Every finding on record at Health Center at Sinai Residences

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for 2 of 2 kitchen observations. It also failed to practice hand hygiene during meal observation for 4 of 4 residents observed during dining (Resident #35, Resident #48, Resident #15, and Resident #115). The findings included: In an observation conducted on 02/12/24 at 9:50 AM in the Main Kitchen, the reach-in Freezer was noted with an internal temperature of 20 degrees Fahrenheit and not at the recommended 0 degrees and below Fahrenheit. Closer observation revealed that some of the food items (breads) were soft to the touch. In this observation, Staff G (Cook) stated that the temperature of the reach-in Freezer is not within guidelines because it's been opened and closed all morning by staff members. A chart review revealed that Resident #35 was readmitted to the facility on [DATE]. The Modification Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #35 had a Brief Interview of Mental Status (BIMS) score of 14, which was cognitively intact. In an observation conducted on 02/13/24 at 8:17 AM, Staff E (Certified Nursing Assistant) brought the meal tray into Resident #35 ' s room. A closer observation did not show that Staff E encouraged or asked Resident #35 to clean his hands before touching his breakfast meal. A chart review revealed that Resident #48 was readmitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] showed that Resident #48 had a Brief Interview of Mental Status (BIMS) score of 15, which was cognitively intact. In an observation conducted on 02/13/24 at 8:40 AM, Resident #48 was noted in his room eating the breakfast meal. In this observation, Resident #48 said that they never ask him or remind him to wash his hands or clean his hands before eating. A chart review revealed that Resident #15 was admitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] showed that Resident #15 had a Brief Interview of Mental Status (BIMS) score of 15, which was cognitively intact. In an observation conducted on 02/13/24 at 8:41 AM, Resident #115 was noted in his room with the breakfast tray, which did not have hand sanitizer or sanitizing wipes to clean his hands. In this observation, Resident #115 stated that the Staff never told him to clean his hands before eating or encouraged/reminded him to wash his hands. A chart review showed that Resident #41 was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] showed no BIMS score for Resident #41. In an observation conducted on 02/13/24 at 8:45 AM, Staff D, a Certified Nursing Assistant, brought the breakfast tray into Resident #41's room. Staff D set up the tray for Resident #41 and left the room. In this observation, Staff D did not help Resident #41 clean her hands before she started eating. A second visit to the central kitchen conducted on 02/14/24 at 11:30 AM revealed that the reach-in Freezer had an internal temperature of 20 degrees Fahrenheit and not the recommended 0 degrees and below Fahrenheit. In this observation, Staff J, the Registered Dietitian, acknowledged that some of the food items (bread) in the reach Freezer were still soft to the touch, as observed on 02/12/24. Further observation revealed a metal container that had nine corn beef and cheese sandwiches cut in halves. Staff G was observed placing the metal container with the nine sandwiches on top of another metal container filled with ice. Staff G said that these are the sandwiches that are for the lunch meal today. Staff G took the temperature of one corn beef and cheese sandwich using the facility-calibrated thermometer. The temperature was noted at 53.9 degrees Fahrenheit and not the recommended 41 degrees Fahrenheit and below. Two other corn beef and cheese sandwiches were noted with a temperature of 50.7 degrees Fahrenheit and 53.2 degrees Fahrenheit and not the recommended 41 degrees Fahrenheit and below. In an observation conducted on 02/14/24 at 11:44 AM on the second-floor satellite Kitchen, Staff I, Culinary Laison, was observed taking a metal container that was noted with nine corn beef and cheese sandwiches cut in halves that were sent earlier from the central kitchen. Staff, I proceeded to take the temperature using a facility-calibrated thermometer of two corn beef and cheese sandwiches. One sandwich was noted at 51.0 degrees Fahrenheit, and the second sandwich was noted at 54.9 degrees Fahrenheit. Continued observation revealed Staff I plated the two corn beef sandwiches on a lunch plate and placed them on the meal cart that was getting ready to leave the kitchen to the floor. In an interview conducted on 02/15/24 at 10:30 AM with Staff D, the Certified Nursing Assistant stated that during mealtimes, she needs to place disposable hand sanitizer wipes on each meal tray so the residents can clean their hands. When asked about residents who cannot do it themselves, she said she does it for them. In an interview conducted on 02/15/24 at 11:00 AM with the facility's Administrator, he was told of the findings.

Based on observations, interviews, and record review, the facility failed to honor resident choices for showers for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADLs), Resident #219. The findings included: A review of the facility's policy titled, Bath; Shower/Tub, revised in February 2018, revealed the following: be sure that the bath area is at a comfortable temperature for the resident. In an interview conducted on 02/12/24 at 11:10 AM, Resident #219 stated that the water in his room was not cold enough and that he had told staff about it in the past. In an interview conducted on 02/13/24 at 2:39 PM with the Maintenance Director, he was told that Resident #219 complained that the hot water in his room was not working well. The Maintenance Director stated that he would follow up immediately with Resident #219. A chart review revealed that Resident #219 was admitted to the facility on [DATE] with diagnoses of Repeated Falls and Type 2 Diabetes. The Interim Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #219 had a Brief Interview of Mental Status score of 13, which is cognitively intact. The Resident Preferences Evaluation assessment dated [DATE] showed the following: when asked how important it was for Resident #219 to choose between a tub bath, shower, bed bath, or sponge bath, he said it was very important. When asked what his preference for bathing was, it showed showers. The Functional Abilities and Goals Admission assessment dated [DATE] revealed the following: Shower/bathe self: The ability to wash self, including washing, rinsing, and drying self (excludes washing of back and hair), Resident #219 needed substantial maximal assistance. In an interview conducted on 02/14/24 at 3:11 PM, Resident #219 stated that he has been at the facility for about three weeks and has only received one shower because the water temperature in the shower is too cold. According to Resident #219, he received sponge baths using a towel that was placed in the sink water, which was cold to the touch. He further said that he would like to shave every other day but does not because the water in the sink is too cold and never gets hot enough for him to shave often. Resident #219 stated that he loves taking showers and that he was not able to do so while in the facility. He reported that he told multiple staff members regarding the water temperature in his room, but nothing was done. In this interview, the Surveyor went into Resident #219 ' s bathroom and turned the hot water knob on for the sink. After waiting one minute (timed), the hot water in the sink was cold to the touch. The Surveyor proceeded to turn the hot water knob in the shower and waited one minute. After one minute, the hot water in the shower remained cold to the touch. A record review of the Certified Nursing Assistants (CNAs) documentation under the task section titled PRN (as needed) ADL-bathing (prefers to specify) revealed the following: question one regarding the bathing task completed showed yes. Section 2, regarding how the resident takes full body, baths/showers, and sponge baths, revealed the type of assistance that was provided but did not show what type of bath was given. The 3rd section asked if Resident #219 needed one-person assistance or two-person assistance with bathing, which showed the resident needed one-person assistance with baths. Interview with Staff A, Certified Nursing Assistant (CNA), on 02/14/24 at 3:52 PM, she stated that the residents are scheduled for baths on specific days noted in a shower book on the unit. She said that most residents get a bath three times a week, and some want their baths every day. When asked where she documents in the electronic system after she gives residents their baths, she said it is in the PRN (as needed) ADL-bathing (prefers to specify) and proceeded to show the Surveyor. Staff A was not able to show the Surveyor what type of bath was given under this documentation section of the electronic system. Further review of the shower book that was provided by Staff A did not show any documentation regarding showers for residents. In an interview conducted on 02/14/24 at 4:08 PM, Staff B, Certified Nursing Assistant, she stated that the PRN ADL-bathing (prefers to specify) section under the task is where she documents when a shower is given to any residents. According to Staff B, this section in the electronic system does not have a section where one can write what type of bath is given. In an interview conducted on 02/14/24 at 4:18 PM with Staff C, Certified Nursing Assistant, she stated that Resident #219 likes sponge baths and that this is his preference for bathing. Staff C reported that she uses the sink water to give Resident #219 his bath using a soaked towel. She then proceeded to walk into Resident #219 room and turn the hot water on in the sink. She waited about 30 seconds and said, I think it is getting warm. The Surveyor touched the hot sink water, which was Lukewarm to the touch. The Surveyor then asked Staff C if she thought this was warm enough; she then said, I guess it can be warmer. The Surveyor waited another minute and touched the hot sink water again, which felt the same. In an interview conducted on 02/14/24 at 4:50 PM with Resident #219, he stated that the Maintenance Director did not come into the room to look at the hot water temperature in his bathroom. When asked if another staff came to check the situation, he said no. In an observation conducted on 02/14/24 at 5:01 PM, accompanied by the facility ' s Administrator, Resident #219 's sink hot water was checked using the facility's thermometer. The temperature of the hot water took 5 minutes to get from 86.9 degrees Fahrenheit to 100.2 degrees Fahrenheit.

Based on observations, interviews, and record reviews, the facility failed to provide nutritional intervention in a timely manner for 1 of 3 sampled residents reviewed for nutrition (Resident #48). The findings included: A review of the facility's policy titled, Weight Recording, revised on 09/11/23, revealed the following: the nurse at each station is responsible for maintaining weights in the electronic medical record, verifying, and reporting any weight discrepancies of 3 pounds in a day and 5 pounds in a week or 5% in a month. The Registered Dietitian is responsible for any diet modifications necessary to stop any undesired weight changes. In an observation conducted on 02/13/24 at 8:40 AM, Resident #48 was noted in his room eating the breakfast meal. In this observation, Resident #48 was asked if he lost weight; he said yes and that it was not intentional. He further said that he had asked for nutritional supplements in the past to help with his weight loss and was given a few times. He stated he really likes the Ensure complete (nutritional supplement) chocolate flavor and would drink the supplements if provided. Record review revealed that Resident #48 was readmitted to the facility on [DATE] with diagnoses of Cancer, Depression, and Chronic Kidney Disease. The Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #48 had a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. A review of the Physician's orders showed an order for a regular diet, which was dated 01/14/24, but no nutritional supplements were ordered. The weight log showed the following weights recorded for Resident #48: 175 pounds noted on 01/15/24, 166 pounds noted on 01/24/24, and 155.2 pounds on 01/31/24. This showed that Resident #48 lost 5.1% severe weight loss in 9 days from 01/15/24 to 01/24/24. Resident #48 lost 11.3% severe weight loss in two weeks from 01/15/24 to 01/31/24. A review of the nutrition admission assessment dated [DATE] revealed the following: Resident #48 is at nutritional risk due to weight change, varying PO intake, refusal of nutritional supplements, and needs cues and encouragement for increased intake. Weight remains within the high end of the healthy weight range and noted with 10-13 pounds of weight loss in the last six months. The next nutrition progress note was not until 02/01/24, not addressing the severe weight loss noted on 01/24/24. The nutritional progress note dated 02/01/24 revealed the following: Resident #48 was noted with a further weight decline of 11.3% (19.8 pounds) from readmission on 01/15/24 to 01/30/24. It further showed that Resident #48 was eating between 50% to 75% of his meals. Resident #48 agreed to receive Ensure Complete (chocolate) twice a day to prevent further weight loss. A review of the Physician's orders did not show that an order was written for Ensure supplements two times a day, as noted in the nutrition progress note on 02/01/24. The nutrition care plan showed the following: The dietitian will evaluate and make diet changes and recommendations as needed, Resident #48 will be weighed at the same time of the day, and the weights will be recorded as per the facility's policy. In an interview conducted on 02/13/24 at 3:18 PM with Staff, H, the Registered Dietitian, she stated that she prints out a weekly report on all residents and reviews any weight changes of 3% plus or minus. The weight report usually runs on Wednesdays, and any weight changes will be identified on time. She often evaluates the accuracy of some of the weight changes and asks Staff to reweigh the residents again. They also conduct weekly weight meetings to discuss any significant weight losses that are noted. Staff H stated that she would provide nutritional supplements if needed to help with any weight loss that is identified. The Ensure Complete will give an extra 360 calories and 30 grams of protein per can. When asked what percent weight loss Resident #48 had from 01/15/24 to 01/24/24, she said 5.7% and acknowledged that it was a significant weight loss. According to Staff H, she only identified the significant weight loss on 02/01/24, which was about one week later. When asked why she did not order the nutritional supplements (Ensure) she recommended in her nutrition progress note on 02/01/24, she said, I do not know how it was missed.

Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to provide Activities of Daily (ADL) care, including fingernail grooming for 1 of 10 sampled residents observed, Resident #22. The findings included: Review of the facility policy and procedure titled Activities of Daily Living (ADL); Supporting, provided by the Director of Nursing (DON) revised March 2018 documented in the Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, oral care); Review of facility un-dated Certified Nursing Assistant (CNA) job description on 10/12/22 at 2:54 PM documented Purpose of Your Job Position: General Summary: The Nursing Assistant assists the licensed nursing staff by performing routine nursing duties and activities of daily living within the Skilled Nursing areas. Principles Duties: Essential Job Duties: 1. Assists residents with dressing, grooming, eating, bathing, positioning, turning, toileting and exercising . Resident #22 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) score, indicating moderately impaired cognition. During an initial observational screening tour conducted on 10/10/22 at 10:21 AM, Resident #22 was observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. Photographic evidence was obtained. On 10/10/22 at 10:25 AM a brief interview was conducted with Resident #22 in which she was asked if she prefers her fingernails long or if she would like to have her fingernails to be trimmed and cut, and she replied by saying that she remembers telling someone here about cutting and trimming her fingernails and making them pretty some time ago, but she stated that nothing happened and they were never done. During a second observational tour conducted on 10/10/22 at 12:27 PM, Resident #22 was still observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. During a third observational tour conducted on 10/11/22 at 10:12 AM, Resident #22 was still observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. During a fourth observational tour conducted on 10/11/22 at 1:30 PM, Resident #22 was still observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. During a fifth observational tour conducted on 10/12/22 at 10:11 AM, Resident #22 was still observed with long, dirty, sharp, unkempt fingernails on both hands: with some unidentified black matter located under three (3) of the five (5) fingernails on Resident #22's left hand. Record review of the Resident #22's Monthly CNA (Certified Nursing Assistant) ADL Flowsheet Record dated 09/29/22 thru 10/12/22 revealed that resident's (ADL)s for Personal Hygiene indicated that Resident #22 required limited to extensive assistance from facility staff. Record review of Resident #22's Care plan initiated 09/01/22 and revised 10/05/22 indicated Focus: Activities of Daily Living (ADL): Resident #22 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She is at risk for ADL/self-care performance deficit Interventions: She requires assistance of staff x1 with personal hygiene Goal: Resident #22 will improve current level of function through the review date. Further record review of the Minimum Data Set (MDS) sections A and G dated 09/05/22 for Resident #22 indicated that Resident #22 requires extensive assistance with personal hygiene, and she also requires one person physical assistance. An interview was conducted with Staff C, a CNA on 10/12/22 at 10:33 AM, which she revealed that they had not provided fingernail care to Resident #22 and she said that it is the responsibility of the CNAs to clean and trim the residents fingernails. She further acknowledged that the resident's fingernails were long, sharp, untrimmed, and unkempt. An interview was conducted with Staff D, a Licensed Practical Nurse (LPN) on 10/12/22 at 10:37 AM, regarding Resident #22's long, unkempt nails and she also agreed that Resident #22's fingernails were long, sharp, untrimmed and unkempt. An interview was conducted with the Activities Director on 10/12/22 at 10:50 AM in which she stated that her department has been doing fingernail polishing and filing for the residents, as requested or needed by the resident by either one (1) of her three (3) activities assistants. However, she added that her department is not allowed to cut any of the resident's fingernails. There is also a Beauty Salon located on the third floor and open on Mondays which can also only polish and file resident fingernails; no cutting. She added that if her staff were to see a resident with long, dirty fingernails that she would alert the nurse of the floor, wing or unit involved and to let them know to follow-up with the resident. The Activities Director said that her department had not provided any nail care service to Resident #22. The Director also acknowledged that Resident #22's fingernails were all long, untrimmed and unkempt. On 10/12/22 at 11:17 AM, an interview was conducted with Staff E, a Registered Nurse (RN), daytime Supervisor, regarding Resident #22's fingernails being long, sharp and untrimmed. She agreed that it is the responsibility of the CNAs to clean and trim the residents nails and she further acknowledged that the resident's fingernails were long and that they should have been cleaned/trimmed/cut. On 10/12/22 at 11:48 AM, an interview was conducted with the DON regarding Resident #22's fingernails being long, sharp and untrimmed and she also acknowledged that it is the responsibility of the CNAs to clean and trim the resident's nails and she further acknowledged that the resident's fingernails were long and that they should have been cleaned/trimmed/cut; this was not done. On 10/13/22 at 9:30 AM, a follow up observation was conducted of Resident #22, it was noted that her fingernails were now cut, neat and trimmed. She expressed to the surveyor that she was happy and pleased with her clean fingernails. Resident #22's fingernails were not cleaned and trimmed from 10/10/22 - 10/12/22, until after surveyor inquisition/intervention.

Based on observation, interview, and record review the facility failed to ensure an accurate nutritional assessment and failed to order an additional nutritional supplement to aid with wound healing for 1 of 3 sampled residents reviewed for nutrition (Resident #5). Resident #5 had a pressure ulcer, which would indicate a need for increased nutrition. The findings included: A chart review showed that Resident #5 was discharged to an acute care hospital on 06/30/22 and readmitted to the facility on [DATE]., with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, dated dated dated [DATE] showed that Resident #5 had a stage 4 pressure ulcer under section M for the skin. Section C showed that Resident #5 was severely cognitively impaired. In an observation conducted on 10/11/22 at 8:35 AM, Resident #5 was noted in bed. Staff B, Certified Nursing Assistant, was in the room assisting the Resident with her breakfast tray. Closer observation showed a tray with thickened liquids for the coffee and the juice. Weighted forks and knives were also noted on the plate with a scoop plate. Staff B encouraged the Resident to eat her meal and assisted her in grabbing the food with the weighted utensils. The care plan initiated on 07/09/20 for pressure ulcers showed that Resident #5 has a stage-4 pressure ulcer to her Sacro-coccyx. Alteration in nutritional status as evidence By potential for weight change and aspiration-related therapeutic and mechanically altered diet. It further showed that Resident #5 would consume adequate kcal/protein and fluids to meet estimated needs and prevent significant weight loss. A wound care note dated 07/11/22, which was three days after readmission, showed that Resident #5 was with a stage 4 sacrum wound. It further showed to maintain adequate nutrition and supplement to promote wound healing. A wound care note dated 07/18/22 showed that Resident #5 was with a stage 4 sacrum wound. It further showed to maintain adequate nutrition and supplement to promote wound healing. A wound care note dated 08/01/22 showed that Resident #5 was with a stage 4 sacrum wound. It further showed to maintain adequate nutrition and supplement to promote wound healing. A Dietary follow-up note written a day after readmission showed that Resident #5 was with a sacral wound and that she was going to be followed up by the Wound Care Team. Protein and vitamin intake appear to be adequate to meet needs for nutrition and wound healing. It was further documented that the Resident was also receiving Prostat (a protein supplement for wound healing). The Initial Readmission Assessment conducted on 07/11/22, which was four days after readmission, showed that the facility's Clinical Dietitian documented that Resident #5 had [CONDITION(S)] on the skin but did not document any staged four wounds. In this note, she further stated that Resident #5 is receiving Prostat (protein supplement for wound healing) and the that the protein and vitamins appear to be adequate to meet needs for nutrition and wound healing. A follow-up note dated 07/20/22 showed that Resident #5's appetite and intake are good to excellent, and there is no documentation regarding the stage four sacral wound. A Dietary follow-up note dated 07/29/22 showed that Resident #5 was receiving a Magic cup daily (a small container of an ice cream-like dessert with additional nutrients), to aid in protein intake and help with wound healing with an open area to the sacrum. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed that the order for Prostat twice a day was stopped on 07/01/22 and restarted on 07/09/22 but with only one scoop a day and not twice a day. A review of Resident #5's intake of meals documented by the CNAs (Certified Nursing Assistants) from 09/28/22 to 10/10/22 showed the following: Resident #5 ate two meals at 0 intakes, three meals between 26% to 50% intake, 12 meals between 76% to 100% intake, and 47 meals between 51 to 75% intake. In an interview, conducted on 10/12/22 at 1:27 PM with the facility's Clinical Dietitian, it was stated that residents who are admitted with stage 4 pressure ulcer wounds are considered high-risk residents. The protein needs will be assessed at higher needs, and she recommends Prostat for wound healing twice a day as well as a nutritional supplement. When asked why she did not document in her assessment that Resident #5 had a stage four pressure ulcer after she was readmitted . She said that she did not know that Resident #5 had a pressure ulcer wound. According to the Clinical Dietitian, after admission or readmission, the Wound Care Team will assess the residents. They will then send an email to the clinical staff to let them know if any residents have pressure ulcers and the stage. She further noted that she cannot see any of the wound care assessments in the current electronic system and must wait for the emails the Wound Care Team sends. When asked about the magic cup supplements, she stated that Resident #5 refused the supplements but was not able to provide any documentation regarding Resident #5 refusing the supplements. In an interview conducted on 10/12/22 at 1:35 PM, with the facility's Corporate Dietitian, she was told of the findings.

Based on observations and interviews, the facility failed to ensure daily nurse staffing was updated properly. The findings included: Multiple observations were made on 10/10/22 (9:40 AM, 10:20 AM, 12:05 PM, 2:08 PM) on the 3rd floor of the facility in between the East and West wings of the posted nurse staffing being dated 10/08/22. Photographic evidence obtained. An additional observation was made on 10/11/22 at 8:50 AM of this posted nurse staffing still dated 10/08/22. On 10/11/22 at 1:15 PM, the surveyor observed the facility Administrator changing this posted nurse staffing. Upon closer observation, the date on the new posted nurse staffing was 09/11/22. Photographic evidence obtained. An additional observation was made on 10/12/22 at 8:20 AM of this posted nurse staffing still dated 09/11/22. A tour of the facility was conducted on 10/12/22 at 11:20 AM with the facility Administrator. During this tour, the surveyor made the facility Administrator aware of this issue. He stated he would talk to the staffing office as they are responsible for updating these posted nurse staffing. An interview was conducted with the facility Director of Nursing on 10/13/22 at 11:22 AM. She stated she had talked to the staffing office, and they are aware of the issue and they will be more mindful of updating the posted nurse staffing daily.

Based on observations, interviews, and record review, the facility failed to ensure proper storage of medications. The findings included: Review of the facility policy titled Storage of Medications, revised April 2007 revealed the following: The Policy Statement states, The facility shall store all drugs and biologicals in a safe, secure and orderly manner. The Policy Interpretation and Implementation states, The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe and sanitary manner and Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. 1) During a tour of the facility conducted on 10/11/22 at 1:11 PM, the surveyor observed three medications which were left unattended in Resident #301's room. The three medications were observed to be an inhaler, an antibiotic to be infused through an intravenous line, and an unidentified white capsule in a medication cup. Photographic evidence obtained. Staff A was interviewed about these unattended medications. She stated she planned to administer these medications to Resident #301, but the therapy staff had taken Resident #301 to complete her therapy treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff A stated she would put the medications in the medication cart until Resident #301 was returned to her room. When the surveyor asked Staff A how much longer Resident #301 would be at therapy, she stated Resident #301 would return to her room in approximately 30 minutes from therapy. The surveyor stated she would return in 30 minutes to observe the medication administration. The surveyor then observed Staff A place the inhaler and intravenous antibiotic back into the medication cart. Review of Resident #301's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) During a tour of the facility conducted on 10/11/22 at 1:45 PM, the surveyor observed a white capsule on the floor in the main hallway in front of the medication cart on the 3-East wing near the nurse's station. Closer observation revealed this white capsule appeared to be the same [MEDICATION(S)] that had been taken out of Resident #301's room earlier. When Staff A was interviewed on 10/11/22 at 1:48 PM about this white capsule, she picked it up from the floor, took it to the medication room, and placed it in the bottle of Pill Buster in front of the surveyor. 3) Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) score of 12 (moderately impaired). During an initial observational screening tour conducted on 10/10/22 at 10:07 AM, it was observed that there was a used container of OTC [MEDICATION(S)] 20% cream medication in Resident #10's bathroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. Photographic evidence was obtained. 4) During a continued initial observational screening tour on 10/10/22 at 10:10 AM, it was also observed that there was a used tube of prescription [MEDICATION(S)] and [MEDICATION(S)] Diproprionate 1%/0.5% with an expiration date of 07/24 observed in plain sight in Resident #10's open bedside dresser drawer, visible, unattended, accessible to other residents, employees and visitors. Photographic evidence was obtained. During a second observational tour conducted on 10/10/22 at 12:42 PM, it was observed again that there was a used container of OTC [MEDICATION(S)] 20% cream medication still at the bedside of Resident #10's bedroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. And, it was also observed that there was a used tube of prescription [MEDICATION(S)] and [MEDICATION(S)] Diproprionate 1%/0.5% with an expiration date of 07/24 still observed in plain sight in Resident #10's open bedside dresser drawer, visible, unattended, accessible to other residents, employees and visitors. During a third observational tour conducted on 10/11/22 at 9:49 AM, it was observed again that there was a used container of OTC [MEDICATION(S)] 20% cream medication still at the bedside of Resident #10's bedroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. And, it was also observed that there was a used tube of prescription [MEDICATION(S)] and [MEDICATION(S)] Diproprionate 1%/0.5% with an expiration date of 07/24 still observed in plain sight in Resident #10's open bedside dresser drawer, visible, unattended, accessible to other residents, employees and visitors. During a fourth subsequent tour conducted on 10/11/22 at 1:30 PM, it was observed again that there was a used container of OTC [MEDICATION(S)] 20% cream medication still at the bedside of Resident #10's bedroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. And, it was also observed that there was a used tube of prescription [MEDICATION(S)] and [MEDICATION(S)] Diproprionate 1%/0.5% with an expiration date of 07/24 still observed in plain sight in Resident #10's open bedside dresser drawer, visible, unattended, accessible to other residents, employees and visitors. During a fifth observational tour conducted on 10/12/22 at 10:11 AM, it was observed again that there was a used container of OTC [MEDICATION(S)] 20% cream medication still at the bedside of Resident #10's bedroom with an expiration date of 03/2025 observed in plain sight, visible, unattended, accessible to other residents, employees and visitors. An interview was conducted with Resident #10's Staff F, a private duty aide, on 10/11/22 at 1 PM in which she was asked about the OTC cream medication located in Resident #10's bathroom, and she acknowledged that the cream medication was there, and she added that it is applied Resident #10's buttock area. On 08/05/22 the Treatment Administration Record (TAR) documented Skin barrier cream to buttocks during toileting or adjusting in bed to prevent skin breakdown. Every day and night shift for skin integrity. And, on 10/03/22 the TAR also documented [MEDICATION(S)] Cream 1-0.05% ([MEDICATION(S)]-Betamethsone) Apply to groin topically two times a day for rash for fourteen (14) days, as being initialed and administered by facility nursing staff. However, both the prescription and OTC cream medications remained unattended and accessible at Resident #10's bedside. An interview was conducted on 10/12/22 at 11:06 AM with Resident #10's nurse, Staff D, a Licensed Practical Nurse (LPN) regarding the prescription and OTC cream medications observed in Resident #10's bathroom and she acknowledged that the prescription and OTC cream medications should not have been there. During an interview conducted on 10/12/22 at 11:13 AM with Staff E, a Registered Nurse (RN), daytime Supervisor, she indicated this resident does not self-administer any of her own medications and neither was she assessed to be able to do so. Side-by-side record review was conducted with Staff E, in which it was noted that neither Resident #10's hard copy chart nor her computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for her to be to administer her own medications. In fact, the tube of prescription medication and the container of OTC cream medication was not removed from this resident's bedside along with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/22 at 11:50 AM the DON further acknowledged and recognized that the prescription and OTC cream medications should not have been left at the resident's bedside.

Based on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: During tour of the kitchen conducted on 08/09/21 at 8:52 AM, accompanied by the Executive Chef, the following were noted: a. Third Floor Kitchen: 1. The True reach-in freezer located under the prep table was observed with a wet, gray residue on the top gasket of the door and with brown debris on the bottom gasket of the door. 2. The floor underneath the prep table was observed with an accumulation of debris. 3. The floor underneath the beverage dispenser table was observed with an accumulation of debris 4. At the request of the surveyor, the chemical concentration of the cleaning cloth bucket located next to the handwashing sink was tested by the Executive Chef. The result of the chemical testing revealed that the cleaning cloth bucket had a concentration of 100 parts per million (ppm). The Executive Chef stated that the concentration of the cleaning cloth bucket was below the required regulatory concentration of 200 ppm. 5. At the request of the surveyor, the chemical concentration of the cleaning cloth bucket located next to the prep sink was tested by the Executive Chef. The result of the chemical testing revealed that the cleaning cloth bucket had a concentration of 100 ppm. The Executive Chef confirmed that the concentration of the cleaning cloth bucket was below the required regulatory concentration of 200 ppm. 6. In the reach-in refrigerator, one plastic take-out container was observed with lettuce, capers, sliced tomatoes, sliced cucumbers, sliced [NAME], and a sliced hardboiled egg. Closer observation showed that the container was labeled with a preparation date of 08/02/21 and was designated for the resident in room #327. Staff A, Dietary Aide, was asked about the container and stated that the resident in room #327 had asked the kitchen to hold onto this food item to have at a later time. She further stated that the resident did not like to waste food. When asked if this was safe to serve 7 days after it had been prepared, the Executive Chef stated, I wouldn't serve it. The Executive Chef then asked the Registered Dietitian (RD) about the container and she stated that the items in the container were only good for 3-4 days after preparation. She further stated that she was on vacation and was going to discard the container this morning. The Executive Chef then stated that staff needed to be re-educated. 7. The area around the dumpster was observed with clear gloves and blue gloves on the ground. The Executive Chef stated that he thought that housekeeping was responsible for maintaining the dumpster area. b. Second Floor Kitchen: 8. In the dry storage area, one, 63.4 ounce can of [NAME] Sliced Water Chestnuts was observed with a dent on the seal of the can. 9. At the request of the surveyor, the chemical concentration of the cleaning cloth bucket located on a utility cart was tested by the Executive Chef. The result of the chemical testing revealed that the cleaning cloth bucket had a concentration of 100 ppm. The Executive Chef confirmed that the concentration of the cleaning cloth bucket was below the required regulatory concentration of 200 ppm. He further stated that a company (Proctor and Gamble) came out last week to adjust the sanitation solutions for the second and third floor kitchens. During observation of breakfast tray line on 08/10/21 at 7:27 AM in the third floor kitchen, accompanied by the Executive Chef, the following were noted: 10. At the request of the surveyor, the Executive Chef checked the temperature of the hardboiled eggs from the hot holding unit with the facility's calibrated metal stemmed thermometer. The temperature test revealed that the temperature of the hardboiled eggs was 120 degrees Fahrenheit (F). The Executive Chef confirmed the temperature reading and stated that it was ok if the hardboiled eggs were not at the regulatory temperature of 135 degrees F or above because the eggs were pasteurized. During a phone interview conducted on 08/10/21 at 3:38 PM, the Food Safety Specialist from the United States Department of Agriculture (USDA) Meat and Poultry Hotline stated that hardboiled eggs were required to be kept in hot holding at a temperature of 135 degrees F or higher. He further stated that this guideline applied to both pasteurized and unpasteurized hardboiled eggs. During an observation of the lunch tray line conducted on 08/11/21 at 11:37 AM, accompanied by the Executive Chef, RD, and Consultant RD, the following were noted: c. Third Floor Kitchen: 11. At the request of the surveyor, the Consultant RD checked the temperature of the cinnamon baked apples and pureed cinnamon baked apples with the facility's calibrated digital thermometer. The temperature test revealed that the temperature of the cinnamon baked apples was 45 degrees F and that the temperature of the pureed cinnamon baked apples was 46 degrees F. A second temperature test was conducted on a second cup of cinnamon baked apples. The second temperature test revealed that the temperature of the cinnamon baked apples was 46 degrees F. The Executive Chef stated that the cinnamon baked apples had been kept in the refrigerator for the past 2 days. The Executive Chef, Consultant RD, and RD confirmed all temperature readings and acknowledged that the cinnamon baked apples and pureed cinnamon baked apples were not at the regulatory temperature of 41 degrees F or below. 12. The RD was observed standing next to the tray line without wearing a hairnet. The surveyor informed the Executive Chef and Consultant RD who acknowledged the surveyor's observations and instructed the RD to put on a hairnet. The RD then stated that her hairnet must have fallen off. d. Second Floor Kitchen: 13. At the request of the surveyor, the Consultant RD checked the temperature of the coleslaw with the facility's calibrated digital thermometer. The temperature test revealed that the temperature of the coleslaw was 51 degrees F. The Consultant RD stirred the coleslaw and attempted a second temperature test which revealed that the coleslaw was 50 degrees F. Staff B, Dietary Aide, stated that the temperature of the coleslaw was 52 degrees F at 11:35 AM. He stated that he immediately placed the coleslaw in the freezer, kept it there for 20 minutes, and then pulled it out of the freezer right before the surveyor requested the temperature test. The Consultant RD and Executive Chef confirmed the temperature readings and acknowledged that the coleslaw was not at the regulatory temperature of 41 degrees F or below.

Based on interviews, observations, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment in resident rooms throughout the facility. The findings included: Review of the facility's policy titled, Resident Rooms, dated 2019, documented the following: All areas within the Health Center will be cleaned daily according to specific procedures and prescribed quality standards. These areas include but are not limited to: resident rooms. Review of the record showed that Resident #22 was admitted to the facility on [DATE] with the following diagnoses: Unsteadiness on Feet and Abnormalities of Gait and Mobility. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #22 had a Brief Interview for Mental Status (BIMS) of 11, which indicated that he was moderately cognitively impaired. Review of the record showed that Resident #59 was admitted to the facility on [DATE] with the following diagnoses: Unspecified Fall and Abnormalities of Gait and Mobility. Review of Section C of the MDS dated [DATE] showed that Resident #59 had a BIMS of 11, which indicated that she was moderately cognitively impaired. Review of the record showed that Resident #328 was admitted to the facility on [DATE] with the following diagnoses: Unspecified Fall and Abnormalities of Gait and Mobility. Review of Section C of the MDS dated [DATE] showed that Resident #328 had a BIMS of 15, which indicated that she was cognitively intact. During an observation conducted in Room #216 on 08/09/21 at 10:43 AM, the wooden foot board of the bed was torn and chipped. During an observation conducted in Resident #22's room on 08/09/21 at 11:02 AM, black marks were observed on the wall over the right side of the head of the bed. Resident #22 and his wife stated that they thought the black marks might have been caused by the bed scraping against the wall as it moved up and down. During an observation conducted in Resident #59's room on 08/09/21 at 11:10 AM, the wooden foot board of the bed was torn and chipped, multiple spots of white residue were observed on the carpet, and about 3 pairs of clear gloves were observed on bathroom floor. During an observation conducted in Resident #328's room on 08/09/21 at 11:24 AM, the wooden foot board of the bed was torn and chipped. During an observation conducted in Room #220 on 08/09/21 at 11:27 AM, the wooden foot board of the bed was torn and chipped. During an observation conducted in Room #225 room on 08/09/21 at 11:55 AM, the wooden foot board of the bed was torn and chipped. During an observation conducted in Room #227 on 08/09/21 at 12:02 PM, the wooden foot board of the bed was torn and chipped. During a second observation conducted in Resident #59's room on 08/09/21 at 12:33 PM, the wooden foot board of the bed was still torn and chipped, and multiple spots of white residue were still observed on the carpet. During a third observation conducted in Resident #59's room on 08/11/21 at 12:39 PM, the wooden foot board of the bed was still torn and chipped, and multiple spots of white residue were still observed on the carpet. During a tour of the facility conducted on 08/12/21 at 7:40 AM, accompanied by the Director of Environmental Services and the Plant Operations Manager, the following were noted: 1. Room #216: The wooden foot board of the bed was torn and chipped. 2. Resident #22's Room: Black marks were observed on the wall over the right side of the head of the bed. The Plant Operations Manager stated that the room might have a pending work order. 3. Resident #59's Room: The wooden foot board of the bed was torn and chipped, and multiple spots of white residue were still observed on the carpet. Resident #59 stated that the white spots on her carpet were from an ointment that she used. According to her, the ointment had gotten on her bedsheets, which then touched the carpet, leaving behind the spots of white residue in her carpet. 4. Resident #328's Room: Resident #328 stated that the bed that was observed by the surveyor on 08/09/21 had been removed from the room on 08/11/21 as she required a rented bed. The Director of Environmental Services stated that even though the original bed was not in the room during the tour, the torn and chipped wooden foot board observed by the surveyor on 08/09/21 would still need to be addressed by maintenance because the original bed would be brought back into the room once the rented bed was returned. 5. Room #220: The wooden foot board of the bed was torn and chipped. 6. Room #225: The wooden foot board of the bed was torn and chipped. 7. Room #227: The wooden foot board of the bed was torn and chipped. The Plant Operations Manager stated that he had been working in the facility for almost 1 year and that that he had been aware of the torn and chipped wooden foot boards. According to him, the foot boards of the beds had been like this since he started working in the facility. He further stated that he did not have any documentation regarding the torn and chipped foot boards as all conversations were done verbally. 8. Room #228: The wooden foot board of the bed was torn and chipped. Following the environmental tour, an interview was conducted with the Director of Environmental Services and the Plant Operations Manager to confirm the findings of the tour. The Director of Environmental Services and the Plant Operations Manager stated that work orders for maintenance and housekeeping were placed electronically. According to them, only receptionists, nursing, and directors were able to place work orders into the electronic system. Once a work order was placed, the Director of Environmental Services and the Plant Operations Manager would receive a notification via email of any new work orders. During an interview conducted on 08/12/21 at 8:52 AM, the Director of Environmental Services stated that housekeeping was able to remove the multiple spots of white residue in the carpet of Resident #59's room. During an interview conducted on 08/12/21 at 8:53 AM, the Plant Operations Manager stated that Resident #22's room was on a quarantine hold which began on 08/10/21. According to him, this meant that maintenance and housekeeping were not allowed to go into the room until they received an email from the Administrator. He further stated that Resident #22's room was not on a quarantine hold prior to 08/10/21 and that maintenance and housekeeping would have been allowed to go in his room.

Based on observations, interviews, and record review, the facility failed to provide nutritional assessments and interventions in a timely manner for 3 out of 5 sampled residents reviewed for nutrition (Resident #13, Resident #22, Resident #327). The findings included: Review of the facility's policy titled, Weight Assessment and Intervention, revised on September 2008, documented the following: (1) Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. (2) The dietitian will respond within 24 hours of receipt of written notification. (3) The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater than 5% is severe, 3 months - 7.5% weight loss is significant and greater than 7.5% is severe, 6 months - 10% weight loss is significant and greater than 10% is severe. Review of the facility's policy titled, Weight Recording, revised on 07/10/19, documented the following: The Registered Dietitian (RD) is responsible for any diet modifications necessary to stop any undesired weight changes. Review of the facility's RD Job Description, updated on July 2015, documented the following: Essential Job Duties - Maintains pertinent and appropriate records, reports, schedules, and studies as required by local, state, and federal regulations. 1. Review of the record showed that Resident #13 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that a Brief Interview for Mental Status (BIMS) was not conducted as Resident #13 was rarely/never understood. Review of the Care Plan dated 07/20/21 documented that Resident #13 had an alteration in nutritional status. Review of the weight history showed that Resident #13 weighed 190.6 pounds (lbs.) on 07/19/21 and 179.4 lbs. on 07/24/21. This showed that Resident #13 experienced a 5.8% severe weight loss in 5 days. Review of the Nutrition Evaluations showed that the last evaluation was conducted on 03/12/21. Review of the Dietary Progress Notes showed that the last progress note was conducted on 06/23/21. This showed that there were no Nutrition Evaluations or Dietary Progress Notes regarding the 5.8% severe weight loss that occurred between 07/19/21 - 07/24/21. During an interview conducted on 08/11/21 at 8:03 AM, the RD and Consultant RD stated that they were responsible for conducting initial assessments, annual assessments, significant change assessments (based on the MDS), quarterly progress notes, and progress notes for dietary consults, wound reports, and weight reports. According to them, all notes were documented in MyUnity (electronic charting system). When asked about weights, they reported that weights were documented in MyUnity under the Vitals tab. The Consultant RD further reported that there was also a weight sheet that was kept at each nursing station. They stated that a significant change in weight would be 5% in 30 days, 7.5% in 90 days, 10% in 180 days, or 3% from one weight to the next regardless of the timeframe. The RD further stated that once a significant weight loss was identified, she would try to follow up with the resident within 24 hours. When asked about Resident #13's 5.8% severe weight loss, the RD stated that she obtained a re-weigh and spoke with Resident #13 and his wife where they stated that weight from 07/19/21 was not accurate. When asked where this was documented, the RD confirmed that there were no nutritional evaluations or progress notes to show that she had followed up with Resident #13 following his 5.8% severe weight loss. She further stated that she should have written a note updating the weight status. The RD then changed the record by inactivating the weight of 190.6 lbs. from 07/19/21 from MyUnity during the conversation with the surveyor. 2. Review of the record showed that Resident #22 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the MDS dated [DATE] documented that Resident #22 had a BIMS of 11, which indicated that he was moderately cognitively impaired. Review of the Care Plan dated 06/25/21 documented that Resident #22 had an alteration in nutritional status as evidenced by potential for weight change related to varying po intake, weakness, [CONDITION(S)], and previous history of weight loss. Review of the weight history showed that Resident #22 weighed 196.2 pounds (lbs.) on 07/10/21, 189.4 lbs. on 07/19/21, 188.4 lbs. on 07/25/21, and 183.8 lbs. on 07/31/21. This showed that Resident #13 experienced a continuous downward trend in weight with a 6.3% significant weight loss from 07/10/21 - 07/31/21 (21 days). Review of the Nutrition Evaluations showed that the last evaluation was conducted on 06/24/21. Review of the Dietary Progress Notes showed that the last progress note was conducted on 06/28/21. This showed that there were no Nutrition Evaluations or Dietary Progress Notes regarding the 6.3% significant weight loss that occurred between 07/10/21 - 07/31/21. During an interview conducted on 08/09/21 at 11:02 AM, Resident #22 and his wife stated that Resident #22 had lost some weight during his stay. Both were unable to recall how much weight was lost or the timeframe in which the weight loss occurred. During an interview conducted on 08/11/21 at 8:03 AM, the RD was asked about Resident #22's 6.3% weight loss and stated, The weight on 07/31/21 was an outlier. I spoke with the family and private aide. I saw him eat a lot and I know that he didn't lose weight. It happens often that there are weights that are outliers and I don't always have a chance to go back and inactivate them all. When asked where this was documented, the RD confirmed that there were no nutritional evaluations or progress notes to show that she had followed up with Resident #22 following his 6.3% significant weight loss. She further stated that she should have written a note updating the weight status. The Consultant RD brought the weight sheet from the nursing station and confirmed that the weight for 07/31/21 was 183.8 lbs. The RD then stated, In my mind he was stable because he was eating well and had no other issues. 3. Review of the record showed that Resident #327 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the MDS dated [DATE] documented that Resident #327 had a BIMS of 15, which indicated that he was cognitively intact. Review of Section M of the MDS dated [DATE] documented that Resident #327 had one stage 4 pressure ulcer. Review of the Care Plan dated 05/26/21 documented that Resident #327 had an alteration in nutrition status as evidenced by potential for weight change related to open areas. Review of the Dietary Progress Note dated 03/10/21 documented that Resident #327's intake varied greatly from 25-75% of meals and that Resident #327 continued to receive Ensure Max (nutritional supplement) twice per day. It was further documented that Resident #327 complained of lack of hunger and would be receiving an appetite stimulant. The RD further recommended to increase Ensure Max to three times per day. Review of all orders from February 2021 - August 2021 showed that Resident #327 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of all orders showed that no orders were placed for Ensure Max three times per day. During an interview conducted on 08/11/21 at 8:03 AM, the RD and Consultant RD reviewed all orders in MyUnity and confirmed that there were no orders for Ensure Max three times per day. The Consultant RD reviewed the telephone orders from the paper chart and confirmed that there were also no telephone orders for Ensure Max three times per day. The RD stated, His weight has been fluctuating and I think we ended up not giving him any Ensure at the end of it all. When asked where this was documented, the RD confirmed that she did not have any to show why her recommendation for Ensure Max three times per day was not ordered. The RD and Consultant RD further acknowledged that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation and interview, it was determined that the facility failed to provide food service to ensure the required storing, preparing, distribution, and serving of food in accordance with professional standards for food service safety. The findings included: 1) During the observation of the breakfast meal service in the second floor satellite serving kitchen conducted on 12/03/19 at 7:30 AM accompanied with the Certified Dietary Manager (CDM), the temperatures of foods being held for the meal were taken with the facility's calibrated digital thermometer. The findings of the temperature testing revealed that hot foods were not being held at the regulatory required minimum temperature of 135 degrees (Fahrenheit). The findings revealed the following: Sausage Links = 115 F Fried Eggs = 119 F Hard Boiled Eggs = 117 F Poached Eggs = 124 F Waffles = 110 F Egg Omelets = 130 F During the observation and temperature testing it was noted that the steam table top and basins (4) were not hot to the touch. The water located in the basins was also not hot to the touch. Interview with the dietary staff at the time of the observation revealed that the steam table is not tuned on until the opening time of 7 AM. It was discussed with the CDM that there is insufficient time to properly heat up the steam table to be able to hold hot foods at the minimum regulatory temperature requirement of 135 degrees F . 2) During the observation of the breakfast meal service in the third floor food preparation/serving kitchen conducted on 12/03/19 at 8:00 AM accompanied with the Certified Dietary Manager, the temperatures of foods being held for the meal were taken with the facility's calibrated digital thermometer. The findings of the temperature testing revealed that hot foods were noted being held at the regulatory required minimum temperature of 135 F and cold foods at the required minimum temperature of 41 degrees F. The findings revealed the following: Raw Eggs = 50 F Poached Eggs = 124 F Liquid Egg Product (quarts Containers) = 49 F Milk (8 ounce Carton) = 50 F Orange Juice (4 ounce portions ) = 55 F Cream Cheese (individual Portions) = 63 F 3) During the observation of the lunch meal service in the third floor preparation/serving kitchen on 12/04/19, the temperature foods being held for the meal service were taken by the use of the facility's calibrated digital thermometer. The results of the temperature test indicated that hot foods were not being maintained at the regulatory requirement of 135 degrees F or above and cold food regulatory requirement of 41 degrees F or below. The temperatures were recorded as follows: Flank Steak = 128 degrees F Pasta Salad = 40 degrees F 4). In a dining observation conducted on12/02/19 at 12:16 PM, Staff B/ a Certified Nursing Assistant was observed pushing a cart with 3 lunch trays on it. She entered room [ROOM NUMBER], proceeded to set up Resident #165's lunch tray on her over bed table, she uncovered the resident's beverages and soup, exited the room without sanitizing or washing her hands. Staff B then proceeded to enter room [ROOM NUMBER]. Staff B touched Resident #166's shoulder, uncovered resident's beverages and soup, exited the room without sanitizing or washing her hands. Staff B then proceeded to enter room [ROOM NUMBER]. She proceeded to set up Resident #167's meal. Staff B touched all items on resident's bedside table including the table, she uncovered resident's soup and beverage, unwrapped the silver ware, grabbed the spoon by the handle, and placed it in the residents soup. In an interview conducted with Staff B on 12/02/19 at 12:22 PM she confirmed the findings.

Based on observation, interview, record review and policy review, the facility failed to implement their policies and procedures and did not perform a criminal history background screening for 1 of 10 (Staff A) sampled employee records reviewed. The findings included: Record review of the facility's policy titled, Abuse Prevention Policy, dated 07/2019, revealed that the facility has established policies and procedures that will provide personnel ( including consultants, contractors, volunteers and other caregivers who provide care and services to residents) with the knowledge to further ensure each resident is treated with individual respect and dignity. The community will not knowingly employ any individual convicted of resident abuse, neglect or misappropriation of property. The community will not knowingly employ any direct care staff convicted of any disqualifying crimes or with a finding of abuse listed on the appilcable nursing personnel registry or criminal history background check. Prior to a new employee starting a work schedule, this community will: obtain a limited criminal history for nurses aides and other unlicensed employees. During a tour conducted of the facilty's 3rd floor on 12/02/19 at 9:20 AM, a sign was observed on a locked door that indicated Salon. A review of the facility provided list of staff on 12/03/19 revealed that there was no cosmetologist listed. In an interview conducted on 12/03/19 at 2:10 PM with the Director of Human Resources, she stated she did not have a file for the cosmetologist and did not know her name. In an interview conducted on 12/03/19 at 2:30 PM with the Administrator, he stated that he does not have a file for the cosmetologist and did not know her name, but that he has a contract for salon services with a contractor. He further stated that the facility pays the contractor who in turn pays the cosmetologist, as she is their employee. He also stated that he would furnish the cosmetologist's license for review. In a subsequent interview with the Administrator he confirmed that the cosmetologist does not have a background screening, and that salon services have been suspended until an eligible background screening is obtained for Staff A/ cosmetologist. In a telephone interview conducted on 12/04/19 at 10:26 AM with a representative for the salon contractor, she reviewed the personnel file for Staff A, she stated that Staff A's date of hire was 08/11/17, she confirmed that Staff A does not have a background screening, an attestation of compliance and that she is not in the clearinghouse roster. She further stated that they usually leave the background screening component up to the facilities, as it is easier for them to obtain it and that way they have a copy for their files. She added that facilities can put the individual on their roster and if there is a problem they are notified. Upon review of Staff A's cosmetologist license and a search of the Florida Agency for Health Care Administration background screening website revealed that Staff A did not have a Level II background screening in the system. Review of Contractor log for cosmetology services from 9/5/19-11/26/19 revealed services provided to skilled nursing home residents included manicure, cutting fingernails, color, hair cut, eyebrow and lip wax. A review of the Salon and Spa services menu revealed that personal care services such as shampoo, haircut, style, beard and moustache trim, comb out, perm, hair color, manicure, pedicure, tweezing and hair removal services are offered. A review of the facility's resident handbook provided to residents in the admission packet revealed that Salon Services are offered by the facility by licensed staff for residents and guests, the salon is located on the 3rd floor and arrangements may be made by calling the concierge, and the hours are Wedsneday 9am-12pm, Thursdays and Friday 9am- 1:30 pm.

Based on observation, interview, and record review, it was determined that the facility failed to follow the approved menu entree portion for 4 non-sampled residents receiving a regular diet, and 2 (Resident #33 and #60) of 2 sampled resident's receiving a physician ordered Mechanical Soft diet. The findings included: During the review of the approved menu for the lunch meal of 12/04/19 it was noted that the documented serving size of the Regular Diet- Flank Steak was a minimum 3 ounce portion. It was also noted that the documented serving size of the Mechanical Soft Diet was also a minimum 3 ounce portion of ground Flank Steak. During the observation of the lunch meal service in the Third Floor preparation/serving kitchen, the surveyor requested that a standard portion of the Regular Flank Steak and Ground Flank Steak be weighed, by utilizing the facility's calibrated portion scale by the facility's CDM. A resident's serving of the regular and ground Flank Steak were selected and weighed. The weight of the regular steak was recorded at 1.25 ounces and the weight of the ground steak was recorded at 2.0 ounces. The facility's Chef who was present for the weighing stated that he was unaware that 3 ounces of the steak was documented on the approved menu and that a standardized portion was not weighed by the cooks who were serving on the lunch tray production line. It was further discussed with the Certified Dietary Manager (CDM) that the serving portion on the protein entree was insufficient and that the approved menu was not being followed for the meal. Following the observation, it was determined through the CDM that the insufficient protein entrée portion effected only 6 facility resident who had selected the steak entree for the lunch meal . Further review indicated 4 of the non-sampled residents were receiving physician ordered regular diets and 2 sampled facility residents were receiving physician ordered Mechanical Soft diets that included Resident #33 and Resident #60.

Based on observation and interview, the facility failure to prepare distribute and serve foods in accordance with the professional standards for food service safety. The findings include: During a tour of the satelite kitchen on the second floor on [DATE] at 9:15 AM, accompanied by the lead Diet Aide (Staff J) the following was noted: 1) Observation of the reach in refrigerator revealed that there was a 5 lb. container of cottage cheese with an expiration date of [DATE]; and a 1 gallon container of skim milk with an expiration date of [DATE]. 2) Observations noted 1 of 2 Diet Aides (Staff I) preparing and serving in the kitchen had facial hair and was not wearing a beard gaurd. On [DATE] at 12:04 PM, in a interview with the RD (Registered Dietician), she stated that she had inspected the refrigerator on [DATE] and the staff was told to discard the expired items.

Based on observation, interview and record review, the facility failed to check for tube feeding placement and residual prior to feeding and medication administration; and failed to obtain a physician order for [REDACTED]. The findings included: Review of the facility policy titled Medication administration through an Enteral Tube effective 10/31/16, documents facility should check the placement of .gastrostomy tube in accordance with facility policy .insert a small amount of air into the tube with a syringe and listen with stethoscope for placement . Review of the facility policy titled Enteral Nutrition revised (MONTH) 2014 documents Risk for aspiration will be assessed by the nurse .risk of aspiration may be affected by .failure to confirm placement of the tube feeding prior to initiating the feeding . On 09/24/18 at 10:11 AM, an interview conducted with Resident #23 revealed that he has had a tube feeding for 2 years due to stomach problems. The resident was asked who is administering the feeding and he stated that the nurse provides the feeding three time a day. Review of Resident #23's medical record documents an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's attending physician note dated 09/17/18 documented under assessment and plan .weakness .dehydration .Dysphagia Review of the resident's physician order dated 08/13/18 documented discontinue [MEDICATION NAME] (tube feeding); Glucerna 1.5-300 cc (cubic centimeters) five times a day .1500 bolus tube feeding with 120 cc of water flush five times a day per Dietitian. Review of the Consultant Dietitian Nutrition assessment dated [DATE], documented resident requires a tube feeding to meet nutrition and hydration needs . On 09/26/18 at 12:15 PM, observations of tube feeding and medication administration for Resident #23 via Gastrostomy tube (GT) performed by Staff-A was conducted. Observations revealed Staff-A gathered medications and three cans of [MEDICATION NAME] (tube feeding) and entered the resident's room. Continued observations revealed Staff A poured a can of [MEDICATION NAME] into a cup, poured water over the medications, pulled a 60 cc syringe from a drawer, placed her stethoscope, over her ears, withdrew 30 cc of water with the syringe and stated that she checks the GT placement while flushing it with water. Further observations revealed Staff A connected the syringe to the resident's GT, placed her stethoscope over the resident's abdomen near the GT and flushed the GT with 30 cc of water. Further observations revealed Staff A removed the syringe from the resident's GT, checked for bowel sounds, reconnected the syringe to the tube, administered a medication, then flushed the tube with five (5) cc of water. Staff-A then administered Resident #23 three cans of [MEDICATION NAME] tube feeding via GT and medications with a last flush of 30 cc of water. During a subsequent interview, Staff A was asked when she checks for GT feeding residual and stated that she usually checks that first, but she did not do it and added I flushed, I was supposed to check for residual. Staff A was asked about the facility's policy regarding GT checks for placement and stated that she was not sure and added that she was told that the GT placement can be done while flushing it with water. Staff A was asked how many water flushes was Resident #23 supposed to have. She stated 30 cc of water before and after feeding and 5 cc of water before and after medications. Staff A was asked if Resident #23 was to have any other flushes between feedings and stated No. On 09/26/18 at 4:05 PM, a review of Resident #23's Minimum Data Set (MDS) assessment dated [DATE] revealed coding for feeding tube. Review of Resident #23's Care plan initiated on 08/13/18 for Alteration in nutritional status as evidenced by potential weight change documents interventions as provide flushes as ordered Review of the resident care plan initiated on 08/08/18 Receiving tube feeding documents check tube placement .before giving feeding . On 09/27/18 at 10:09 AM, an interview was conducted with the facility Consultant Dietitian. The Consultant Dietitian stated that Resident #23 was admitted on [DATE] and had a nutrition evaluation on 08/10/18. The Consultant Dietitian stated that Resident came in to the facility eating nothing by mouth and receiving [MEDICATION NAME] bolus feeding at home. The Consultant Dietitian stated that the resident's tube feeding was switched to Glucerna and the resident requested to go back on [MEDICATION NAME]. The Consultant Dietitian stated that Resident #23's needs were 1500 to 1800 calories, 1500 to 1800 cc of fluids and 60-70 gm protein. The Consultant Dietitian revealed that the resident was getting 1750 calories, 112 grams (gm) of protein and 26.6 gm of fiber. The Consultant Dietitian stated that the resident's total free fluid is 1875 cc. The Consultant Dietitian reported that Resident #23 is receiving 150 ml (millimeters) of water after each tube feeding bolus and flushes before and after each medication, plus the free fluid in the product ([MEDICATION NAME]) is 800 ml. A side by side review of Resident #23's physician orders for (MONTH) (YEAR) was conducted with the Consultant Dietitian. The Consultant Dietitian stated that the physician order for [REDACTED]. Review of Resident #23's (MONTH) (YEAR) physician orders documents PEG/[DEVICE] placement before used; PEG/G- tube flush with 5 cc of water before and after each medication Further review of the physician orders for (MONTH) (YEAR) lacked an order for [REDACTED]. Review of Resident #23's Medication Administration Record [REDACTED].[MEDICATION NAME]-Fiber seven cans daily via GT started on 08/27/18 . On 09/27/18 at 11:14 AM, an interview was conducted with Staff B-Licensed Practical Nurse. Staff B stated that she follows facility protocol and has been giving Resident #23, 30 cc of water before and after medications and 5 cc between medications. Staff B stated that she did not see a physician's order for tube feeding flushes prior or after feeding and that she will call the supervisor. On 09/27/18 at 2:30 PM, the Consultant Dietitian provided a copy of a physician order for [REDACTED].

Based on observation, interview and record review, the facility failed to remove expired urine specimen containers from 1 of 4 medication storage rooms; failed to remove expired bleach wipes from 2 of 4 treatment carts. The findings included: 1) On [DATE] at 2:00 PM, a review of the facility's medication storage room located at the second (2nd) floor-east wing was conducted with Staff-C Licensed Practical Nurse. The review revealed eighteen (18) Vacuette urine culture container (laboratories tube) with an expiration date on [DATE]. A side by side review of the urine container was conducted with Staff-C. Staff-C removed the container from the medication storage room. 2) On [DATE] at 2:33 PM, a review of the facility medication storage room located on the third (3rd) floor-west wing was conducted with Staff-D-Registered Nurse. Review of the treatment cart located in the medication storage room revealed three quarter full boxes of PDI Sani-cloth bleach individual wipes with an expiration date on ,[DATE]. Further review revealed exp ,[DATE] on top of the box. A side by side review of the PDI Sani-cloth bleach individual wipes was conducted with Staff-D. During an interview, Staff-D stated that the wipes are used to clean the glucose meter and added that they have more in central supply. 3) On [DATE] at 3:21 PM, a review of the facility treatment cart located in medication storage room on the third (3rd) floor-east wing was conducted with Staff-E Registered Nurse. A side by side review with Staff-E revealed thirteen (13) PDI Sani-cloth bleach, individual wipes with an expiration date on ,[DATE]. An interview was conducted with Staff-E it was reported that they use the wipes to clean the glucose meter. On [DATE] at 3:28 PM, review of the facility central supply room was conducted with Staff-F Medical Records and the Director of Nursing (DON). Staff-F was asked for the PDI Sani-cloth bleach individual wipes supply and stated that she has never ordered those and added that she orders the big bottle. A side by side review of the expired PDI Sani-cloth bleach individual wipes was conducted with Staff-F and the DON. A side by side review of the treatment cart on the facility second (2nd) floor- east and west wing was conducted with Staff-F and revealed no supply of PDI Sani-Cloth Bleach individual wipes. During an interview, the DON was apprised about the expired Vacuette urine container in the medication storage room on the second floor.

Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan, that includes the development of care planning interventions for areas triggered by the MDS (Minimum Data Set) that have measurable objectives, timeframes, and to monitor medication to meet a resident's needs as identified in the comprehensive assessment for 1 of 5 sampled residents (Resident #172). The findings include: Review of Resident #172 clinical record revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident physician order [REDACTED]. Review of the resident comprehensive Minimum Data Set ((MDS) dated [DATE] documents that the resident received anticoagulant (blood thinner) seven days prior to the assessment. Review of the resident care plan revealed that a care plan related to anticoagulation therapy was not initiated. On 10/12/17 at 10:47 AM, an interview was conducted with Staff C, a Licensed Practical Nurse (LPN). Staff C stated that Resident #172 has received anticoagulants since admission on 09/28/17. A side-by-side review of Resident #172 Medication Administration Record [REDACTED]. The review revealed that the resident is currently receiving [MEDICATION NAME] (blood thinner) injection 5,000 units every 12 hours. On 10/12/17 at 11:03 AM, an interview was conducted with the MDS Coordinator who stated that she was not aware that Resident #172 was on anticoagulant therapy. The MDS Coordinator was apprised that Resident #172 is receiving an anticoagulant since admission on 09/28/17. The MDS coordinator acknowledged that a care plan should have been initiated and confirmed that an interim care plan for the use of anticoagulation therapy was not initiated. On 10/12/17 at 11:09 AM, an interview was conducted with the facility Pharmacist Consultant (PC). The PC confirmed that Resident #172 was started on anticoagulant therapy on 09/29/17. The PC stated that residents on [MEDICATION NAME] should have a care plan for risk for bleeding.

Based on interview and record review, the facility failed to implement the care plan for 1 of 14 sampled residents (Resident # 62) reviewed. The findings included: Clinical record review for Resident # 62 revealed that the resident was admitted to the facility on [DATE], with a Brief Interview of Mental Status (BIMS), of 4 indicating severe cognitive impairment. The residents [DIAGNOSES REDACTED]. During a medication review on 10/11/17 at 9:00 AM, revealed Resident # 62 was currently prescribed two medications for depression including [MEDICATION NAME] 2.5 mg twice a day and [MEDICATION NAME] 60 mg daily. On 10/11/17 at 3:00 PM an interview was conducted with the Director of Nurses (DON) inquiring how the [MEDICATION NAME] is being monitored. The DON produced an Administration History document where the behavior monitoring would be found, but was unable to show behavior monitoring and stated that it is not being done. Review of Resident #62's care plan dated 10/10/17 revealed a problem of potential for alteration in mood related to [DIAGNOSES REDACTED]. Intervention for this problem is: Record behavior on Behavior Tracking Record. During an interview with Consultant Pharmacist on 10/11/17 by telephone at 4:06 PM, she stated that behavior monitoring is necessary when a resident is taking [MEDICATION NAME]. Record review revealed the facility policy, dated August 2016 for Antipsychotic Medication Use documented, The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications.

Based on observations and interviews the facility failed to ensure that the medication room was free of food and personal belongings (2-East unit) ; failed to lock an Intravenous emergency kit (3-East unit); failed to properly store medication in the medication cart (3-east unit and 2-west unit); failed to remove an expired nutritional supplement from the medication cart (2-West unit). The findings included: Review of the facility policy titled Emergency Medication Supplies revised [DATE] documents facility should ensure that Emergency Medication Supplies remain in the nursing unit until either an item is withdrawn . 1) On [DATE] at 9:19 AM, the facility 2-East unit, Medication Storage review was conducted with Staff C, a Licensed Practical Nurse (LPN). Observations in the Medication Room revealed a small shopping bag with a bottle of juice and lunch inside. Further observations revealed a green purse next to the shopping bag. Staff C stated that the shopping bag and the purse belong to her. 2) On [DATE] at 9:50 AM, the facility 3-East unit, a Medication Storage review was conducted with Staff - D a LPN. Observations made revealed an Intravenous emergency kit box without a tag (unlocked box). Further observation revealed Staff D opened the box and stated that she was looking for a pharmacy slip. Staff D stated that once the box is opened, a slip is completed and the box is locked. Staff D was not able to locate a pharmacy slip. Staff D stated that the emergency box should be locked after an item is pulled from the kit. Continued Medication Storage review revealed a loose pill in the medication cart drawer. Further observations revealed Staff D discarded the loose pill into the sharp container. 3) On [DATE] at 11:00 AM, the facility 2-West unit, Medication Storage review was conducted with Staff E, a Registered Nurse (RN). Observations revealed one nutritional supplement can with an expiration date [DATE]. Staff E confirmed that the nutritional supplement can was expired and did not why it was in the medication cart. Further observations revealed one loose pill in the bottom of the medication cart drawer. Further observation revealed Staff E discarded the loose pill into the sharp container. On [DATE] at 11:45 AM, an interview was conducted with the Director of Nursing (DON). The DON was apprised regarding the aforementioned findings. The DON stated that she was aware that Staff C left her lunch and purse in the medication room and further stated that Staff C was aware that she should not keep her purse or lunch in the medication room. On [DATE] at 2:20 PM, the DON stated that she contacted the pharmacy and was informed that the nurses are supposed to lock the emergency kit after an item is removed.