation in the dish room on [DATE] at 10:20 am, the manufacturer's plate on the dish machine showed when used as a (low temperature) chemical sanitizing machine the wash temperature should be minimum 130 F (degrees Fahrenheit), the rinse temperature should be minimum 120 F, and the final rinse should be minimum 120 F. In a concurrent interview DW 2 stated the machine used a chemical to sterilize the dishes. DW 2 stated the wash temperature should be 140 degrees or greater, however the Final Rinse temperature hasn't shown anything except XXX for a long time. In further observation, the Opti-Rinse screen on the dishwasher showed the wash temp was 140 degrees, the middle of the screen was blank, and the right side of the screen showed Final Rinse XXX F. The screen did not show the first rinse temp at all. In continued interview, DW 2 was asked how he knew the chlorine was working to sanitize the dishes. He explained and then demonstrated three times how they ran a chlorine sanitizer strip through the dish machine on a rack with result less than 10 ppm sanitizer when it should be 100 ppm. The FSD was asked to assist with the process. He confirmed the final rinse cycle did not register a temperature and that was a problem. He confirmed that one of the containers with test strips was expired. The FSD then tested the chemical concentration by putting a dish thought the dish machine then immediately touching the dish with the test strip when it came out. The strip color registered at 100 ppm. On [DATE] at 9:45 am a review of documents titled Dishwashing/Ware washing Machine Temperature Log, dated [DATE] for breakfast, lunch and dinner meal periods showed temperature requirements for high temperature machines, but did not show the required temperatures for the low temperature machine the facility used. The form defined desirable chemical sanitizer concentration as ,d+[DATE] ppm. Multiple staff documented wash, rinse, and final rinse dish machine temperatures on the logs despite the malfunctions identified above, as reported by staff, and confirmed by the FSD. Multiple staff documented sanitizer concentration values on the logs ranging 100 ppm to 140 ppm. There was no evidence the logs were being monitored by the IFSM or RD. Review of the training checklists titled New Hire - Two Step Food Safety Training Program Training Roster for DW 2 dated [DATE] showed training within the Completed within 60 days section, for the topic Cleaning and Sanitizing, washing pots and pans, and food contact surfaces. It did not indicate that training and competency on the dish machine use and care, or testing chlorine concentration had occurred. 8. Staff did not describe or perform the correct process for checking the concentration of quat sanitizer (Cross Reference F812). Review of a policy titled Food Safety revised [DATE] showed Clearly labeled sanitizer of the proper concentration must be available and used to sanitize all food-contact surfaces of stationary equipment, i.e., work counter/tables. Sanitizer test strips must be used to ensure proper concentration. During an observation in the kitchen near the three-compartment sink on [DATE] at 10:00 AM, a sign posted on the wall from the facility's chemical vendor showed (quaternary ammonia, Quat or QAC) sanitizer was an agent that killed bacteria, viruses, mold and fungi. DA 3 used a red bucket of solution and a rag to clean resident meal carts. In a concurrent interview DA 3 stated the red bucket contained sanitizer and demonstrated how test the sanitizer concentration using test strips. There was confusion among DA 3, Cook 1 and DW 2 regarding which of two bottles of test strips should be used and what the correct concentration should be. DW 2 and DA 3 thought 100 ppm was the correct concentration. A concurrent review of the test strip instructions indicated the proper range was ,d+[DATE] ppm. DA 3 tested a new bucket of sanitizer at 300 ppm and confirmed the correct ppm was ,d+[DATE] ppm, not 100 ppm as she previously thought. During an interview on [DATE] at 10:15 AM, the FSD explained that the facility had switched to Diversey from Ecolab in February 2023. He continued to explain the Ecolab strips had been left over from the switch. The FSD confirmed that the quat sanitizer range should be ,d+[DATE] ppm. He stated, But they are both quat, so you would think you should be able to use either one. The two test strip packages were re-examined, and the FSD confirmed the Ecolab package had three color match choices, while the Diversey package had six. During an observation of the three-compartment sink and concurrent interview with DW 3 on [DATE] at 2:45 pm he explained how to test the quat sanitizer concentration in sink #3 and stated the goal was ,d+[DATE] ppm. He did the testing process. Test strip showed ,d+[DATE] ppm. He stated, So it's a little high? The test strip instructions indicated the proper range was ,d+[DATE] ppm. During an interview on [DATE] at 3:30 PM IFSM confirmed that the Quat test strips should be dipped for 10 seconds, and concentration color should be ,d+[DATE] ppm in sanitizing buckets and the final rinse sink. Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for DA 3, dated [DATE] included topics Cleaning and Sanitizing, Washing Pots and Pans, and Food Contact Surfaces, Optional: Inspector HACCP video You Call That Clean? It did not show a topic for training or competency regarding checking sanitizer concentration and did not show the three-step process (wash, rinse, sanitize) that should be used for cleaning pots and pans and food contact surfaces. 9. Staff did not chop meat according to diet manual standards and were unclear regarding the correct size modified textures should be (Cross Reference F805). During an observation on [DATE] at 11:33 am, Resident 38's lunch tray arrived containing egg whole noodles, whole Swedish meatballs, and a half garlic bread stick. Her tray ticket indicated she was on a renal diet with regular texture, thin liquids, high protein, and chopped meats. Resident 38 required help with eating, and a staff member was in to assist. During an observation and concurrent interviews with Cook 2 and Cook 4 on [DATE] at 9:55 am, they modified textures of food for lunch using blenders and food processors. Cook 2 prepared mechanical soft textures. He stated he pulsed it until it was the right size. When asked what that size should be he stated he guessed that would be about ,d+[DATE] inch, and he pulled out any chunks that were too large. Cook 4 stated I was told they should be small enough to fall off the fork, but big enough to stay on the fork. A review of the policy titled Texture Modified Diets revised [DATE] showed Whole meats for mechanical soft diets will be chopped and served with gravy or sauce to promote ease of chewing/swallowing. Follow the (Food Service Contractor) Diet Manual for Health Care Communities instructions for mechanical soft diet. Review of the diet manual showed it contained the IDDSI 6 guidelines. During an interview on [DATE] at 3:30 pm, the Interim Food Service Manager (IFSM) and the Clinical Nutrition Manager (CNM) stated chopped food should follow IDDSI level 6 guidelines where small/bite size pieces would measure approximately 1.5 cm (about ,d+[DATE] inch). The surveyor shared a photo of Resident 38's lunch meal from [DATE]. The RD and IFSM confirmed Resident 38's diet order was chopped meats and the Swedish meatballs served to her were too large and were not bite size. They confirmed the meatballs should have been chopped up and they were not. Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for Cook 2 ([DATE]) and Cook 4 ([DATE]) provided no evidence that staff training or competency occurred regarding the texture modification of food in regard to resident safety in chewing, swallowing and self-feeding. 10. Food was not stored, labeled, and dated correctly (Cross Reference F812). Review of a policy titled Food Safety revised [DATE] showed All foods prepared in operation must be covered and labeled as to the contents and date of preparation prior to storage in refrigerators and freezers. Labels for TCS foods must also include time of storage. A use-by date should be specified. Review of a policy titled Labeling & Dating dated [DATE], showed All foods are labeled, dated, and securely covered, and use-by dates are monitored and followed. During observations of the walk-in refrigerator on [DATE] at 9:45 AM, bags of pre-cut butternut squash had a received-on date [DATE] and were mushy with a milky liquid around them. One bag of pre-cut onion/carrot/celery mix had translucent slimy onions. Portioned salads, with a prepared date of ,d+[DATE], use by date of ,d+[DATE], appeared like the lettuce had been frozen. Cook 1 stated the refrigerator got too cold for the salads and confirmed the diced squash and onion/carrot/celery were not in good shape and should be tossed. During an observation of the walk-in refrigerator and interview with the FSD on [DATE] at 9:48 the FSD confirmed the labeling/dating on the Lactaid milk in the walk-in refrigerator was incorrect. During an observation in the cold food preparation room on [DATE] 10:35 AM, the refrigerator contained two frozen heads of iceberg lettuce. In a concurrent interview the FSD stated we will not be using this. In addition, a large plastic bin that contained a substance resembling rice had no label or date. The FSD stated it was brown rice and confirmed there was no date or label. During an interview on [DATE] at 8:55 AM, the FSD explained that short-dated or expired pre-cut produce should be caught and sent back at delivery. If product was expired, for example the squash and Mirepoix (carrot/celery/onion mix) it should have been discarded. During an observation in the walk-in refrigerator on [DATE] at 9:10 AM a plastic bag of diced potatoes was not closed and had no opened-on date. The FSD stated whenever staff opened a bag of produce, they were supposed to remove it from the bag and put it in a plastic storage container. The FSD confirmed the bag of diced potatoes was open, should not be like that, and should have been put in a Lexon (plastic container) for storage. Review of in-service documents titled Food Labeling and Dating, dated [DATE] showed Cook 1, Cook 1, Cook 2, Cook 4, DA 1, DA 3, DW 2, DW 3, and the RD attended. The lesson stated Labeling and dating items is an important step in preventing foodborne illness, and food waste. Proper labeling and dating will ensure spoiled items are discarded, not consumed, and can prevent errors with recipe ingredients. It did not show what information should be on the label or what the dating parameters should be. Staff performed a five-question quiz highlighting everyone was responsible to perform labeling and dating and that it was an important component in preventing foodborne illness. Review of a food service contractor document titled New Hire - Two Step Food Safety Training Program Training Roster for Cook 2 ([DATE]), Cook 4 ([DATE]), DA 3 ([DATE]), and DW 2 ([DATE]) showed Within 60 Days they were trained on receiving and storing food and chemicals, receiving temperatures, perishables storage, and dry storage, yet food was not stored properly in the facility.

Based on observation, interview, and record review, the facility failed to ensure professional food safety and sanitation practices were in place when: 1. Eleven of 11 kitchen staff did not perform hand hygiene and glove use according to professional standards of practice which increased the likelihood of cross contamination. 2. Two of three hand washing areas used by kitchen staff had the potential to contaminate hands during the hand washing procedure when one sink area had drying towels that were contaminated due to dispensing onto the soiled sink and the second sink areas faucet dispensed water close to the sides of the sink which caused hands to touch the sides of the sink during the hand washing process. 3. Three of five kitchen staff did not have their hair, beards and mustaches completely covered while preparing and serving food. 4. Two of three refrigerators had frozen lettuce, undated open milk, slimy fruit and vegetables, and an undated open bag of diced potatoes 5. The kitchen, dish room, coffee room, and nursing station nourishment rooms had multiple unclean areas containing dust, dirty walls, black grime, crumbs, dried food on utensils, chipped and peeling paint, black spots, and a filter thick with dust in the dishwasher hood. 6. Sanitizing buckets used to clean and sanitize tray carts were being used at the wrong concentration and two of three staff were unaware how to test for the proper concentration of the sanitizer of the dish washing machine and cleaning buckets. 7. Staff did not check temperatures or perform cooling logs for TCS (Time and temperature Control for Food Safety) foods prepared at ambient (room) temperature. These practices had the potential to result in foodborne illness for residents consuming food in the facility and could lead to negative clinical outcomes. Findings: 1. During a review of the facility's policy titled Disposable Glove Use dated [DATE], the policy indicated, All personnel shall wash their hands each time before gloves are put on. Gloves shall be discarded after each use and if they are soiled, torn or contaminated. During an observation on [DATE] at 11:30 am, in the kitchen, Cook 3 was observed cooking on the stove with gloves on. Cook 3 left the pot he was stirring and walked over to the garbage can, which had a push open lid, pushed the lid open with his gloved hand, and threw something away. Cook 3 did not change his gloves or wash his hands before resuming cooking at the stove with those same now soiled gloves. During an observation on [DATE] at 11:44 am, the tray line (assembly process for resident meal trays) was observed. Five kitchen staff were preparing resident's trays for their lunch meal. A dietary aide rang a bell, and five of five staff doffed (took off) their gloves, did not do hand hygiene, donned (put on) new gloves, and continued to prepare residents food trays. During an observation in the kitchen on [DATE] at 9:55 am, Cook 2 wore gloves while using the food processor. Cook 2 put the dirty dish into the sink, then used a sanitizer rag to wipe down the food processor base and the counter. Cook 2 doffed his gloves, pushed them against the contaminated push lid into the garbage can, then donned new gloves and went back to preparing food. No hand hygiene was done between glove use. During an observation on [DATE] at 11:19 am, Cook 2 came into the kitchen to help with the tray line process, and without performing hand hygiene he donned gloves and assisted in preparation of resident's trays for lunch. During an observation on [DATE] at 11:35 am, Cook 2 was working on the tray line. He discarded one glove, and without washing hands he donned a new glove. Cook 2 proceeded to prepare residents food trays for lunch with one old and one new glove. Cook 2 had to push the soiled trash can lid open to throw the one glove away. During an observation on [DATE] at 11:38 am, Cook 4 was working on the tray line and stated, I just burned my finger. Cook 4 then doffed her gloves, blew on her finger, and without performing hand hygiene, she donned new gloves and went back to preparing residents food trays. During an observation on [DATE] 11:47 am, dishwasher (DW) 2 was placing residents drinks on their lunch tray. DW 2 dropped one tray ticket (this displayed the resident's diet and tray contents) on the floor. He picked it up, changed gloves, did not wash hands, placed contaminated tray ticket on the tray. During an observation of tray line on [DATE] at 11:54 am, dietary aide (DA) 3 doffed her gloves, crumbled them in one hand, obtained a new set of gloves and crumbled them up in the other hand. DA 3 walked over to garbage, threw away old gloves and without performing hand hygiene donned new gloves and went back to work on the tray line. During an observation on [DATE] at 11:58 am, DA 4 was observed working on the tray line. She touched the cold food refrigerator handle with gloves on, and without changing gloves or washing hands DA 4 continued working on the tray line touching trays and other items on the resident's food tray. During an interview on [DATE] at 3:40 pm, with the Registered Dietitian (RD) and the Interim Food Service Manager (IFSM), the RD indicated that kitchen staff were to supposed to change gloves every 30 minutes. The RD stated staff were supposed to wash their hands when they changed their gloves. During an interview on [DATE] at 2:05 pm, with Cook 2, he confirmed he did not always have time to wash his hands between glove changes. 2. During multiple observations between [DATE] thru [DATE], the kitchen handwashing sink directly under the motion sensor towel dispenser was observed. On [DATE] at 9:40 am, a paper towel had been dispensed and hung down more than 12 inches into the sink, and about an inch from the faucet. On [DATE] at 9:30 am, and 9:40 am, the towels were observed dispensed and touching the handwashing sink faucet. On [DATE] at 3:00 pm, the kitchen handwashing sink was observed to have a towel hanging into the sink and touching the faucet. In a concurrent interview, DA 1 confirmed that the paper towels were contaminated due to them touching the dirty sink. She indicated that the towel dispenser should be moved. During an observation on [DATE] at 10:35 am, in the cold food preparation room (separate from rest of kitchen) a hand washing sink was observed. The faucet water stream was about 1 inch from the back of the sink and the surveyor was unable to wash her hands without touching the back of the sink. In a concurrent interview, the FSM confirmed that it was hard to wash your hands in that sink. 3. A review of the facility Audit tool titled Fountains Kitchen Sanitation/Food Storage Audit dated ,d+[DATE], the tool indicated Hair is covered completely with hair NET. During multiple observations on [DATE] between 10:00 am, and 3:15 pm, in the kitchen, the wearing of hair coverings was observed. At 10:00 am, Cook 2 wore a hat but no hair net or beard net. His hair was exposed below his hat and his beard and mustache were exposed. At 11:22 am, Cook 2 was observed with a yellow surgical mask over his chin but his mustache was exposed. At 11:43 am, Cook 3 was observed cooking soup, he had a yellow surgical mask on, but it was not covering his mustache. He had a hat on but no hair net. His hair was exposed below his hat line. At 3:15 pm, Cook 3 was observed in the cold food area and the kitchen area with his beard and mustache exposed. During multiple observations in the kitchen on [DATE] between 9:30 am and 3:00 pm, wearing of hair coverings was observed. At 9:30 AM, Cook 2 had no beard net on to cover his beard or mustache. At 9:50 am, Cook 4, was observed to have a hair net on but multiple hairs were not contained in the net. Her hair was straggling out the back and sides and the net was two inches higher than her hair line on the back of her head. At 11:00 am, Cook 3 had a surgical mask on that was not covering his mustache. During an observation of lunch tray line at 11:54 AM, Cook 4 had hair hanging out below his hair net, and Cook 2 wore a surgical mask that did not cover his mustache. During an interview on [DATE] at 3:30 pm, the IFSM indicated that the hair net policy states there should be no loose hair and hair should be fully covered. She was unaware that hair nets should be worn with hats and that all facial hair must be covered. 4. A review of a policy titled Labeling & Dating dated [DATE], indicated All foods are labeled, dated, and securely covered, and use-by dates are monitored and followed. During an observation of the walk-in refrigerator on [DATE] at 9:45 am, two of three plastic bags of pre-cut butternut squash showed received-on date [DATE] and were mushy with a milky liquid around them. One bag of pre-cut onion/carrot/celery mix had translucent slimy onions. Portioned salads, with a prepared date of ,d+[DATE], use by date of ,d+[DATE], appeared like the lettuce had been frozen. Cook 1 indicated the refrigerator got too cold for the salads and confirmed the diced squash and onion/carrot/celery were not in good shape and should be tossed. During a concurrent observation and interview on [DATE] at 9:48 am, with the Food Service Director over all facilities (FSD), an open Lactaid Milk carton was observed. A yellow sticker on the milk cap which showed a received-on date of [DATE]. A facility label on the carton read Prepped or received dated [DATE], Use by [DATE]. The Manufacturer's use-by date was [DATE]. The Manufacturer's label showed: This milk is ultra-pasteurized to last longer unopened. Once opened, consume within 14 days. There was no opened-on date on the milk container. The FDS confirmed that the labeling/dating on the Lactaid milk in the walk-in refrigerator wasn't right. During a concurrent observation and interview on [DATE] 10:35 am, in the cold food preparation room (where salads and sandwiches were made and stored), the sandwich refrigerator contained two frozen heads of iceberg lettuce. The FSD stated we will not be using this. There was a large plastic container filled with a rice looking substance that had no label or date on it. The FSD confirmed it was brown rice and that there was no date or label. During an interview on [DATE] at 8:55 am, the FSD explained that short-dated or expired pre-cut produce should be caught and sent back at delivery. If product was expired, for example the squash and Mirepoix (carrot/celery/onion mix) it should have been discarded. During a concurrent interview and observation on [DATE] at 9:10 am, in the walk-in refrigerator, a plastic bag of diced potatoes was observed lying open, not sealed and no opened-on date. The FSD indicated that whenever staff open a bag of produce, they are supposed to remove it from the bag and put it in a Lexon (plastic storage container). FSD confirmed that the open bag of diced potatoes should not be like that, and it should have been put in a Lexon for storage. 5. A review of their Kitchen Audit tool titled Kitchen sanitation/Food storage Audit dated ,d+[DATE], indicated the cook's work area, worktables and prep areas were to be clean, cutting boards clean with no deep knife marks, food processors clean, range, oven, grill clean and grease free, cutlery/rack clean and dry vegetable prep sink clean and work and prep tables clean and sanitized properly. During a concurrent observation and interview on [DATE] at 10:00 am, with Cook 1, the kitchen was observed. A large blender, a food processor, and small blenders, were noted to have buildup of grime, were wet inside, with their lids on, and were in place for use. Cook 1 indicated they were all used that morning and just rinsed out until they could be washed in the dish washing area. The knife rack that held 5 knives had dust and debris on it. One of five knives and one of five ready-to-use sampled spoodles (a type of serving spoon) were observed with dried food residue on them. The knife back splash, wall behind the mixing table, the range oven and behind the range oven had buildup of grime, food, debris, dust, crumbs, and food splatter. Two clean saute pans were inside the oven which had a heavy buildup of black, burned residue and unknown white debris. Cook 1 indicated the clean pans were being stored in there so they did not get scratched. She confirmed that this area was not a clean storage area. During an observation on [DATE] at 10:15 am, a room identified as the Coffee Room by staff contained a microwave oven, hand sink, and a lemonade/iced tea dispensing machine. Shelves storing beverage pitchers and other supplies were dusty. The floor had black grime on it, crumbs under the counter and an ant crawling on the floor. During a concurrent observation and interview on [DATE] at 10:20 am, two of two glove boxes in the kitchen, were ripped with gloves hanging out of them touching the outside of the boxes which had red, black, and brown spots resembling food splashes. DTR confirmed the boxes were soiled and the gloves were contaminated by the soiled boxes. DA 4 indicated she had used these gloves to perform kitchen duties During an observation on [DATE] at 10:20 am, in the dish room and walkways near the dish room, there were uncleanable surface areas of peeling and chipped paint, and damaged drywall. The hood/vent above the dish machine was severely soiled with dark brown/black substance and the filter was thick with dust. During a concurrent observation and interview on [DATE] at 10:30 am, in the dry food storage room, walkway, and walk-in freezer. The dry food storage room had two bulging ceiling tiles located over stored food with brown stains on them. The FSD confirmed the facility had a condensation problem about 3 or 4 months ago and he believed they had worked on that issue. The freezer was cramped with green and yellow substances and food crumbs on the floor. There was ice condensation on the ceiling and frozen drips hanging down from the fan. The FSD confirmed the walk-in freezer was too small and that the ceiling condensation was from the freezer door being open when deliveries were being put away. During a concurrent observation and interview on [DATE] at 11:22 am, the cook's work area was observed: a. The tray line cutting board was severely scored with black knife marks. b. The lowerator (plate warmer) was soiled with brown grime and food crumbs and the suction cup used to handle the plates was sitting on top of the grime and food crumbs while serving up the plates. c. A food preparation sink (A two-compartment sink with an attached disposal sink) had a middle sink with food emersed in a container full of water with cool water running over it. The food was being defrosted for later use. In the attached sink to the left there was multiple soiled mixing utensils, plates, two bowls, and a strainer that were soiled with food debris. The attached area to the right had a disposal sink with water puddles and water leaking down into the middle sink. Cook 2 indicated the middle sink was used for food prep like draining pasta or vegetables, washing produce in a colander, and thawing meat. The right area (the disposal sink) was used to spray/rinse out blender containers, and the left sink they used to stack dirty dishes in. He confirmed that the clean sink was in the middle of the two dirty sinks. Cook 2 indicated that when they have time, they take their dirty dishes to the dish room and wash them, but he put them in there while he was preparing food. Cook 2 indicated the sinks got cleaned at the end of the day. During a concurrent observation and interview on [DATE] between 4:20 pm and 4:32 pm, with the RD, the nursing station nourishment rooms (where they stored the residents' nourishments) were observed: a. Nursing station 1 nourishment room had a coffee cup in the sink with brown stains around and in the cup. The RD indicated this was a staff members used cup. Three out of three drawers had food debris, one with an unknown sticky brown substance, all three with damage/uncleanable surfaces. The RD confirmed this room was dirty. b. Nursing station 2 nourishment room counter had two brown ring stain. The second drawer was soiled with food debris and stored unprotected plastic spoons used for the residents. The refrigerator door was dirty and had a hair in it. A cleaning log was hanging on the wall that indicated the room was last clean on the 13th (5 days ago). c. Nursing station 3 nourishment room had an open Styrofoam cup of water on top of regular size white refrigerator. Drawer containing paper cups had 2 dead ants. Three other drawers had multiple dead ants. There was damaged uncleanable surfaces. The RD confirmed that the cabinet and drawers were not clean and that they had had an ant problem During an interview on [DATE] 3:30 pm, the IFSM stated to clean fixed equipment, staff should wash with soapy water, rinse with clean water, then sanitize and air dry. She did not know how often the meal carts were cleaned but they should be sanitized between meals. 6. During observation and interview on [DATE] at 10:00 am, DA 3 was observed sanitizing the meal carts. DA 3 was using a red bucket and wash rag to sanitize the carts. She indicated the red bucket had sanitizer in it. A sign on the wall next to the sanitizer containers read Diversey (a quaternary, [Quat or QAC], sanitizer, an agent that kills bacteria, virus, mold, and fungi). The sanitizer containers read Diversey. DA 3 proceeded to demonstrate how to assure that the right concentration of sanitizer was in her bucket. DA 3 reached for test strips that were stored over the three-compartment sink. The container read Ecolab (a brand of quaternary sanitizer) QAC test papers The instructions read Dip about one inch of a test paper into the solution about to be tested and hold there for 90 seconds. Then compare the test paper color to the color standards shown. The container showed a 3 color comparisons range (100 ppm [parts per million], 200 ppm, 400 ppm). While reading this container, Cook 1 walked by and stated those were the wrong test strips and then handed DA 3 a different container of test strips that were titled Diversey. Those instructions were to Immerse for 10 seconds. Compare when wet. Parts Per Million. Proper range was ,d+[DATE] ppm The Diversey test papers showed 6 color comparisons ranging zero to 500 ppm. Cook 1 stated the Ecolab QAC papers on the shelf were the same thing as the Diversey test papers, but she had never used them before, and called DW 2 over. DW 2 indicated that he thought 100 ppm was the correct concentration for the quat sanitizer. DA 3 then put a piece of the test strip into the sanitizer bucket for ,d+[DATE] seconds. She matched the color of the test strip to the Diversey color scale. The test strip was orangish which matched the 100-ppm color scale. According to the instructions the proper range should be ,d+[DATE] ppm. DW 3 confirmed that the correct ppm was ,d+[DATE] and not 100 as she thought, she confirmed that her sanitizing bucket was not within the right range to properly sanitize. She dumped the bucket and made a fresh bucket of sanitizer which tested at 300 ppm, the right range. During an interview on [DATE] at 10:15 am, the FSD explained that the facility had switched to Diversey from Ecolab in February 2023. He continued to explain the Ecolab strips had been left over from the switch. The FSD confirmed that the quat sanitizer range should be ,d+[DATE] ppm. He stated, But they are both quat, so you would think you should be able to use either one. The two test strip packages were re-examined, and the FSD confirmed the Ecolab package had three color match choices, while the Diversey package had six. During a concurrent observation and interview on [DATE] at 10:20 am, with DW 2, the dish washing machine was observed. DW 2 indicated it was a low temp rinse cycle and it used a chemical to sterilize the dishes and the dispenser will beep if the chemicals were empty or weren't going through. He stated the chlorine dispenser did not beep if the chlorine was empty. The wash temperature should be 140 degrees or greater. DW 2 stated the Final Rinse temperature hasn't shown anything for temperature except XXX for a long time. Observation of the dishwashing process revealed the wash temperature was 140, and there was no rinse temp at all, the final rinse digital display read XXX F (degrees Fahrenheit). DW 2 explained that each morning they were supposed to run a chlorine sanitizer strip through the dish machine on a rack to verify adequate chlorine was in the final rinse. Four containers of test strips were observed. One container had an expiration date of ,d+[DATE] the other three were ,d+[DATE]. The labels had four ppm color comparisons ranging from light lavender (10 ppm) to purplish black (200 ppm). DW 2 demonstrated this process three times by putting a strip on a dish rack and sending it through the dishwasher. The first time the strip was white (less than 10 ppm sanitizer), the second time the strip was lost in the dish machine, the third time the strip was white again. The FSD was asked to assist with the process. He confirmed the final rinse cycle did not register a temperature and that was a problem. He confirmed that one of the containers with test strips was expired. The FSD then tested the chemical concentration by putting a dish thought the dish machine then immediately touching the dish with the test strip when it came out. The strip color registered at 100 ppm. During an observation and interview on [DATE] at 2:45 pm, with DW 3, the three-compartment dishwashing sink was observed. DW 3 demonstrated how to correctly test the chemical in sink #3 which was the final rinse sink. He stated the goal was ,d+[DATE] ppm. He did the testing process. Test strip showed ,d+[DATE] ppm. He stated, So it's a little high? During an interview on [DATE] at 3:30 pm, IFSM confirmed that the Quat test strips should be dipped for 10 seconds, and concentration color should be ,d+[DATE] ppm in sanitizing buckets and the final rinse sink. She stated she did not know about the dish machine testing. 7. During a concurrent observation and interview on [DATE] at 4:10 pm, in the cool preparation room where sandwiches and salads were made, the room temperature was 84.2 degrees. DA 1 stated that some days it was hard to breath in here because it was so hot. During an interview with DA 1 on [DATE] at 9:45 am, she stated she made sandwiches for residents, and the types of sandwiches she made depended on what residents requested, or what was on the food production tally for the day. DA 1 stated she mostly made turkey with cheese, egg salad, tuna salad, or chicken salad sandwiches, and they were made from scratch (not an item purchased already prepared). She explained the egg/tuna/chicken salads were good for two days, she made it in small amounts, and sometimes she made it every day. She added she was making four egg salad sandwiches that day. DA 1 was asked to describe how she made tuna salad. She stated she used a small can of tuna and made only enough for two days even though it's good for four days. She obtained the tuna from the dry storage room (ambient temperature), added mayonnaise and pickle relish from the refrigerator, and used a #12 scoop to make the sandwich. DA 1 was asked to describe how she made egg salad. She stated they purchased pre-cooked hard-boiled eggs, added pickle relish, mustard, mayonnaise and pepper. She stated they should have a recipe, but she had been here too long, and they had changed companies (so she just made it as she always had). She stated she knew what to put in it and preferred to make it ahead of time and put it in the refrigerator so the flavors could meld. DA 1 stated she did not take the temperature when she made egg, tuna, or chicken salad, but she took the temperature before she gave the items to the residents to make sure they were cold for the residents, adding they should be less than 40 degrees. DA 1 stated she did not keep a temperature log for that. During an interview with the IFSM on [DATE] at 3:30 PM she was asked what process staff used to prepare tuna salad from room temperature ingredients? She replied, I'm not really sure. A review of their policy titled Taste and Temperature Control/Food Holding dated [DATE], the policy indicated that food is maintained at proper temperatures during service to meet resident expectations for palatability and to ensure that food safety principles are maintained to prevent foodborne illness. All cold foods must be held at 40 degrees Fahrenheit or below. Any cold foods that have been held at greater than 40 degrees for 2 hours must be discarded. A review of the facility's recipe for egg salad, and tuna salad, undated, did not specify to use prechilled ingredients and did not guide to check the temperature and to perform a cooling log if greater that 41 degrees. Review of the 2022 FDA Food Code ,d+[DATE].14 showed Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as .canned tuna.

Based on observation, interview, and record review the facility failed to accommodate resident food preferences/dislikes when: 1. Resident 134 complained of having too much curry (a spice, mainly associated with South Asian cuisine) with her meals (Cross Reference F803 #4). 2. Resident 23 received pies and cakes when she continually refused them due to her diagnoses. (Cross Reference F803 #3) 3. Resident 69 and 38 refused their meal trays and the facility did not provide an alternative entree of equal nutritive value. This failure had the potential to result in resident dissatisfaction with meal service, decrease meal intakes, nutritional status, and overall health decline. Findings: A review of a facility's policy titled Food Preferences dated 10/26/22, indicated Resident food and beverages preferences will be obtained upon admission and periodically as needed to assist the food and Nutrition Services department in providing preferred foods to enhance/maintain quality of life and nutritional status. 1. A review of Resident 134's medical record showed she was admitted on [DATE] with diagnoses of Iron deficiency anemia, cancer, and malnutrition. A review of Resident 134's Admission Minimum Data Set (MDS, a clinical assessment tool) dated 4/9/23 indicated she required supervision with eating and her cognition was intact. A review of Resident's 134's lunch tray ticket dated 4/17/23 showed: Regular, Mechanical soft, thin liquids, Gluten-Free (GF), Lactose-Free, Low-Fiber diet Chef's Choice Entree GF Lactose-Free, Chef's Choice Soup GF Lactose-Free, Soy milk, apple juice, condiments, Banana. During an interview with Resident 134 on 4//17/23 at 9:45 am, she stated I have trouble finding something to eat. The doctor wanted me to have lots of protein because of my Chemotherapy (Cancer medication). Resident 134 indicated she was gluten and dairy free and liked meat and potatoes, but the facility kept giving her tofu curry or chickpea curry and she could not eat it. She stated don't put curry in front of me, I had tilapia once which was wonderful. The dietician said she could not find anything else, so my husband brings in food. During an interview with the Interim Food service Manager (IFSD) on 4/17/23 at 3:15 pm, regarding Resident 134, she stated We don't do plain meat here very often. We always add flour (contains gluten) into foods, and she can't have gluten. IFSD indicated Resident 134's husband brought food in for her, especially meat. 2. A record review of Resident 23's quarterly MDS dated [DATE], revealed she was admitted on [DATE] with the diagnoses of diabetes (a group of diseases that affect how the body uses blood sugar), heart disease, and lung disease. She required supervision with eating and her cognition was moderately impaired. During a concurrent observation and interview with Resident 23 on 4/17/23 at 12:37 pm, her lunch tray contained a banana cream pie, pasta, and juice. Resident 23 indicated that she received dessert (pie and cake) every day but continued to tell them she did not want it and could not eat it because she was a diabetic. Resident 23 indicated the dietician had never been in to see her that she could recall. 3. During an observation of Resident 69 on 4/17/23 at 12:00 am, Resident 69 was in her room with her lunch tray. She had a plate of red and green pasta. She was yelling something in Spanish and pointing to her food. She pushed her food tray away and kept yelling. During an interview with Restorative Nursing Assistant RNA 1 (who spoke Spanish) on 4/17/23 at 12:02 pm, he indicated Resident 69 said her food was ugly, and that she did not like it. When asked if there was something else Resident 69 could have, RNA 1 stated feeding someone with a Hispanic culture was tough and I don't know how flexible the kitchen was. It's not often residents ask for alternatives Resident 69 did not receive an alternate for lunch that day. During an interview with Registered Dietitian (RD) on 4/17/23 at 3:12 pm, she indicated the staff can offer an alternative option if someone did not like something. She continued For the Hispanic culture we have tortillas now as a regular item and were looking at adding beans daily. During a concurrent observation and interview with Resident 38 on 4/17/23 at 11:33 am, her lunch tray arrived with egg whole noodles, and whole Swedish meatballs. Resident 38 stated she was not feeling very good and did not want to eat right now. She asked for some spaghetti and meatballs or Chinese food but was told by the Director of Staff Development (DSD) that they could not accommodate that.

Based on observation, interview, and record review, the facility failed to implement pharmaceutical policies and procedures when a used Emergency Kit (E-Kit, a storage box that houses an emergency supply of medications) was not removed and replaced according to facility policy. This failure had the potential for an E-Kit to have an insufficient amount of an emergency supply of medication available for the facility's residents. Findings: During an observation on 4/18/2023 at 1:34 PM, the E-Kit at nurse's station two of the facility had an E-Kit opened on 4/13/2023 at 12:53 PM, for a ipratropium bromide and albuterol sulfate inhalation solution (a combination medication for helping with shortness of breath), 0.5mg/3mg (milligram, unit of measure for weight), and again opened on 4/18/2023 at 1:40 AM for another ipratropium bromide and albuterol sulfate inhalation solution 0.5mg/3mg. During an interview on 4/18/2023 at 2:07 PM with Licensed Nurse (LN) 1, it was stated and acknowledged that the E-Kit was accessed on 4/13/2023 and had not yet been renewed by the pharmacy within 72 hours. She stated the E-Kit was once again accessed on 4/18/2023 and the pharmacy was called for a renewal of the E-Kit. During an interview on 4/20/2023 at 8:23 AM with the Director of Nursing (DON), the DON stated the pharmacy that was used to supply medications comes to the facility two times in a day to refill medication prescriptions. The DON acknowledged that this would have given multiple opportunities for the facility and pharmacy to renew and replace the E-Kit that was opened and accessed on 4/13/2023. A record review of a policy titled, Emergency Pharmacy Service and Emergency Kits, dated June 2016, indicated, If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening. If replacing used medications, the replacement doses are added to the kit within 72 hours of opening.

Based on observation, interview, and record review, the facility failed to ensure menus were in place to adhere to diet orders or meet residents needs when: 1. The facility-specific diet manual provided no indication that the Registered Dietitian responsible for nutrition care at the facility had reviewed and approved the diet manual. 2. The facility-specific diet manual did not contain guidelines and the facility did not have a consistent system in place for provision of fortified diets ordered by providers. 3. Consistent Carbohydrate Diet meals did not match the carbohydrate guidelines in the diet manual. 4. Meals planned for residents receiving Plant Based/Vegetarian diets had little variety and there was no menu posted or available for their use. 5. The facility did not have an effective tool or system in place to monitor or evaluate the accuracy of resident meal trays in relation to the diet order. These failures had the potential to result in meals that did not meet resident nutritional needs or comply with doctors' orders, leading to a decline in health status and quality of life. Findings: 1. The facility-specific diet manual provided no indication the facility's Registered Dietitian (RD) had reviewed and approved the diet manual. Review of a policy titled Long-Term Care Diet Manual revised 10/26/22 showed the diet manual Serves as a guide in meal planning for differing conditions and needs, aiding physicians in prescribing modified diets, and assisting health care staff to interpret and carry out diet orders .The manual should include a list and description of the standard and unit-specific diet orders that a physician may order .The manual is signed and approved by the medical director, administrator and qualified dietitian annually. State of California Facilities Letter (AFL) 14-32 reminds facilities that the nutritional needs of patients must be met through menu development in accordance with the physician's diet orders, as delineated in the facility diet manual. The analysis of the menu is the foundation of meal planning to assure that the menu meets the nutritional needs of the patient and are in accordance with the physician ordered diet. Review of the facility document titled (Food Service Contractor) Diet Manual for Health Care Communities revised 2020, showed it was evaluated and approved by members of the Patient Care Policy Committee including the administrator, medical director, Dietary Supervisor and the Clinical Nutrition Manager (CNM) from the Hospital, as well as other positions from housekeeping, marketing, maintenance, rehab and medical records in January 2022. It did not include the signature of the Registered Dietitian who, at time of survey, had been the facility's dietitian for 16 months and was responsible for the nutrition care of its residents. During an interview with the RD, CNM and Interim Food Service Manager (IFSM) on 3/19/23 at 3:30 pm, the RD stated all diets ordered in the facility were in the Diet Manual. 2. The facility-specific diet manual did not contain guidelines or have a consistent system in place for provision of fortified diets ordered at the facility. A review of lunch tray tickets on 4/17/23 at 11:05 am showed Resident 26 was on a consistent carbohydrate (CCHO), mechanical soft, thin liquids, vegetarian, no eggs, fortified diet. The foods listed on his tray ticket included Madras Vegetable Curry (1 cup), white rice (1/2 cup), banana cream pie (one slice), skim milk (8 oz), unsweetened apple juice (4 oz), and Buttery Spread (3 piece), with a note to add extra vegetables and butter. Review of ten fortified diet lunch tray tickets (Residents 17, 26, 52, 69, 84, 92, 103, 108 and 112), dated 04/17/23, showed 6 out of 9 residents (Residents 52, 69, 84, 92, 108 and 112) were provided with whole milk (160 calories) instead of skim (100 calories). One out of nine residents (Resident 26) were provided with three buttery spreads (90 calories) instead of one (30 calories) for extra calories. Ten out of ten residents on fortified diets received Banana Cream Pie. Review of the (Facility) Weekly Menu Week 4 showed the Banana Cream Pie was a standard menu item (not extra calories or protein) for Regular, CCHO, and Low Sodium Diets. Review of the facility's diet manual, titled (Contractor) Diet Manual for Health Care Communities revised 2020, showed these Guidelines for Diet Order Interpretation: If a High Calorie, High Protein diet was ordered, it would be provided as a Regular Diet (Fortified). The diet manual did not provide any further reference to the High Calorie, High Protein/ Fortified diet or how a diet would be modified to achieve it. During an interview with the RD, CNM and Interim Food Service Manager (IFSM) on 3/19/23 at 3:30 pm, the RD stated all diets ordered in the facility were in the Diet Manual. When asked about fortified diets she explained it included cheese, higher fat milks, extra sauces, gravy, and extra [NAME]. The RD stated the facility had no specific guide or plan for fortified foods. I am not making any adjustments for fortified diets, and I am not checking calories. She stated she recommended fortified diets, and the doctors ordered them. The RD was asked why Resident 26 who was on a consistent carbohydrate (CCHO) fortified diet received skim milk instead of whole milk like other fortified diet residents. She checked his record, and it showed no preference for skim milk. She stated he probably received the skim milk because it was the default milk for the CCHO diet and was not caught. The RD agreed there was no tool or guide for cooks/staff to follow, to know if they were providing the correct food and portions for the fortified diet. She confirmed there were no guidelines for the fortified diet in the facility's diet manual. When asked how they would know if a resident was getting the correct food and portions (for example with fortified diets) on their trays per doctor's orders, the CNM stated they would know by resident weight changes. 3. Consistent Carbohydrate Diet meals did not match the carbohydrate guidelines in the diet manual. During an observation and concurrent interview on 4/17/23 at 12:37 pm, Resident 23 stated she received pie or cake every day on her meal tray but continuously told facility staff she didn't want it because she was diabetic. She received her lunch tray that included banana cream pie and again stated she did not want it because she was diabetic and couldn't eat that. She stated the dietician had never been in to see her that she could recall. Review of Resident 23's medical record showed she was most recently admitted [DATE] following a stroke and had Type 2 diabetes. Her diet order was Consistent Carbohydrate, thin liquids, mechanical soft. During an interview with Resident 33 on 4/17/23 at 2:40 pm, she stated I'll eat pudding and cake, I don't know why they send it though. I'm diabetic. I'd rather have a baked potato and some butter with gravy and a piece of meat and a vegetable. That's how I'm accustomed to eating. Review of Resident 33's medical record showed she was admitted [DATE] had Type 2 Diabetes. Her diet order was Consistent Carbohydrate, thin liquids, mechanical soft, with special instructions for bite size, extra sauce/gravy, no straws, regular texture salads allowed. The American Diabetes Association website guidelines for healthy living with diabetes, accessed April 2023, encouraged a consistent carbohydrate diet to minimize spikes and drops in blood glucose (sugar) levels. To avoid blood sugar spikes, it helps to eat a consistent amount of carbs (carbohydrates) at meals throughout the day. Spikes or elevation in blood glucose damages blood vessels resulting in complications of diabetes. Spikes and drops in blood glucose can make a resident feel unwell, lack energy, and other negative symptoms. Review of the facility diet manual's Chapter 6 Consistent Carbohydrate Diet showed the goals of the diet were to provide a nutritionally adequate diet, maintain blood glucose and lipids (fats) as close to the resident's target goals as possible, and help prevent or treat complications associated with diabetes mellitus. It described the meal pattern as three meals and one snack each day, with consistent mealtimes and portion sizes to provide greater glycemic control and decrease the risk of malnutrition. Carbohydrate values are determined from the American Diabetic Association Exchange List for Meal Planning with 1 CHO (carbohydrate serving) = 15g (grams) and 5-6 CHO (carbohydrate servings) per meal dependent on the individual. Order as Consistent Carbohydrate Diet. Review of facility documents titled Nutrient/Cost Analysis Summary - Season's Harmony 2021 (Spring), printed 4/17/23, contained one page of nutrient analysis for each of the five weeks of the menu cycle. These documents also showed the consistent carbohydrate diet (CCD) contained 5-6 (servings) of carbohydrate each meal. Review of the (Facility) Weekly Menu, Week 4 Consistent Carbohydrate Diet showed that for lunch on Monday 4/17/23, residents on a consistent carbohydrate diet (CCHO) should receive Garden Salad, Penne Pesto Vegetables with Sausage, Garlic Knot (roll), and Banana Cream Pie. Review of the CCHO lunch tray tickets included the following carbohydrate (CHO) foods and serving sizes: Penne Pasta Vegetables with Sausage (1 each), Banana Cream Pie (1 slice), Garlic Knot (1/2 each), Skim Milk (8 oz), Sugar Free Apple Juice (4 oz). Review of a document titled, The (Facility) Production Counts, dated 4/17/23 showed portions available for Banana Cream Pie were 1 slice, 1/2 slice, and 1 1/2 slice. Use of the facility diet manual's CCHO exchange lists and the manufacturer's nutrition label for Banana Cream Pie (provided by the IFSM) to evaluate this meal showed approximately eight servings /120 grams(g) of carbohydrate and was not aligned with facility's diet manual or American Diabetes Association guidelines for 5-6 servings per meal. Approximate CHO in this meal was: 1/3 cup Pasta = 15 g (but appeared greater than 1/3 cup pasta per serving during tray line), 1/2 each Garlic roll = 15 grams of CHO, Milk = 12 g, apple juice = 15 g. The manufacturer's nutrition label for the banana cream pie showed 1 slice contained 63 g CHO = 4 servings CHO. During an interview on 4/19/23 at 3:30 PM with the IFSM, RD, and CNM, they stated they did not know the goal for how many servings or grams of CHO should be on each consistent carbohydrate diet tray. The CNM stated We don't do exchanges here. They were unable to describe how they would know CCHO diets were appropriate to meet resident needs. 4. Meals planned for residents receiving Plant Based/Vegetarian diets had little variety and there was no menu posted or available for their use. During an interview with Resident 134 on 4/17/23 at 9:45 am she complained she received chickpea curry or tofu curry daily. Don't put curry in front of me. During an interview with the RD, IFSM and CNM on 4/17/23 at 3:15 pm, the RD stated meeting the cultural needs of their [NAME]/Indian residents was easy with their vegetarian diet, and There are quite a few curries on the vegetarian diet. The surveyor shared that nursing surveyors reported some of the vegetarian residents stated, All we get is curry. The RD stated she had heard that as well, visited those residents, and offered alternate choices if appropriate. A copy of the vegetarian menu was requested. The IFSM stated they did not have ability to create a vegetarian menu, but she could print out tray tickets for a fictitious resident to show what was served to a vegetarian diet during their five-week menu cycle. A review of breakfast, lunch and dinner tray tickets provided by the IFSM were dated 5/1/23 through 6/4/23 and were for a fictitious resident [NAME], with regular diet, regular texture, thin liquids Lacto-Vegetarian diet. The tray tickets showed a lack of variety for vegetarian residents when 11 out of 35 lunches and 14 out of 35 dinners contained curry. Curry was served 24 out of 35 days, and curry was served at both lunch and dinner on two days. Further review showed a theme of three curry recipes: Out of 70 possible lunch and dinner meals, Curry Sesame Tofu with Curry Sesame Vegetables were served 9 times, Madras Vegetable Curry was served 9 times, and Cauliflower Tofu Curry was served 8 times. 37% of vegetarian meals provided curry entrees. Review of the facility's Facility Assessment ethnicity/race information dated November 2022 showed seven out of 130 residents in the facility (5%) were [NAME]. Review of five documents titled Nutrient Analysis Summary - Season's Harmony 2021 (Spring), menu cycle weeks one through five, printed 4/27/23 showed nutrient analysis for Regular, Sodium Restricted, Cardiac, CCD (Consistent Carbohydrate Diets), Renal, Mechanical Soft, Dysphagia, and Pureed diets, but did not provide nutrient analysis to demonstrate the nutritional adequacy of vegetarian diets served at the facility. Review of the California Health and Safety Code 1265.10 showed a licensed health facility .shall make available wholesome, plant-based meals of such variety as to meet the needs of patients in accordance with their physicians' orders. 5. The facility did not have effective tools or systems in place to monitor or evaluate the accuracy of resident meal trays in relation to the diet order. During the initial tour of the kitchen on 4/17/23 at 9:30 am, the IFSM and RD were asked to provide copies of the menu for the week, the tray tickets for lunch that day, and the therapeutic diet spreadsheets (a tool that would indicate a standard for foods and portions to be provided on resident meal trays in relation to the diet order and diet manual). The IFSM provided the following documents: Review of the (Facility) Weekly Menu, dated 4/17/23 through 4/23/23 included separate pages for Regular, Consistent Carbohydrate (CCHO), two-gram Sodium, Heart Healthy, Renal, Full Liquid and Clear Liquid diet/menu foods, but they did not include the portions that should be provided. Review of the The (Facility) Production Counts Lunch-Combined Jobs, dated 4/17/23 through 4/20/23 showed they were a tool used by the cook and other food production staff. They provided a list of the foods and their quantities to prepare for each meal. They did not provide information regarding foods or portions to be served on individual trays related to the diet orders. Review of lunch meal tray tickets, dated 4/17/23, showed the diet order, food, and portions to be given to each resident, as well as many individualized menu notes. During an interview on 4/19/23 at 3:30 pm the RD agreed the facility had no cook's therapeutic diet sheet or other tool to help them quickly and easily evaluate if tray tickets and trays were correct.

Based on observation, interview, and record review, the facility failed to ensure: 1. The washing machine final rinse cycle was rinsing at the right temperature to maintain sanitation when the machine rinse cycle temperature display showed only XXX. This had the potential to cause the dish sanitation to be ineffective and cause foodborne illness and negative clinical outcomes to residents in the facility. 2. The walk-in freezer was free of condensation on the celling and fan which could result in the failure of the freezer over time. Findings: A review of the facility's undated policy titled Preventative Maintenance, the policy indicated Department managers participate in and administer a preventive maintenance program in the facility to control equipment maintenance and repair expenses by avoiding repetitive maintenance and excessive parts replacement. 1. During an observation and interview in the dish room on 4/19/23 10:20 am, the dish washing machine had a digital temperature screen displaying the wash temperature at 140 F (degrees Fahrenheit) and the final rinse temperature at XXX F. Dishwasher (DW) 2 indicated it was a cool final rinse dish machine, meaning it needed chemicals to sterilize the dishes instead of hot water. DW 2 indicated the wash temperature should be 140 degrees or greater. He stated the final rinse temperature hadn't shown anything except XXX for a long time. During an interview with the Food Service Director (FSD) and Cook 1 on 4/19/23 at 10:25 am, FSD indicated that he thought the staff ran temperature strips through the machine to record the final rinse temperature. In a concurrent record review of the dish machine temp logs there was no indication of that. FSD asked Cook 1 if they were used. FSD stated they had never used temp strips, but there used to be a digital temperature gauge on top of the dish machine, but it disappeared when the new company took over. FSD confirmed that there was a problem with the final rinse temperature not showing. 2.During an observation and interview in the walk-in freezer with FSD, on 4/17/23 at 10:30 am, the shelves were full, and the freezer was cramped with standing room only for one person due to a cart (full of items) in the middle of the freezer. There was ice condensation on the ceiling and the fan. FSD agreed the walk-in freezer and walk-in refrigerator were too small for this facility and its population. He confirmed that there was ice on the ceiling and fan due to condensation from the freezer door being open when deliveries were being put away.

Based on observation, interview, and record review the facility failed to provide regular maintenance to the facility kitchen to ensure a safe and sanitary environment when: 1. The temperature in the cold prep room was not maintained at a safe level. 2. The walls, floor trim, floor drains, and ceiling tiles were not maintained in good repair. These failures had the potential to negatively impact the food safety and sanitation of food services areas and can be a safety issue for staff. (Reference F812) Findings: 1. During a concurrent observation and interview, with the Food Service Director (FSD), and dietary aide (DA) 1, on 4/17/23 at 10:35 am, the cold food prep room contained rice, flour and other dried food, a refrigerator that contained individual salads, sandwiches, and other snacks. DA 1 stated she had worked there for [AGE] years prepping snacks for residents. She confirmed that she made the sandwiches, salads, and snacks in this room. The room temperature felt very warm and stuffy during the whole observation. The FSD confirmed that this room felt very warm. During a concurrent observation and interview, in the cool prep room, on 4/18/23 at 3:40 pm, The Registered Dietitian (RD) and the Interim Food Service Manager (IFSM) agreed the cold food prep room was warm. Surveyor temperature of the room was 84.2 degrees Fahrenheit. DA 1 stated It's always warm in here. I always complained it's hard to breath in here. We're not allowed to open doors. They told me it (the hot air) couldn't be fixed because it's connected to patients. A review of the All Facilities Letter 16-06 Dated October 6th, 2017, Pursuant to Title 42 of the coded of Federal Regulations section 483.159(h) (6), skilled nursing facilities must have comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81 F. A review of the facility's undated policy titled. Building Maintenance Program indicated It was important that an effective preventive maintenance program be carried out for all hospital equipment to ensure a safe and comfortable environment for all patients, visitors, and employees. A review of kitchen work orders dated 1/8/23 to 4/19/23, were reviewed and there were no requests for the cool prep room temperature to be checked. There were no documents provided by the facility indicating when the cool prep room was last inspected for a safe temperature. 2. During a concurrent observation and interview on 4/17/23 at 10:20 am, there were multiple areas in dish room and walkways near dish room with peeling paint, chipped paint, and damaged drywall. The coffee room had partially detached floor trim sticking out with thick black grime exposed. The floor drain under the sink was grimy, uncovered, and had a cup of milky white water sitting in it. An ant was noted to be crawling towards it. FSD indicated the general manager of the Fountains food service had been off since 4/21/23. During a concurrent observation and interview with the FSD on 4/17/23 at 10:30 am, the main dry storage area had bulging ceiling tiles with some brown stains on them directly over some dried food. FSD indicated they had a leak in that area from some pipes about 3-4 months ago. He stated, I think it needs to be fixed. During an interview with the Quality Compliance Analyst (MAINT. 1) on 4/18/23 at 3:13 pm, when asked if Plant Services did regular inspections of the kitchen, she replied they did at least quarterly EOC (Environment of Care) rounds. During a concurrent observation and interview in the dry storage room on 4/18/2023 at 3:40 pm, the registered dietitian (RD)and the IFSM confirmed that the ceiling tiles were damaged due to a roof leak. They indicated the facility needed a new roof and they had to use buckets in the hallways because of the heavy rains this year. Maintenance replaced the ceiling tiles many times for 6 years. They did not repair/replace the ceiling over the dry storage room when other roof areas were replaced/repaired. RD stated they have never had to replace the food. During an interview with the Administrator on 4/19/23 at 8:05 am, he stated the damaged ceiling in the kitchen dry storage room was due to a roof leak and they plan to have it repaired this summer. During an interview with the Director of Facility's (DOF) on 4/19/23 at 8:43 am, he confirmed there was some ripped wallpaper, bulging ceiling tiles and some drains uncovered. Surveyor asked how often he inspected, and he said he did not and that the staff would normally bring it to his attention of things that needed to be fixed. He did rounds before Covid but post Covid not so much anymore. The DOF indicated that the kitchen staff that work in the various areas would communicate any problems they noticed and would put in a work request. He would do rounds in the kitchen and look for low hanging fruit.

Based on observation, interview, and record review, the facility failed to implement their medication storage policy when: 1. Expired pharmaceutical products were not removed from the medication cart (a cart where resident medications are stored and dispensed from) 2. Several medications did not have open date labels This failure had the potential for the administration of expired and ineffective medications to residents. Findings: 1. During an observation on 4/18/2023 at 1:45 PM of the medication room at nurse's station two in the facility, several expired medications were found in medication cart three that was stored inside the medication room. These expired medications included: Insulin glargine (a medication used to lower blood sugar), 100 u/mL (units per millimeter, unit of measure) that expired 4/11/2023, Insulin aspart (a medication used to lower blood sugar), 100 u/mL that expired 4/14/2023, azelastine eye drops (a medication used to treat itching eyes) that expired 4/6/2023, and Azopt eye drops (a medication used to decrease the amount of fluid in the eye) that expired 4/13/2023. During an interview on 4/18/2023 at 2:07 PM, with Licensed Nurse (LN) 1, she acknowledged that the medications were expired. During an interview on 4/20/2023 at 8:23 AM, with the Director of Nursing (DON), it was acknowledged that these medications were expired and pulled out of medication cart three. It was also stated that these medications should have been pulled out of the medication cart upon expiration. During a review of the facility's policy titled, Resident Care - Medication Administration, with a revision date of 3/17/2023, this document indicated that, If medication is discontinued, or outdated, remove medication for proper disposal. During a review of the facility's policy titled, Medication Storage in the Facility, dated June 2016, this policy indicated, Drugs shall not be kept in stock after the expiration date on the label . 2. During an observation on 4/18/2023 at 1:50 PM of the medication room located at nurse's station two in the facility, several medications were found in medication cart three that did not have open date labels according to the facility policy. The medications that did not have an open date label included: Insulin glargine, two separate containers of Artificial Tears (eye drops that provide moisture to dry eyes), Azopt eye drops, and Tuberculin Purified Protein Derivative Tubersol (used to inject medication to test for Tuberculosis, a lung disease). During an interview on 4/18/2023 at 2:15 PM with LN1, she acknowledged that each of these medications did not have an open date label, therefore it would be difficult to know of the expiration date of the medication. During an interview on 4/20/2023 at 8:23 AM with the DON, it was acknowledged that these medications did not have an open date label in accordance with the facility policy. During a review of the facility's policy and procedure titled, Dating of Containers when Opened, with no date provided, indicated that, . Medications require the container to be dated when opened and discarded a number of days after opening . Eye drops . will need to have the date opened noted on the container .

Based on observation, interview, and record review the facility failed to ensure an effective pest control system was in place when a live ant was found in the kitchen's coffee room, and multiple dead ants were found in a nursing unit food storage and preparation pantry for resident food. This had the potential to result in foodborne illness for residents consuming food from the kitchen and nursing unit pantry. Findings: During an observation of the room identified by staff as the Coffee Shop or Coffee Room on 04/17/23 at 10:15 AM, one live ant crawled on the floor near the floor drain. The floor drain was half covered by a grate. The drain itself had nothing over it. The floor drain had a clear cup full of a milky colored liquid sitting in it. During an observation and concurrent interview with the Facilities Analyst (Maint1) and Facilities staff (Maint 2), and Registered Dietitian (RD) in the coffee room on 4/18/23 at 3:20 pm they confirmed that the floor under the cabinet had black grime and food crumbs, and the interior of the cabinet under the sink had debris and grime. The RD confirmed they had had issues with ants. During an observation and concurrent interview with the Registered Dietitian (RD) in the Nursing Unit 3 Pantry (food storage for residents) on 04/18/23 at 3:58 PM, three drawers had damaged, uncleanable surfaces and contained dead ants while also storing food service supplies. The RD stated housekeeping was responsible to clean the food pantry areas. In an additional concurrent observation, an unwashed yellow plastic food storage container containing oily food debris was a potential attractant for vermin and microbial growth. It was stored on the top shelf of a cabinet in the Nursing Unit 3 dining room with food and food service supplies. In an interview with the Food Service Manager (FSM) on 04/19/23 at 3:30 PM she stated the facility had a monthly pest service. She thought housekeeping cleaned the nursing pantries but wasn't sure. During an interview on 4/20/23 at 11:00 AM, with the head of Housekeeping for the facility (HHSK), the HHSK indicated housekeeping personnel was not responsible for cleaning inside the drawers or cabinets for the nursing unit pantries. Review of a policy titled Pest Control, revised 10/26/22 showed It is the Food & Nutrition Services Department's responsibility to ensure an environment that is sanitary, and which presents no hazard to the well-being of the residents, staff, or visitors. An ongoing program to control rodent, pests, and insects must be evident. Review of invoices from the pest service company showed on service date 4/12/23 the kitchen was sprayed for ants and bait was applied to the exterior of the facility. On service date 4/19/23 the facility was baited on the exterior of the building for ants.

Based on observation, interview, and record review, the facility failed to ensure personal and medical records were kept private and confidential for two of two sampled residents (Resident 122 and Resident 71) when medication blister packs (packaging that contains resident medication and a label with their personal identifying information) were left unattended on medication cart three (a cart where resident medications are stored and dispensed from) in the facility hallway on nursing station two. This failure violated the resident's right for privacy and had the potential of unauthorized release of personal information. Findings: During an observation on 4/20/2023 at 8:10 AM of medication cart 3 located at nurse's station two, a total of three medication blister packs were found for two residents (Resident 122 and Resident 71) unattended on the outside compartment of the medication cart, visible and labeled with residents' information. During an interview on 4/20/2023 at 8:23 AM with the Director of Nursing (DON), it was acknowledged that this was a privacy issue for the two residents, as their personal information was visibly displayed unattended on a medication cart in the hallway. The DON stated that the identifying resident labels should have been discarded or the blister packs should not have been left visibly on the cart. During a review of the facility's policy titled, HIM-PHI SECURITY, with no date provided, indicated, All records will be kept in locked areas . Information in the medical record shall be confidential and shall be disclosed only to authorized people .

Based on observation, interview, and record review the facility failed to prepare food in a manner to meet an individual's needs for one of one sampled resident (Resident 38) when she was served meat that was not chopped up as per her diet order. This failure had the potential for her nutritional status to decline. Findings: A review of The International Dysphagia (difficulty in swallowing) Diet Standardization Initiative (IDDSI, a global standard to describe texture modified foods for all care settings.) indicated chopped foods should be small/bite size, 1.5 cm (centimeters, or 1/2 inch). A review of Resident 38's admission record indicated, she was admitted to the facility on [DATE], with diagnoses of Lung disease, end stage kidney disease and on dialysis, and Gastroesophageal reflux disease (GERD, occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). During an observation on 4/17/23 at 11:33 am, Resident 38's lunch tray arrived containing egg whole noodles, whole Swedish meatballs, and a half garlic bread stick. Her tray ticket indicated she was on a renal diet with regular texture, thin liquids, high protein, and chopped meats. Resident 38 required help with eating, and a staff member was assisting her. During a concurrent observation and interview on 4/18/23 at 9:56 am, Cook 2 indicated he was preparing the meat for the mechanical soft/chopped diets. He put some meat into the blender and pulsed the on button for a couple seconds, looked at the meat then pulsed it again and placed it in the serving dish. Cook 2 stated he did not know the exact measurements for the meat, and that he guessed. Then he said, What is the right size? During an observation of the tray line (assembly process for resident meal trays) on 4/18/23 at 11:18 pm, Cook 4 stated that the minced and moist meat had pieces that were to big. She took them out of the serving dish and blended them some more. During an interview on 4/19/23 at 3:30 pm, with the Interim Food Service Manager (IFSM) and the Clinical Nutrition Manager (CNM), they confirmed Resident 38's diet order was chopped meats and the Swedish meatballs served to her were too large and were not bite size. They confirmed that they should have been chopped up and they were not. A review of training and orientation checklists revealed there were no indication of training or competencies in texture modification for Cook 2, Cook 4, dietary aide (DA) 3, and dishwasher (DW) 2. The facility had no training competency documents for Cook 1 and Cook 3 who were long time employees. A review of the policy titled Texture Modified Diets revised 10/26/22 showed Whole meats for mechanical soft diets will be chopped and served with gravy or sauce to promote ease of chewing/swallowing. Follow the (Food Service Contractor) Diet Manual for Health Care Communities instructions for mechanical soft diet.

Based on interview, record and policy review, the facility failed to provide resident protection from abuse when Resident 1 reported that he had been assaulted by an employee and the facility did not remove the employee from resident care while they investigated the allegation. This had the potential for Resident 1 and other vulnerable residents to be unprotected from continued abuse by staff. Findings: Resident 1 was admitted to the facility on [DATE] with partial paralysis following a stroke, a communication deficit (inability to express himself), diabetes, kidney disease, and cognitive impairment (inability to think and comprehend). A review of the facility's policy titled, Policy and Procedure: Prevention, identification and reporting of abuse Revision 3, indicated that the purpose of the policy was to, ensure that residents' rights are protected by providing a method for the prevention, identification, and reporting of any type of resident abuse. 5. Protection, a. If a resident incident is reported, discovered, or suspected, where the health, welfare or safety of the residents is involved, the facility will take the following steps .If the suspected perpetrator is an employee: A. Remove employee from the care or vicinity of the patient, and B. Suspend employee during the investigation. A review of the facility's abuse investigation report dated 6/28/22, indicated that Resident 1's spouse called the facility stating that her husband had been punched in the private area by staff. In an interview on 3/21/23 at 2:30 PM, the Director of Staff Development (DSD) A indicated that on 6/28/22, Resident 1's wife called the facility to report that Resident 1 had been assaulted by a staff member of the facility. DSD A further stated that during a follow-up interview with Resident 1, he clarified that a large white female Certified Nursing Assistant [CNA] punched him in the [testicles] while he had been laying in bed under the covers. DSD A stated that the facility narrowed down this description to CNA A, who was the only staff meeting that description. DSD A confirmed that CNA A was not suspended from working and caring for residents while the facility was conducting their investigation. DSD A added that CNA A had been reassigned to another area of the facility where she took care of other residents, instead of being put on suspension. DSD A indicated that the facility's investigation was in progress from 6/28/22 to 7/3/22. In an interview on 3/21/23 at 2:55 PM, CNA A confirmed that she had not been suspended while the facility was investigating Resident 1's allegation that she had hit him. A review of the facility's record titled, Nursing Staffing Assignment and Sign-in Sheet dated 6/28/22 to 7/2/22, indicated that CNA A was assigned to, and actually worked taking care of residents from 6/28/22 through 7/1/22. Based on interview, record and policy review, the facility failed to provide resident protection from abuse when Resident 1 reported that he had been assaulted by an employee and the facility did not remove the employee from resident care while they investigated the allegation. This had the potential for Resident 1 and other vulnerable residents to be unprotected from continued abuse by staff. FINDINGS Resident 1 was admitted to the facility on [DATE] with partial paralysis following a stroke, a communication deficit (inability to express himself), diabetes, kidney disease, and cognitive impairment (inability to think and comprehend). A review of the facility's policy titled, Policy and Procedure: Prevention, identification and reporting of abuse undated, Revision 3 , indicated that the purpose of the policy was to ensure that residents' rights are protected by providing a method for the prevention, identification, and reporting of any type of resident abuse. 5. Protection, that, a. If a resident incident is reported, discovered, or suspected, where the health, welfare or safety of the residents is involved, the facility will take the following steps: . II) If the suspected perpetrator is an employee: A. Remove employee from the care or vicinity of the patient, and B. Suspend employee during the investigation. A review of the facility's abuse investigation report dated 6/28/22, indicated that Resident 1's spouse called the facility stating that her husband had been punched in the private area by staff. In an interview on 3/21/23 at 2:30 PM, the Director of Staff Development (DSD) A indicated that on 6/28/22, Resident 1's wife called the facility to report that Resident 1 had been assaulted by a staff member of the facility. DSD A further stated that during a follow-up interview with Resident 1, he clarified that a large white female Certified Nursing Assistant [CNA] punched him in the [testicles] while he had been laying in bed under the covers. DSD A stated that the facility narrowed down this description to CNA A, who was the only staff meeting that description. DSD A confirmed that CNA A was not suspended from working and caring for residents while the facility was conducting their investigation. DSD A added that CNA A had been reassigned to another area of the facility where she took care of other residents, instead of being put on suspension. DSD A indicated that the facility's investigation was in progress from 6/28/22 to 7/3/22. In an interview on 3/21/23 at 2:55 PM, CNA A confirmed that she had not been suspended while the facility was investigating Resident 1's allegation that she had hit him. A review of the facility's record titled, Nursing Staffing Assignment and Sign-in Sheet dated 6/28/22 to 7/2/22, indicated that CNA A was assigned to, and actually worked taking care of residents from 6/28/22 through 7/1/22.

Based on observation, interview and record review the facility failed to ensure medications were administered to the right resident when one out of three residents (Resident 1) was given medications that were not prescribed to them. This failure caused Resident 1 to go to the emergency room for monitoring and had the potential for causing serious adverse reactions (harmful side effects). Findings: A review of the facility ' s Policy and Procedure titled: Resident Care-Medication Administration-FTNS, dated 4/14/2022 read, A. Procedure: 1. Administration of Medications, d. The licensed nurse shall check the resident ' s identity by: armband with name and photo ID or verbal confirmation of name by the resident or by another care giver etc. prior to administering medication. At least two methods of identification shall be utilized for identification of the resident. A review of Resident 1 ' s face sheet dated 9/2/2022, indicated, Resident 1 was admitted to this facility on 6/26/18 with diagnoses of Parkinson (a [CONDITION(S)] disorder of the central nervous system), dementia with behavior disturbances, and depression. A review of Resident 1 ' s Minimum Data Set (MDS, an assessment of the resident) annual assessment on 7/2/22, indicated that his Brief Interview for Mental status (BIM ' s an interview to assess a residents ' level of attention, level of orientation and ability to recall information) was 99 (unable to complete interview), was absent of spoken words and rarely/never understands staff or was understood by staff. A review of Resident 1 ' s Medication Administration Record (MAR), dated 9/1/2022, indicated Resident 1 had no 5:00 pm medications due at that hour. A review of the facilities census, dated 9/7/2022, indicated that Resident 1 and Resident 2 were roommates. A review of Resident 2 ' s MAR, dated 9/1/22, indicated Resident 2 had six medications due at 5:00 pm. The medications were: [MEDICATION(S)] 100 milligrams (mg), take 1 capsule at 5:00 pm for neuropathic(nerve) pain(side effects include nausea, vomiting, diarrhea); [MEDICATION(S)] (a schedule 4 narcotic) 0.25 mg, take 1 tablet at 5:00 pm for muscle tremors (shaking movements in one or more parts of the body)(side effects include drowsiness, tiredness, dizziness), [MEDICATION(S)] 500 mg, take 1 tablet at 5:00 pm for diabetes (high blood sugar)(side effects include stomach pain, nausea, vomiting, diarrhea), [MEDICATION(S)] 250 mg, take 1 tab at 5:00 pm for tremors(side effects include dizziness, nausea, vomiting); [MEDICATION(S)] 0.5 mg, take 1 tab at 5:00 pm for tremors(side effects include confusion, falling, hallucinations, drowsiness, swelling of the legs); [MEDICATION(S)] sodium 250, mg take 1 capsule at 5:00 pm for stool softener; senna 8.6 mg, take 2 tablets at 5:00 pm for constipation. An observation and interview on 9/7/2022, at 1:15 pm, with Resident 1, revealed Resident 1 in a recliner wheelchair, alert, and arms folded up. Resident 1 made unidentified noises when responding to questions. I was unable to understand him.[NAME] 100 mg capsule, [MEDICATION(S)] 0.25 mg tablet, [MEDICATION(S)] 500 mg tablet, [MEDICATION(S)] 250 mg tablet, [MEDICATION(S)] 0.5mg tablet, [MEDICATION(S)] 250 mg in error at 5:00pm. Resident 1 was observed for arrhythmia (irregular heartbeat), [CONDITION(S)] (slow heart rate), chest pain, dyspnea (shortness of breath), [CONDITION(S)] (swelling), [CONDITION(S)] (low blood pressure), orthostatic [CONDITION(S)] (low blood pressure when standing up), respiration depression, [CONDITION(S)] ([CONDITION(S)]), and weight gain. Resident 1 went to the emergency roiagnom on [DATE], at 2:13 am, for a heart rate of 46. Resident returned to facility on 9/2/2022 at 8:20 am, with normal vital signs. An observation and interview on 9/7/2022, at 1:15 pm, with Resident 1, revealed Resident 1 in a recliner wheelchair, alert and arms folded up. Resident 1 made unidentified noises when responding to questions and unable to be understood. An observation and interview on 9/7/2022, at 1:20 pm, with Resident 2, revealed he was alert and oriented and able to answer questions appropriately. Resident 2 and Resident 1 were roommates. An interview on 9/7/2022, at 1:28 pm, with the Director Of Nursing (DON), indicated that LN A worked on 9/1/22, and was assigned to pass medications to Resident 1 and Resident 2 that day. LN A was a registry nurse, and it was her first time working at this facility. During an interview on 9/7/2022, at 2:00 pm, with the Director Of Staff Development (DSD), she stated that she did not do medication pass orientation with registry nurses. During an interview on 9/7/2022, at 2:35 pm, with the DON, she confirmed that LN A gave the wrong medications to Resident 1. The DON indicated that a licensed nurse should verify which resident they are giving medications to by two of the four methods, by asking the resident their name, checking the picture on the MAR, checking their arm band or asking another care giver to verify the resident. The DON confirmed that LN A must have missed a step with the medication pass process. An observation on 9/7/2022, at 3:30 pm, of Resident 1, revealed Resident 1 had an armband on with his name on it for identification. During an observation and interview on 9/7/2022, at 3:31 pm, at medication cart 4 (a cart that holds residents ' medications), LN C verified that Resident 1 and Resident 2 ' s medications were all labeled with the appropriate names and had a divider between each resident ' s medications. The MAR ' s had pictures of each resident for identification. During a phone interview on 9/8/2022, at 9:00 am, with LN A, she confirmed that she gave Resident 1 the wrong medications on 9/1/2022 at 5:00 pm. She stated it was her fault because she did not check his arm band.

Based on observation, interview, and record review, the facility failed to implement COVID-19 (COVID-19, an acute respiratory illness caused by a coronavirus, capable of producing severe symptoms and in some cases death) strategies to mitigate the spread of the virus for 68 of 75 resdients (Residents 1-68) when the Yellow zone (quarantine for residents exposed to COVID-19 with a negative test or awaiting results within the last 14 days) was not designated to a separate location from residents in the Green zone (residents with COVID-19 negative results without known exposure within the last 14 days and recovered residents who have completed their isolation period ), and staff were not designated to the Yellow zone to avoid cross contamination. This failure had the potential to expose COVID-19 negative residents and staff to the virus. Findings: During an interview with the Director of Nursing (DON) and Infection Preventionist (IP), on 08/25/2021 at 10:04 AM, they stated as of 08/24/2021 there were three COVID positive staff in quarantine at home, and eight residents that tested COVID positive and were isolated in the Red zone of the facility, with 27 residents in quarantine. IP stated a staff member was tested (due to community exposure) on 08/17/2021 and received a positive result on 08/18/2021 and had contact with 10 residents on 08/17/2021. She stated the 10 residents have been placed in quarantine In a concurrent observation and interview with IP on nurse Station 1, on 08/25/2021 at 11:15 AM, it was noted that COVID-19 negative residents had a strip of green duct tape above the door frame to indicate the Green zone Resident rooms with person(s) under investigation (PUI) for the virus had a strip of yellow duct tape above the door frame to indicate the Yellow zone. IP stated the colors let staff know which residents are under quarantine and which residents are negative and in the Green zone. It was noted that both Yellow zone and Green zone residents were cohorted on the same unit or wing. A review of a facility policy titled [CONDITION(S)]-COV2/COVID-19 Mitigation Plan Requirements revised on 08/10/2021, stated All residents who are not suspected to be infected with COVID-19 are in rooms or units that do not include confirmed or suspected cases, unless they are already cohorted with a symptomatic or confirmed positive roommate. Further the policy stated, If multiple residents test positive in a specific wing/station of the Fountains, then that area will be re-zoned and residents moved accordingly. During a concurrent observation and interview with IP on nurse Station 1, on 08/25/2021 at 11:20 AM, it was noted that staff were entering both Yellow and Green zone resident rooms on the same unit/hallway. IP stated that they have designated staff for the Red zone, but the Yellow and Green zone do not have designated staff, as staff can take care of both residents in quarantine and in the Green zone on the same unit. A review of a facility policy titled Emergency Management-Pandemic-Fountains last reviewed on 06/16/2021, stated when a pandemic strain is detected within the facility to Cohort residents and staff on units with known or suspected cases. and to Limit exposure. During a concurrent interview of a facility record titled 24 Hour Daily Nursing Roster dated 08/25/2021, indicated that the current facility census was 143. In a concurrent interview with the Director of Staff Development (DSD), she confirmed the census was 143 and facility capacity was 145. She stated that were anticipating discharges on 08/25/2021 and would try to get residents from the Yellow and Green zone separated from each other. In an interview with the Administrator (AD), on 08/25/2021 at 12:34 PM, he stated Why do we need to have designated staff between the Yellow and Green zones? We follow the AFL 20-53.5 which says that we don't have to move residents from their rooms if they become quarantined. A review of an All Facilities Letter (AFL 20-53.5) from the California Department of Public Health, dated 08/03/2021, stated Place residents into three separate cohorts based on the test results, accordingly: Negative result but exposed within the last 14 days (yellow-exposed area); in general, all residents on the unit or wing where a case was identified in a resident or HCP are considered exposed and should remain in their current rooms unless sufficient private rooms are available; Negative result without known exposure within the last 14 days and recovered residents who have completed their isolation period (green area). During a concurrent observation and interview with a Certified Nursing Assistant (CNA) on nurse Station 3, on 08/25/2021 at 1:15 PM, CNA A stated that the yellow duct tape above the doorway to rooms [ROOM NUMBERS] indicated that the resident(s) in the rooms are Yellow zone and in quarantine, and the green duct tape above door to room [ROOM NUMBER] and 150 indicated that the resident(s) were in the Green zone and not in quarantine. She also stated that she changes PPE and performs hand hygiene when she comes out of the quarantined rooms before going into the Green zone rooms. A review of a facility record titled Station 3 AM Room Assignment dated 08/25/2021, indicated that CNA A was assigned on nurse Station 3 to resident rooms 147, 148, 149, and 150. During a review of a facility list of residents in quarantine, dated 08/17/2021-08/24/2021, it was noted on nurse Station 3 there were: 1. Two residents (Resident 74 and Resident 75) in room [ROOM NUMBER] started quarantine on 08/20/2021. 2. Two residents (Resident 80 and Resident 81) in room [ROOM NUMBER] started quarantine on 08/20/2021. During a review of a facility Resident census and floor map dated 08/25/2021, it was noted on nurse Station 3 that Residents 49 and 50 were in room [ROOM NUMBER] and considered to be in the Green zone and not in quarantine. A review of the Centers of Disease Control (CDC) titled -Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 02/23/2021, stated As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shifts.

Based on interview and record review, the facility failed to implement a plan of care and interventions for one of 24 sampled residents (Resident 18) and one out of sample resident (Resident 27) when: 1. Resident 27's pain management and psychosocial needs were not adequately assessed and treated when 26 of 37 pain medication doses were not reevaluated within a hour after given, the anxiety medication was not reevaluated for 12 of 15 doses after given, and the physician was not notified of the unresolved pain and anxiety. 2. Resident 18 did not have blood sugar monitoring for a total of 14 times and waited over 12 hours on [MEDICAL TREATMENT] (HD, a process for filtering blood to remove waste) days before a finger stick blood sugar (FSBS, blood test for sugar level) was checked on HD treatment days, three times a week. These failures resulted in Resident 27 suffering severe pain and anxiety and the potential for other residents' to have uncontrolled pain and for diabetic complications related to low or high blood sugar for Resident 18 and other diabetic residents. Findings: 1. Resident 27's record review indicated she was admitted to the facility on [DATE] from a hospital with [DIAGNOSES REDACTED]. Resident 27 was unable to make health care decisions for herself. The facility's policy titled, Resident Care Pain Management, dated 2/11/14, indicated, the purpose was To provide an accurate assessment of the resident's pain and respond in a timely manner with pain medication or non-drug intervention. Response to pain medication effectiveness shall be documented on the MAR within one hour of administration of a pain medication. Resident shall be assessed for environmental factors which may contribute to pain and address each issue. If pain has changed in nature or not relieved with current medication notify physician for a review of the medication. Document resident's complaint and response to interventions on the Medication Administration Record (MAR), Nurses Notes, Weekly Summary, and progress notes. The physician's orders [REDACTED]. of [MEDICATION NAME] (APAP) in 24 hours, [MEDICATION NAME] (used to treat moderate to severe pain) 5 mg/325 mg one tablet every 6 hours as need for pain 4-10 not to exceed 4000 mg of APAP in 24 hours. A review of the interdisciplinary nurses progress notes for March 2015 indicated the following: On 3/11/15 at 6:43 pm, Resident 27's pain was rated 7-8/10, severe; On 3/12/15 at 2:16 am, Resident very loud yelling on and off first part of shift increased pain right hip; On 3/13/15 at 3:36 am, Resident yelling loudly first part of shift, I hurt so bad here; On 3/15/15 at 1:53 am, Medicated for pain and anxiety; On 3/14/15 at 1:19 am, Yelling out, call the police I wanna go out from here, I am in a lot of pain; On 3/15/15 at 10:25 am, Increased anxiety with complaints of right hip pain; On 3/21/15 at 8:34 pm, Right hip incision red and hard to touch; On 3/22/15 at 9:04 am, Antibiotic therapy for right hip wound infection (No assessment of pain noted); On 3/22/15 at 9:16 pm, Complaints of pain right hip, medicated; On 3/23/15 at 8:53 pm, Resident yelling for help, redirected did not help. Medicated for pain and anxiety; and On 3/23/15 at 9:28 pm, Resident called granddaughter to report she had been kidnapped. On 3/24/15 at 6:45 pm, the medical doctor came in and stated Klonopin was not effective due to the daughter saying the resident was yelling out and not eating. Resident had been on [MEDICATION NAME] for 2 years prior to admission to facility. A new physician's orders [REDACTED]. The physician ordered the Klonopin (medication used to treat panic and anxiety) to be discontinued on 3/24/15. No change in pain medication orders was found in the record. The MAR's section titled, PRN results and documentation was reviewed from 3/1-3/31/15 and indicated the following for pain management: On 3/13/15 at 10:54 pm, Resident had right hip pain 7/10, Tylenol was given instead of [MEDICATION NAME]. (Tylenol was for pain 1-3 and [MEDICATION NAME] was indicated for pain 4-10); On 3/16/15 at 7:50 am, resident had general pain rated at 7/10, a [MEDICATION NAME] was given and she was not assessed post treatment until 11:39 am (3 1/12 hours later) and results were reported as Minimal help 3/10. Pain medication was not given again until 3 hours later for right hip pain 6/10. The physician was not notified of pain management needs; and On 3/18/15 at 12:41 am, resident had right hip pain rated at 8/10, she was not assessed until 5:59 am (4 1/2 hours later) and she stated her pain was 3/10. No pain medication was given until 12:15 pm, 6 hours later. The physician was not notified of pain management needs. The MAR results area was used to record the response of medication treatment for [REDACTED]. The facility's policy indicated, reassessment of pain will occur within one hour of pain medication administration. The documentation did not indicate any non pharmacological interventions attempted when the pain medication was ineffective, per the facility policy. There was no indication in the results area that the physician was notified of pain management needs. The MAR's section titled, PRN results and documentation was reviewed from 3/1-3/31/15 and indicated the following for anxiety management: On 3/16/15 at 7:26 pm, Resident was yelling for help. Klonopin was given. She was not reassessed until 9:32 pm (2 hours later). The note in the results read Not effective; On 3/18/15 at 12:40 pm, Resident was continuously yelling for help/shaking. Klonopin was given. She was not reassessed until 5:59 am (4 1/2 hours later), and the noted result indicated, Continuing to yell not effective; On 3/19/15 at 9:41 pm, Resident was anxious, yelling out for help. Klonopin was given at 9:41 pm and [MEDICATION NAME] for pain level of 7/10 at 10:10 pm. She was reassessed at 2:17 am (4-5 hours later) and the notation read, Not effective been yelling since 11 pm; and On 3/22/15 at 6:36 pm, Resident was yelling for help. Klonopin was given. She was reassessed at 9:10 pm (3 hours later) and it was noted, Not effective continues to yell for police. Pain medication was given at 6:33 pm before the Klonopin for pain. [MEDICATION NAME] pain medication was given at 12:07 am. Klonopin given at 12:40 am again for Constant yelling for help and shaking. A note at 4:44 am (4 hours later) read, Not effective resident calmed for approximately 1 hour this early am. No physician notification found in record of ineffective treatment of [REDACTED]. The right hip wound infection was identified on 3/21/15. The potential for increased pain documented on 3/22/15 was not identified by nursing staff and the changes were not communicated to the physician. The MAR results area was used to record the response of the medication treatment for [REDACTED]. The documentation did not contain any information that any non-drug interventions i.e. (Relaxing activities may include exercise, mindful breathing, sleep, rest, listening to tapes) were implemented for Resident 27's anxiety. There was no documentation found that the physician was contacted when the anxiety medication was ineffective on four different occasions. During an interview on 3/26/15 at 3:10 pm, Licensed Nurse (LN) P stated Resident 27 had been Calling out in anxiety and pain day and night since admission. LN P explained, You can hear her screaming all the way down at the nurses station. LN P stated the pain was related to her right hip surgery and the infection at the wound site. LN P explained Resident 27's constant screaming indicated that the Klonopin did not seem to be working. LN P stated Klonopin was discontinued and a [MEDICATION NAME] was started on 3/24/15. During a confidential interview with a resident on 3/26/15 at 3:15 pm, they stated Resident 27 had been screaming out in pain for a couple of weeks. The confidential resident stated the constant screaming interfered with their ability to sleep. The confidential resident had reported this to nursing staff and the social work department. The confidential resident stated it had improved just in the past few nights, though it was still happening. During a concurrent interview and record review on 3/26/15 at 3:45 pm, the Director of Nursing (DON) stated she was just recently made aware of Resident 27's screaming on 3/24/15. The nurses notes and MAR's were concurrently reviewed. The DON confirmed that there were no documented assessments of whether Resident 27's screaming was related to pain, anxiety, or both by nursing staff, and if the pain or anxiety medication regimen was adequate and effective. The DON stated that the pain medication order was for a wide range of pain 4-10 and there should have been another PRN order to deal with more severe pain. During an interview on 3/26/15 at 4:15 pm, the Social Service Director (SSD) stated she and her Social Service Assistant (SSA) were aware of Resident 27's screaming. A resident recently discussed the issue last week and the SSA offered to move the affected resident, who refused. SSD and SSA explained moving her would affect other residents as well. When asked if they informed the nursing staff of Resident 27's screaming affecting residents, SSD responded, no. 2. Resident 18's record review indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 18 was able to make health care decisions for herself. The physician's orders [REDACTED]. Resident 18 had orders for sliding scale insulin (used to manage blood sugar levels in diabetes which are based on FSBS results). Resident 18 had HD scheduled on Monday, Wednesday, and Friday at 5:30 am, three times a week. Resident 18 returned around lunch time from the HD center. A record review of Resident 18's FSBS on the Medication Administration Record (MAR) from 02/19-3/24/15 indicated there were no entries for FSBS for Resident 18 on the MAR for the days scheduled for HD; A total of 14 missing entries. The FSBS were scheduled on the MAR to be checked at 7 am, 11:30 am, 4:30 pm, and 10 pm. Resident 18 was out of the facility from 5:30 am until lunch time. The last blood sugars were done at 10 pm the night before HD. Resident 18 went over 12 hours on HD days before a FSBS was checked, for a total of 14 times. A record review of the document titled, Skilled Nursing Facility/[MEDICAL TREATMENT] Assessment Communication form (used to communicate between facility and HD center important resident specific assessment information), dated from 2/20-3/23/15, indicated, there were no FSBS results entered in the section labeled Diabetic today's FSBS am or pm. There were hand written entries by the facility in this area on 2/23, 2/25, 2/27, 3/2, 3/6, 3/9, 3/11, and 3/16/15 that noted no order to check FSBS before HD treatment. An entry on 2/15/15 further questioned the HD center Do you want to check this prior to [MEDICAL TREATMENT]? No response could be found in the post [MEDICAL TREATMENT] communication area used by the HD center. There was no record of any communication between the facility and HD center about blood sugar monitoring before, during, and after the HD treatment. During a concurrent record review and interview on 3/26/15 at 10:20 am with the Director of Nursing (DON) and Licensed Nurse (LN) E, they both stated checking a FSBS to determine if Resident 18's blood sugar was in a safe range was an important assessment before sending for HD treatment, and providing this information ensured continuity of care. The DON stated Resident 18 left before breakfast and was sent with a snack on HD treatment days. The DON and LN E confirmed there were no FSBS entries on the MAR's nor the facility HD communication forms upon Resident 27's return from treatment. The DON could not explain the notations by various staff no order to check FSBS before HD treatment. The DON confirmed the facility did not clarify with the HD center if this information was needed, prior to HD treatment, or if the HD center was checking blood sugars while at the center. The DON confirmed that the physician was unaware that the morning blood sugar was not performed on HD center visit days.

Based on observation, interview, and record review, the facility failed to perform comprehensive bladder function assessments and provide bowel and bladder programs to manage urinary incontinence for three of 24 sampled residents (Residents 2, 13, and 22) when: 1. For Resident 2, bowel and bladder function assessments were not performed quarterly and the resident was not assessed or provided services to address a decline in urinary continence (ability to control urine) for over one year. 2. For Resident 22, no comprehensive bowel and bladder function assessments were performed. 3. For Resident 13, the comprehensive bowel and bladder function assessment was not completed upon admission. These failures resulted in incontinence training not being provided and increased urinary incontinence for Residents 2, 13, and 22, and had the potential for bladder retraining services to not be provided to other residents with incontinence. Findings: 1. Resident 2's record was reviewed. Resident 2 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Sets (MDS, resident assessments), dated 11/19/14 and 2/19/15, indicated Resident 2 was frequently incontinent of urine and no trial toileting program had been attempted to assist Resident 2 to gain urinary continence. Resident 2 required extensive assistance of one staff for toileting and hygiene. Review of a Bowel and Bladder Assessment (B and B), dated 2/23/14, indicated Resident 2 had no history of urinary incontinence, has been 100% continent of bladder and bowel since 2-18-14. During an interview with the Director of Nurses (DON) on 3/26/15 at 10:30 am, she stated a B and B assessment which identifies the type of and risk factors for urinary incontinence was to be completed at least quarterly (four times per year) on all residents and confirmed that a B and B assessment had not been done for Resident 2 for over one year. The DON confirmed she could find no indication Resident 2's urinary incontinence had been assessed by the facility for possible participation in a bladder retraining program. The DON stated no particular staff member was managing a B and B retraining program in the facility to assess and manage residents' urinary incontinence, but night shift was supposed to be performing quarterly assessments. The policy titled, Bowel and Bladder assessment, dated 2/11/14, indicated the facility will Ensure that a resident who is incontinent of bowel or bladder receives the necessary care and treatment to . restore as much normal bladder function as possible. identify the type of urinary incontinence. 2. Resident 22's record was reviewed. Resident 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial MDS, dated [DATE], indicated the resident was occasionally incontinent, dependent upon staff for toileting, had no cognitive impairment, and had not been considered for a toileting program. Her most recent MDS, dated [DATE], indicated Resident 22 had increased from occasionally to frequently incontinent, was still dependent upon staff for toileting, and had not been considered for a toileting program. During an interview on 3/26/15 at 9 am, Licensed Nurse (LN) E, reviewed Resident 22's record. LN E confirmed the only B and B assessment found in the chart was blank (had not been completed). LN E stated she believed this documentation was in the computer system, but was unable to locate any documentation stating, this system is all new for us. LN E stated Resident 22 had mixed occasional incontinence but was unable to find any clinical assessments of her bladder function or incontinence care needs. LN E reviewed the MDS and confirmed that the resident had declined in function and had not been placed on a toileting program. During an interview and record review with the DON on 3/26/15 at 9:12 am, she stated that Resident 22 reported she was fully continent of urine upon admission to the facility. The DON confirmed that Resident 22 had not been assessed or considered for a toileting program and that she had a decline in function. The DON confirmed Resident 22 had a worsened pressure ulcer, which staff partly attributed to her incontinence. During an interview with MDS B on 3/26/15 at 2:05 pm, she stated Resident 22's worsened pressure ulcer was related to a lack of positioning and incontinent care provided while the resident is at [MEDICAL TREATMENT]. She was unable to state or locate documentation indicating any assessment or interventions taken by the facility to address Resident 22's incontinent needs while at [MEDICAL TREATMENT] or in the facility. 3. Resident 13's record was reviewed. Resident 13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admit MDS, dated [DATE], described Resident 13 as having the ability to comprehend instructions, required extensive assistance with hygiene and toileting, and was frequently incontinent of both bowel and bladder (loss of bowel and bladder control). There was no trial toileting program attempted to gain Resident 13's continence. An undated form titled, Bowel and Bladder Assessment, was reviewed. The assessment form contained the following information: Yes, indicating Resident 13 had a history of [REDACTED]. The rest of the information was not completed. There was no evaluation, recommendations for type of Bowel and Bladder program nor signature of staff who failed to completed and dated the form. On 3/26/15 at 9 am, a concurrent interview and record review was conducted with MDS A. MDS Nurse A stated the criteria for bowel and bladder training included the following: the ability for residents to comprehend, no behavior issues, and incontinence on admission. She stated the facility's process was to complete the Bowel and Bladder Assessment form and the Licensed Nurse (LN) would utilize the information to determine if Resident 13 needed a bladder retraining program. She stated the night nurse was responsible to initiate the form, but was not sure of who was responsible for providing oversight and management of all residents' bowel and bladder continence programs. MDS A stated the form should have been completed by the LN and confirmed that there was no documented evaluation. The facility policy and procedure titled, Bowel and Bladder Assessment, dated 2/11/14, indicated It is the policy of this facility to assess each resident's elimination status upon admission in order to determine the type of incontinence and the type of interventions to be used for minimizing complications.