Every finding on record at Northbrook Healthcare Center

Based on interview and record review, the facility failed to ensure an allegation of resident-to-resident abuse involving one of four sampled residents (Resident 2) was reported to the State Survey Agency and the Long-Term Care Ombudsman within the required timeframe.This finding had the potential to result in an inability for the appropriate authorities, such as the State Survey Agency and the Long-Term Care Ombudsman to promptly intervene and ensure the safety and well-being of residents. In addition, the delay in reporting could have prevented a timely investigation, protective measures, and corrective actions, increasing the risk of further harm or unaddressed abuse within the facility.Record review of Resident 1's face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (decline in mental ability severe enough to interfere with daily life) with behavioral disturbance. Record review further indicated Resident 1 had a history of behavioral symptoms requiring staff intervention.Record review of Resident 2's face sheet revealed Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia. Record review of the Minimum Data Set (MDS), dated [DATE], indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident 2 was able to participate in interviews.Record review of the nursing progress note dated 6/03/26 indicated that at approximately 11:45 p.m., Resident 1 was found in Resident 2's room. The progress note documented that Resident 2 alleged Resident 1 struck him in the groin. Because the allegation involved resident-to-resident physical abuse, the allegation required immediate reporting to the State Survey Agency and the Long-Term Care Ombudsman.During an interview on 7/17/26 at 12:21 p.m., Resident 2 stated Resident 1 entered his room during the night and alleged Resident 1 struck him in the groin. Resident 2 stated he declined a physical assessment following the alleged incident.During an interview on 7/17/26 at 12:30 p.m., the Administrator stated the night shift charge nurse did not notify administration immediately after the alleged incident. The Administrator stated administration first became aware of the allegation at approximately 6 a.m. on 6/04/26. The Administrator acknowledged the reporting delay and stated the night shift charge nurse received disciplinary action as a result.During a follow-up interview on 7/17/26 at 4:29 p.m., the Administrator confirmed the SOC 341 (Report of Suspected Dependent Adult/Elder Abuse), was submitted to the California Department of Public Health at approximately 8:15 a.m. on 6/04/26, approximately eight hours after the allegation of abuse occurred.Record review of the facility policy titled, Abuse Prevention, revised 03/2025, indicated, All alleged incidents of abuse, mistreatment or neglect are to be reported to State Licensing Agency immediately or within two (2) hours. The policy further indicated, All allegations of abuse, mistreatment and neglect are to be reported immediately or within two (2) hours to the Long-Term Care Ombudsman.

Based on observation, interview and record review the facility failed to ensure that food was prepared by methods that preserved nutrition and palatability when three residents (Resident 20, Resident 26, Resident 30) out of 38 residents received meals that were flavorless, difficult to chew and overcooked.This failure decreased the facility's potential to serve food to residents with nutritive content and decreased the residents' potential to maintain or increase their meal intake with food served by the kitchen.Findings:During a concurrent interview and observation in Resident 26's room on 1/28/26at 8:30 a.m., Resident 26 complained about the potatoes he was served for breakfast. The cubed potatoes noted on his plate were pale in color. Resident 26 stated the potatoes were too difficult for him to chew because the potatoes were still raw in the center. Resident 26 was observed trying to cut one of the cubed potatoes with a fork and was noted to have difficulty doing so. Resident 26 stated the potatoes served in this fashion were usually hard and were inedible. Resident 26 further stated the oatmeal served to him was always tasteless and he never ate it.During an interview in Resident 26's room on 1/28/26 at 8:56 a.m., the Certified Dietary Manager (CDM) confirmed the potatoes on Resident 26's plate were hard, making it difficult for Resident 26 to chew. The CDM reviewed Resident 26's tray ticket and acknowledged Resident 26 had an ordered texture of easy to chew for his diet.During an observation of the facility kitchen on 1/28/26 at 10:21 a.m. two metal steam table pans were observed on the stovetop with aluminum foil secured on top. The CDM stated [NAME] 1 placed broccoli and carrots in each pan with water to boil on the stove just before leaving for his break.During an observation in the kitchen on 1/28/26at 11:18 a.m., [NAME] 1 placed frozen, filleted pieces of Tilapia fish on heated sheet pans without added seasoning.During an observation on 1/28/26 at 11:25 a.m., [NAME] 1 placed the frozen fish into the oven. [NAME] 1 then opened a large can of diced tomatoes and placed the diced tomatoes in a pot on the stove. He then added an unmeasured amount of dried diced onion, garlic powder, salt and oregano to the tomatoes. [NAME] 1 stated he was making the Italiano sauce for the fish and chicken which was a substitute protein for residents who did not like fish. The fish was removed from the oven at 11:45 a.m. During an observation on 1/28/26 at 11:50 a.m., the broccoli and carrots were removed from the stovetop and drained. The total cooking time on the stovetop was 1.5 hours. [NAME] 1 was not observed adding any seasoning to the carrots. [NAME] 1 added an unmeasured amount of bottled chopped garlic to the broccoli.During an observation in the kitchen trayline plating started on 1/28/26 at 12:30 p.m., [NAME] 1 was observed placing a piece of unseasoned Tilapia on a plate and smothered the fish with an unmeasured amount of Italiano sauce. The [NAME] repeated this process for the substitute chicken. [NAME] 1 was not observed to taste any part of the entree to ensure it was palatable.During an observation in the Station 1 hallway on 1/28/26 at 2 p.m., a food cart that had collected trays after residents completed their lunch was observed to have trays with half eaten or whole pieces of untouched Tilapia fish.During a concurrent observation and interview on 1/29/26 at 8:25 a.m., Resident 20 stated, Breakfast was disgusting. It didn't look appetizing. Resident 20 was observed to have a grilled cheese sandwich given to her as a substitute. The sandwich had a few bites taken from it. Resident 20 stated she was no longer hungry.A review of the facility's recipes indicated the following:- Broccoli with garlic, dated 2025, indicated, Boil or steam broccoli. (Approximate time for steamer is 10 min/pan).- Fish Italiano, dated 2025, indicated, Wash and rinse onions under cold running water. Saute onions in margarine until transparent.Place fish on top of the onions, sprinkle lightly with salt, pepper, and garlic powder. Place tomatoes on top of fish, sprinkle with basil, oregano, and parsley. Cover and bake at 375 F [Fahrenheit-a measurement of heat] for 15-25 minutes. Spoon juice over the fish and serve. Internal temperature must register at least 145 F for 15 seconds. Serve on trayline at the recommended temperature of 160 F- 180 F.A review of the facility's policy titled Food Preparation, dated 2023, indicated, Food shall be prepared by methods that conserve nutritive value, flavor and appearance.The facility will use approved recipes, standardized to meet the resident census.Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time.guidelines.A review of the facility's document titled Season Your Food Without Salt, dated 2025, indicated some herbs and spices may be used to season by taste. Further review of this document indicated, The flavor of herbs and spices varies greatly from brand to brand and by freshness.A review of an article published by PubMed titled Cooking at home to retain nutritional quality and minimize nutrient losses: A focus on vegetables, potatoes and pulses, dated 10/26/22, indicated, Cooking methods that expose plant foods to high temperatures and/or water for long periods of time (e.g. boiling) may be the most detrimental to nutrient content, whereas other cooking methods such as steaming or microwaving may help to retain nutrients.

Based on observation and interview, the facility failed to maintain an environment free of pests for 38 residents for a census of 38 when two flies were observed in the kitchen during food preparation.This failure decreased the facility's potential to prevent foodborne illnesses among residents.Findings:During a concurrent observation and interview in the kitchen on 1/28/26 at 10:55 a.m., two flies were observed flying around the area where lunch was being prepared. The Certified Dietary Manager (CDM) confirmed the presence of flies in the kitchen. The CDM stated the flies may have come in with someone when they entered the building from the outside. There was no electronic air curtain noted upon entry to the facility.A review of the facility's policy titled Pest Control, dated February 2025, indicated, It is the policy of this facility to utilize pesticides.in a safe and efficient manner to control pests.The following are guidelines for pest prevention.All storage and food preparation areas are to be kept clean. This includes.equipment.A review of the FDA 2022 Food Code 6-501.111(A)(B) indicated, the premises shall be maintained free of insects.the presence of insects. shall be controlled to eliminate their presence on the premises by routinely inspecting shipments of food and supplies.routinely inspecting the premises for evidence of pests.

Based on observation, interview and record review, the facility failed to ensure that food was stored, prepared and served safely in accordance with professional standards of food service when:Clean plastic cups were stored in soiled, heavily scratched plastic racks and food crumbs were observed under a layer of dirty plastic netting which clean eating utensils were stored on top of in a utensil tray; and,The front of the facility stove was stained with old grease drippings while the stovetop was encrusted with hardened black residue; and,Cook 1 failed to maintain proper hand hygiene during meal prep and trayline when he repeatedly contaminated his gloves by touching his personal clothing and other kitchen items before handling food products; and,Refrigerated items found with no use by date.These failures posed the risk for food borne illness for 38 residents for a census of 38 residents that resided in the facility and consumed food prepared in the kitchen.Findings:1. During a concurrent observation and interview in the facility kitchen on 1/27/26 at 9:56 a.m., clean plastic cups were noted to be stored lip side down in soiled, heavily scratched racks. The Certified Dietary Manager (CDM) confirmed the racks were visibly scratched and soiled.During a concurrent observation and interview in the facility kitchen on 1/28/26 at 10:41 a.m., clean dining ware was observed to be stored in a utensil tray containing accumulated food debris under a dirty protective netting. The CDM confirmed this posed a risk for contamination of the clean utensils. The CDM removed the utensils from the tray and washed all stored utensils and the utensil tray.A review of the Food and Drug Administration (FDA) Food Code 2022, 4-601.11 (A) indicated, Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch.2. During a concurrent observation and interview in the facility kitchen on 1/27/26 at 9:50 a.m., the CDM confirmed the stovetop had encrusted debris in between and in burners, and the front of the stove was soiled with old grease drippings. The CDM stated the stove was cleaned daily with a scheduled weekly deep clean. The CDM stated, The equipment must be clean and ready to use. The CDM further stated she developed the cleaning and deep cleaning logs. A review of the facility's policy titled Sanitation, dated 2023, indicated, The Food and Nutrition Services Department shall have equipment.necessary for the proper preparation.of food.All equipment shall be maintained as necessary.A review of the FDA Food Code 2022, 4-602.12(A) Cooking and Baking Equipment indicated, .the food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours.A review of the FDA Food Code 2022, 4-602.13 indicated, .the non-contact food surfaces shall be cleaned at a frequency necessary to preclude accumulation of soil residues.3. During an observation in the facility kitchen on 1/28/26, at 11:25 a.m., [NAME] 1 was observed to pull up his pants with gloved hands, retrieve a scale from shelf, and did not wash his hands between changing his gloves and touching food.During an observation on 1/28/26 at 11:30 a.m., [NAME] 1 was looking at a chart that hung on the kitchen wall. When the chart fell off the wall, [NAME] 1 picked up the chart with gloved hands, replaced the chart on the wall, retrieved a cutting board, and began to cut butter without changing gloves and washing his hands.During an observation on 1/28/26 at 11:35 a.m., [NAME] 1 pulled up his pants, checked and touched his watch. [NAME] 1 then immediately continued to stir meat on the stove and made sauce for the risotto without changing his gloves and washing his hands.During an observation on 1/28/26 at 11:50 a.m., [NAME] 1 pulled up his pants and continued to make sauce for the lunch entree and removed vegetables from the stovetop without changing gloves and washing his hands.During an observation on 1/28/26 at 12:17 a.m., [NAME] 1 pulled down his shirt, pulled up his pants and continued to puree carrots in the food processor without changing gloves and washing his hands.During an observation on 1/28/26 at 1:10 p.m., [NAME] 1 pulled up his pants while plating residents' plates on trayline without changing his gloves and washing his hands.During an observation on 1/28/26 at 1:20 p.m., [NAME] 1 pulled up his pants while plating residents' plates on trayline without changing his gloves and washing his hands.A review of the facility's policy titled Inservice: Personal Hygiene, undated, indicated, Hands are a major source of food contamination.wash hands.prior to wearing gloves and.changing tasks.A review of the FDA Food Code 2022, 2-301.14(F)(H)(I), Personal Cleanliness indicated, Food employees shall clean their hands. immediately before engaging in food preparation.and.during food preparation as often as necessary to remove.contamination and to prevent cross contamination.and before donning gloves to initiate a task that involves working with food and.after engaging in other activities that contaminate the hands.4. During a concurrent observation and interview in the kitchen on 1/27/26, this surveyor observed a carton of soy milk with an open date of 1/19/26 and a bottle of vegetable juice with an open date of 1/5/26. Neither the carton of soy milk nor the bottle of vegetable juice had a use by date or expiration date written on it. The CDM confirmed these needed to be discarded, as both had expired.A review of the facility's policy titled Labeling and Dating of Foods, date 2023, indicated, Foods that are commercially processed, ready to eat and intended to be stored cold greater than 24 hours will be marked with a 'use by' date. The 'use by' date will incorporate the open date for TCS (Time, Temperature Control for Safety) foods as defined by the Federal Food Code.Once daily, the PM [evening] cook and/or the PM Diet Aide will be responsible to inspect the refrigerators and discard perishable foods that are TCS in order to ensure food safety.A review of the FDA Food Code 2022, 3-501.17 indicated, .refrigerated, ready to eat, time/temperature control for safety food.held for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises. or discarded when held at a temperature of 5 C [Celsius- a measurement of temperature] (41 F [Fahrenheit- a measurement of temperature]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on observation, interview and record review, the facility failed to ensure food preferences were honored for four residents (Resident 10, Resident 30, Resident 41, Resident 26) of 38 sampled residents when the residents were served meals which contained food they disliked.This failure decreased the facility's potential to serve food that met residents' nutritional needs.Findings: During a concurrent observation and interview in the facility dining room on 1/27/26 at 12:31 p.m., Resident 10 and Resident 41 were eating their lunches. This surveyor observed both residents' plates contained untouched peas. Resident 10 stated she did not like peas and Resident 41 stated she had never liked peas and was confused as to why they were placed on her tray. A review of their meal tray tickets indicated both Resident 10 and Resident 41 disliked peas. During a concurrent observation and interview on 1/27/26 at 1:09 p.m., Resident 30 was eating lunch in her room. Resident 30 stated, I will not eat the peas they served for lunch today because I like my vegetables cooked al [NAME] and these peas are too mushy. This is how the vegetables are usually served. Resident 30 also stated she was intolerant of lactose (a natural sugar found in dairy products) had a problem when the kitchen served her scrambled eggs made with milk for breakfast in the past. Resident 30 stated she became sick and had diarrhea from the eggs. A review of Resident 30's meal tray ticket indicated she had a lactose allergy, disliked milk, milk products and refined sugar and that she preferred .Al [NAME] Broccoli & Cauliflower when on the menu. During a concurrent observation and interview in Resident 26's room on 1/28/26 at 8:43 a.m., Resident 26 had only eaten his scrambled eggs the scrambled eggs on his breakfast tray. Resident 26 stated his oatmeal was tasteless and he could not chew his potatoes. He requested more scrambled eggs and toast from the kitchen because he was still hungry. The kitchen served Resident 26 one fried egg and one piece of dried toast without butter. Resident 26 was angry and asked to speak with the Administrator. During a concurrent observation and interview on 1/28/26 at 1:00 p.m., Resident 30's lunch tray contained a cherry square made with cream cheese and canned cherries on a graham cracker crust. Resident 30 stated it was too sweet for her. During an interview on 1/28/26 at 4:10 p.m., the Certified Dietary Manager (CDM) stated the kitchen referred to the dislike list when printing out resident tray tickets, which was updated quarterly or sooner if needed. The CMS confirmed the Cherry N' Cream Squares recipe called for powdered sugar and cream cheese, which were foods that Resident 30 did not like and cannot eat due to her lactose intolerance. The CDM stated Resident 30 was supposed to be served applesauce with cinnamon in place of the dessert served on the 1/28/26 lunch tray. The CDM further stated she was made aware that peas were served to residents that disliked them. During a concurrent observation and interview on 1/29/26 at 12:30 p.m., Resident 30's meal tray contained turkey, roasted potatoes, and green beans. Resident 30 stated she would not eat the green beans on her plate because they were overcooked and mushy. The resident took one of her chopsticks and stuck it in the green beans and it appeared mushy. During a concurrent observation and interview in Resident 30's room on 1/29/26at 12:57 p.m., Resident 30 stated she had received a piece of pie for dessert when she had asked that no food made with refined sugars be served to her. This surveyor observed a piece of apple pie on Resident 30's tray. A review of Resident 30's meal tray ticket indicated she disliked refined sugar. Resident 30 stated she will not eat it because it is too sweet for her. A review of the facility's policy titled Food Preferences, dated 2023, indicated, Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from appropriate food group.

Based on observation, interview and record review, the facility failed to develop and implement care plans for two residents (Resident 20, Resident 21) of four sampled residents when Licensed Nurses (LN) did not:Initiate a care plan for Resident 20's need for oxygen therapy; and,Implement interventions indicated in Resident 21's care plan regarding the risk of skin impairment.These failures decreased the facility's potential to communicate Resident 20's care needs regarding oxygen therapy among facility staff and resulted in Resident 21 sustaining a wound to her left lateral (a side of the body positioned away from midline) upper calf.Findings:1. A review of Resident 20's admission record indicated admission to the facility on 1/1/26 with a diagnosis of Heart Failure (a chronic disease where the heart cannot pump enough blood to meet the body's needs, often causing fluid buildup in the lungs or body).A review of Resident 20's physician orders dated 1/1/26, indicated, O2 [oxygen] 1 LPM [Liters per minute-indicates how much oxygen will be delivered per minute] via NC [nasal cannula-a flexible device used to deliver oxygen through the nose].A review of Resident 20's MDS (Minimum Data Set- a federally mandated assessment tool) dated 1/2/26, indicated Resident 20 was receiving oxygen therapy upon admission and while a resident in the facility.During an observation on 1/27/26 at 11:18 a.m., Resident 20 was observed with oxygen being administered via a nasal cannula at 1 LPM. A review of Resident 20's care plans was conducted on 1/28/26 and found Resident 20's care plan regarding a need for oxygen therapy had been initiated on 1/27/26, 26 days after admission.During an interview on 1/29/26 at 2:27 p.m., the Director of Nursing (DON) confirmed a care plan for Resident 20's oxygen therapy had not been initiated until 1/27/26. The DON stated the oxygen care plan should have been developed upon admission. The DON further stated care plans were important because they drive care for the residents.2.A review of Resident 21's admission record indicated Resident 21 was admitted to the facility on [DATE] with Chronic Atrial Fibrillation (a long term, irregular and often rapid heart rhythm that can lead to blood clots, stroke or heart failure).A review of Resident 21's care plan, dated 8/12/22, indicated t Resident 21 was at risk for skin impairment due to her fragile skin and blood thinner use. The nursing staff were expected to pad the edges of Resident 21's bedside table and pad the wheelchair armrests to assist Resident 21's to meet her goal of not having any complications.A review of Resident 21's physician orders, dated 7/16/23, indicated Resident 21 was to wear compression stockings 15-25 mmHg [millimeters of mercury-a unit of pressure. A range of15-25 indicates a medium to firm medical grade compression designed to provide therapeutic, graduated pressure that improves blood flow, reduce swelling, and manages venous conditions].A revision to Resident 21's care plan regarding a risk for skin impairment was made on 9/18/23 and indicated nursing staff were expected to apply compression stockings to BLE [Bilateral lower extremities] in the AM [morning] and remove [them] at HS [at bedtime].During a concurrent observation and interview on 1/29/26 at 8:56 a.m., in Resident 21's room, Resident 21 was dressed in slacks and seated in her wheelchair. Licensed Nurse 1 (LN 1) attempted to pull up Resident 21's left pant leg to assess a resolved blister. Resident 21 told LN 1 her left leg hurt but LN 1 was unable to assess Resident 21's leg due to the pain caused by pulling up her pant leg. LN 1 stated she would have the Wound Nurse (WN) assess Resident 21's leg.During an interview on 1/29/26 at 10:18 a.m., the WN stated Resident 21's blister to the left shin had resolved; however, a new wound had developed to Resident 21's left lateral, upper leg. The WN stated Resident 21's wound lined up perfectly to the leg rest pegs on her wheelchair.During a concurrent observation and interview on 1/29/26 at 10:25 a.m., LN 1 confirmed Resident 21 had not been wearing compression stockings as ordered and care planned. In addition, LN 1 observed and acknowledged Resident 21's bedside table had not been padded nor had Resident 21's armrest area and the rest pegs for her legs been padded on her wheelchair.A review of Resident 21's Skin Issues assessment, dated 1/29/26, indicated Resident 21's new wound on her left leg was acquired at the facility and measured 5 centimeters (cm- a unit of measure) in length, 2.5 cm in width, and 0 cm in depth. The exudate (fluid discharged from the wound) was described as sanguinous (containing blood) in a light amount.A review of facility policy titled Care Planning, dated 11/19, indicated, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident.A comprehensive care plan is developed within seven (7) days of completion of Resident Minimum Data Set (MDS). Revision or updating of the care plan will occur with quarterly, annually, upon significant changes of condition, or as requested by resident/resident representative or as deemed necessary by IDT.

Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was clean and in a usable state for one resident (Resident 20) out of four sampled residents when in Resident 20's oxygen concentrator had visible dust and debris in the vents.This failure decreased the facility's potential to prevent bacteria and debris from directly entering Resident 20's lungs, placing her at risk for infection.Findings:A review of Resident 20's admission record indicated Resident 20 was admitted to the facility on [DATE] with a diagnosis of Heart Failure (a chronic disease where the heart cannot pump enough blood to meet the body's needs, often causing fluid buildup in the lungs or body).A review of Resident 20's physician orders dated 1/1/26, indicated, O2 [oxygen] 1 LPM [Liters per minute-indicates how much oxygen will be delivered per minute] via NC [nasal cannula-a flexible device used to deliver oxygen through the nose].A review of Resident 20's MDS (Minimum Data Set- a federally mandated assessment tool) dated 1/2/26, indicated Resident 20 was receiving oxygen therapy upon admission and while a resident in the facility.During an observation on 1/27/26at 11:18 a.m., the outside vent on Resident 20 oxygen concentrator (a medical device that pulls air from the surrounding environment, filters out impurities and delivers medical-grade oxygen to residents with a respiratory condition) had dust buildup. During a concurrent observation and interview on 1/27/26 at 11:45 a.m., the Director of Nursing (DON), Infection Preventionist (IP) and the Maintenance Supervisor (MNS) confirmed there was dust built up on Resident 20's oxygen concentrator's vent. The compartment holding the internal filter was also observed to have dust buildup. The IP confirmed the dust build up was not good for Resident 20 and stated she was surprised to see how much dust had accumulated. The MNS stated he performed weekly checks on each oxygen concentrator in use, and blows out the dust with a compressed air canister. The MNS stated the facility owns all the oxygen concentrators. The MNS further stated he was responsible for cleaning the oxygen concentrators of all debris in addition to changing the filters.During an interview on 1/30/26 at 10:10 a.m., the IP stated an oxygen concentrator with dust buildup would be unhealthy for Resident 20 because the dust and debris which had accumulated in the vents could push the dust and other debris into Resident 20's lungs, placing Resident 20 at risk of developing a lung infection such as pneumonia or bronchitis.A review of the oxygen concentrator instruction guide, undated, indicated, the air filter. should be cleaned at least once a week.Clean the exterior cabinet by using a damp cloth or sponge with a mild household cleaner and wipe it dry.A review of the facility's policy titled Oxygen Therapy, dated January 2019 indicated, It is the policy of this facility to administer oxygen in a safe manner.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 3) of four sampled residents was properly groomed and had her call light within reach when Resident 3 was observed to have uncombed hair, dirty fingernails, and fecal matter (bowel movement) on her pillowcase, sheets and bedside table, and had no way to call for assistance.This deficiency decreased the facility' potential to ensure Resident 3 received personal care to maintain adequate hygiene.Findings:A review of Resident 3's admission record indicated admission on [DATE] with diagnoses of esophageal obstruction (blockage of the tube leading from the throat to the stomach), need for assistance with personal care, muscle weakness, and repeated falls. A review of Resident 3's care plan, initiated on 10/1/25, indicated Resident 3 was at risk for falls. Staff were expected to Be sure the call light is within reach and encourage to use it to call for assistance as needed to decrease her risk of falling.A review of Resident 3's care plan initiated on10/1/25, indicated Resident 3 was at risk for a self-care deficient to carry out Activities of Daily Living (ADL- fundamental, routine self-care tasks necessary for independent living such as bathing, dressing, and toileting) Staff were expected to Encourage to use bell to call for assistance to decrease her risk of self-care decline.During an observation in Resident 3's room on 1/28/2026 at 10:30 a.m., Resident 3 was scrunched down in her bed with her shirt above her breasts with nothing else to cover her breasts. A dark thick brown substance was noted on her pillowcase and bedside table. The sheets on the far side of her bed had large brown streaks. Resident 3's hair was uncombed and all of her fingernails were long and had brown debris underneath the nails. Resident 3's call light was on the floor out of her reach. During a concurrent observation and interview in Resident 3's room on 1/28/26 at 10:32 a.m., Certified Nurse Assistant 1 (CNA 1) verified Resident 3 looked unkempt and her linens were dirty. CNA 1 stated she did not know what the brown substance on Resident 3's pillowcase, sheets, and bedside table were. CNA 1 acknowledged Resident 3 could not reach her call light because it was on the floor. During a concurrent observation and interview in Resident 3's room on 1/28/2026 at 10:35 a.m., CNA 2 stated she had left the room to get gloves. CNA 2 stated Resident 3 had slid down her bed and was scrunched down. CNA 2 stated the thick brown substance on Resident 3's pillowcase and bedside table was bowel movement (BM-fecal matter). CNA 2 stated the brown streaks on Resident 3's sheets were also BM. During a concurrent observation and interview in Resident 3's room on 1/29/2026 at 2:22 p.m., Resident 3 was lying in her bed. When Resident 3 was asked if she could reach her call light if she needed assistance, Resident 3 stated, I don't know where it is. This surveyor observed Resident 3's call light was looped over the drawer of her bedside table and out of reach. When Resident 3 was asked how she let staff know when she needed assistance, Resident 3 stated, I call for help.During a concurrent observation and interview in Resident 3's room on 1/29/2026 at 2:25 p.m., CNA 3 verified Resident 3's call light was out of her reach. CNA 3 verified Resident 3's fingernails were long, some were jagged, and she had what appeared to be food under her fingernails. CNA 3 stated CNAs conducted nail care unless the resident had diabetes. CNA 3 stated Resident 3 liked to eat with her hands, and her fingernails got dirty from her food.During a concurrent observation and interview in Resident 3's room on 1/29/2026 at 2:38 p.m. the Infection Prevention Nurse (IP) verified Resident 3 had debris under her fingernails and that some of the nails were jagged. When IP was asked if BM on Resident 3's tray table posed an infection control risk, she stated, Yes it does.During an interview on 1/30/26 at 10:15 a.m., the IP stated if residents who were dependent on staff could not get help when they needed it and their call light was out of reach, then they had an increased risk of falling while trying to access the call light. During a concurrent observation and interview in Resident 3's room on 1/30/26 at 11:18 a.m., Resident 3 was in her bed eating a piece of cake with her hands. Resident 3's call light was draped over the drawer on the bedside table out of her reach. When Resident 3 was asked if she knew where her call light was, she responded, I have no idea. When Resident 3 was asked if she used her call light when she knew where it was, she stated, Yes.A review of the facility's policy titled, ADL Services revised October 2016, indicated, Residents who are unable to carry out activities of daily living (ADL) will receive necessary services, on a daily and on as needed basis, to maintain.grooming.A review of the facility's policy titled, Call Light/Bell revised January 2019, indicated, Place the call device within the resident's reach before leaving the room.

Based on interview and record review, the facility failed to provide medications as ordered by the prescriber, when two residents (Resident 1 and Resident 2) of three sampled residents received their medications late on two days.This failure decreased the facility's potential to prevent serious health consequences including worsening symptoms, disease progression, and increased risk of complications.Findings:A review of Resident 1's admission record, dated 12/19/25, indicated Resident 1 was admitted with diagnoses that included trigeminal neuralgia (a chronic pain condition causing sudden, severe, electric shock-like pain in the face, affecting the trigeminal nerve) and syndrome of inappropriate secretion of antidiuretic hormone (a condition that causes excessive water retention in the kidneys).During a concurrent interview and record review on 12/20/25 at 3:10 p.m. with the Director of Nursing (DON), Resident 1's Medication Admin Audit Reports dated 12/20/25-12/21/25 were reviewed. The report indicated Resident 1 had the following medications scheduled for 12/20/25 and 12/21/25 at 4 p.m.:- Gabapentin Oral Capsule (used to relieve chronic nerve pain) 100 MG (milligrams, a unit of weight) Give 2 capsules by mouth three times a day for trigeminal neuralgia;- Keppra(R) Oral Tablet (an anticonvulsant used as an add-on therapy for chronic nerve pain) 500 MG Give 1 tablet by mouth two times a day for trigeminal neuralgia;- Flomax(R) Oral Capsule (used to promote urine flow) 0.4 MG Give 1 capsule by mouth two times a day for urinary retention;- DULoxetine HCL Oral Capsule Delayed Release Sprinkle (an antidepressant used to relieve symptoms of various chronic pain conditions) 30 MG Give 1 capsule by mouth two times a day for trigeminal neuralgia; and,- IamoTRIgine Oral Tablet (used to treat trigeminal neuralgia) 100 MG Give 1 tablet by mouth two times a day for trigeminal neuralgia.Further review of the report indicated the five medications had an Administration Time of 5:09 p.m. on 12/20/25, and 5:33 p.m. on 12/21/25. The DON stated medications were supposed to be administered within an hour of schedule, and confirmed Resident 1's 4 p.m. gabapentin, Keppra(R), Flomax(R), duloxetine, and Iamotrigine were given late on 12/20/25 and 12/21/25.A review of Resident 2's admission record, dated 12/25/25, indicated Resident 2 was admitted with diagnoses that included bilateral osteoarthritis of the hip (degenerative joint disease of both hip joints characterized by deep ache or sharp pain), benign prostatic hyperplasia (or BPH, an enlarged prostrate that causes difficulty peeing) and atherosclerotic heart disease (buildup of fats, cholesterol and other substances in and on the artery walls).During a concurrent interview and record review on 12/20/25 at 3:26 p.m. with the DON, Resident 2's Medication Admin Audit Reports dated 12/28/25-12/29/25 were reviewed. The report indicated Resident 2 had the following medications scheduled for 12/28/25 and 12/29/25 at 8 p.m.:- Diclofenac Sodium External Gel 1% (used to relieve pain) Apply to affected areas topically (to the skin) four times a day for pain. Apply 2 grams of gel to affected area 4 times daily;- Atorvastatin Calcium Oral Tablet (used to lower bad cholesterol and fats) 40 MG Give 1 tablet by mouth at bedtime; and,- Tamsulosin HCl Oral Capsule (used to improve urine flow) 0.4 MG Give 1 capsule by mouth at bedtime for BPH.Further review of the report indicated the three medications had an Administration Time of 10:18 p.m. on 12/28/25, and 9:27 p.m. on 12/29/25. The DON confirmed the 8 p.m. medications were given late. The DON stated the atorvastatin and tamsulosin might have been given late as both were labeled at bedtime but added both should have been given within an hour of 8 p.m., as it was it was scheduled as such. The DON stated medications must be administered as ordered, as risks for not following the scheduled for these medications could affect the adequacy of Resident 1 and 2's pain control, and could worsen their urinary symptoms.A review of the facility's policy titled, MEDICATION ADMINISTRATION - GENERAL GUIDELINES, dated May 2022, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices. FIVE RIGHTS - Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. Medications are administered within 60 minutes of schedule time.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5 percent (%) or less. There were 3 errors out of 43 opportunities, which resulted in a medication error rate of 6.98 % for 2 (Resident #2 and Resident #4) of 5 residents observed during medication administration. Findings included: A facility policy titled, Administration Procedures For All Medications, dated 05/2022, indicated, C. Review 5 Rights (3) times: 1) Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR [medication administration record/treatment administration record] for order. b. Note any allergies or contraindications the resident may have prior to drug administration. c. If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. d. Check for vital signs, other tests to be done during/prior to medication administration. e. Prepare resident for medication administration. 2) Prior to removing the medication from the container a. Check the label against the order on the MAR. b. Note any supplemental labeling that applies (fractional tablet, multiple tablets, volume of liquid, shake well, give with another medication, etc. [et cetera, and other similar things]). 1. An Admission Record indicated the facility admitted Resident #2 on 10/10/2008. According to the Admission Record, the resident had a medical history that included diagnoses of heart failure, atherosclerotic heart disease, and constipation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Resident #2's Order Summary Report, reflecting active orders as of 04/09/2025, contained an order dated 10/30/2015 for aspirin 81 milligram (mg), give two tablets by mouth one time a day for coronary atherosclerosis. The Order Summary report also contained an order dated 05/04/2023 for sennosides-docusate sodium 8.6-50 mg, give two tablets by mouth one time a day for bowel care, with instructions to hold for loose stools. Resident #2's 04/2025 MAR revealed the resident's aspirin and sennosides-docusate sodium were scheduled for administration at 8:00 AM each day. An observation of medication administration on 04/09/2025 at 7:05 AM, revealed Registered Nurse (RN) #3 administered one aspirin 81 mg tablet and one sennosides-docusate sodium 8.6-50 mg tablet to Resident #2, instead of two of each tablet as ordered. During an interview on 04/10/2025 at 2:28 PM, RN #3 stated he had been trained and was expected to follow physician orders. During an interview on 04/10/2025 at 4:18 PM, the Director of Nursing (DON) stated staff were trained to verify the dose and the order for the number of tablets to be administered. The DON stated staff were expected to administer medications by using the seven rights of medication administration (right patient, right medication, right dose, right route, right time, right documentation, and right response). During an interview on 04/10/2025 at 4:49 PM, the Administrator stated staff were trained and expected to administer the right medications and doses using the seven rights of medication administration. 2. An Admission Record indicated the facility admitted Resident #4 on 07/31/2023. According to the Admission Record, the resident had a medical history that included diagnoses of aftercare following joint replacement surgery and unilateral primary osteoarthritis, left hip. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/05/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #4's Order Summary Report, reflecting active orders as of 04/09/2025, contained an order dated 03/21/2025 for Bengay greaseless cream 10-15%, apply topically four times a day for arthritis pain management to bilateral knees and bilateral hands. An observation of medication administration on 04/09/2025 at 7:34 AM, revealed Registered Nurse (RN) #4 applied Resident #4's Bengay greaseless cream to the resident's bilateral knees but not their bilateral hands. During an interview on 04/09/2025 at 1:23 PM, RN #4 stated she should have applied the Bengay cream to the resident's hands as well, but it was an oversight. She stated she was expected to administer medications as ordered. During an interview on 04/10/2025 at 4:18 PM, the Director of Nursing (DON) stated staff were expected to administer medications by using the seven rights of medication administration (right patient, right medication, right dose, right route, right time, right documentation, and right response). During an interview on 04/10/2025 at 4:49 PM, the Administrator stated staff were trained and expected to administer the right medications and doses using the seven rights of medication administration.

Based on interview, record review, and facility document and policy review, the facility failed to ensure medication administration records accurately reflected the medications administered for 1 (Resident #27) of 5 residents reviewed for unnecessary medications. In addition, the facility failed to ensure medication orders were correctly transcribed into the electronic health record (EHR) for 1 (Resident #2) of 5 residents observed during medication administration. Findings included: 1. A facility policy titled, Administration Procedures for All Medications dated 05/2022, revealed, J. After administration, return to the cart, replace medication container (if multi-dose and doses remain), and document administration in the MAR [Medication Administration Record] or TAR [Treatment Administration Record]. An Admission Record revealed the facility admitted Resident #27 on 01/17/2025. According to the Admission Record, the resident had a medical history that included diagnoses of gout and chronic kidney disease. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2025, revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Resident #27's Order Summary Report, reflecting active orders as of 04/10/2025, contained the following orders: - an order dated 03/30/2025 for ascorbic acid 1000 milligrams (mg) by mouth twice a day for supplement; - an order dated 03/30/2025 for Eliquis 5 mg by mouth two times a day for anticoagulant; - an order dated 03/30/2025 for potassium chloride extended release 20 milliequivalents (mEq) two times a day for hypokalemia (low potassium levels); - an order dated 03/30/2025 for Senna, two tablets by mouth two times a day for routine bowel care; - an order dated 03/24/2025 for ciclopirox external gel 0.77 percent (%), apply to bilateral toenails topically at bedtime for yellow, brittle, thickened, fungal toenails; and - an order dated 03/09/2025 for nystatin cream 100000 units per gram, apply to groin/ pannus topically every shift for redness. Resident #27's 04/2025 TAR revealed no documentation of the administration of the resident's ciclopirox external gel on 04/02/2025 and 04/03/2025 at 8:00 PM or the resident's nystatin cream on 04/02/2025 or 04/03/2025 for the NOC 1 (evening) doses. Resident #27's 04/2025 MAR revealed no documentation of the administration of the resident's ascorbic acid, Eliquis, potassium chloride extended release, or Senna tablets on 04/05/2025 at 4:00 PM. During an interview on 04/09/2025 at 1:41 PM, Resident #27 stated they had not missed any doses of their medications while at the facility. Resident #27 stated that on 04/02/2025 and 04/03/2025, they received their medications and treatments as ordered. Resident #27 further stated that on 04/05/2025, they left the facility for a memorial service but received their medication after returning to the nursing facility the same day. During an on 04/10/2025 at 12:46 PM, the Director of Nursing (DON) stated Licensed Vocational Nurse (LVN) #1 was the nurse assigned to Resident #27 on 04/02/2025 and 04/03/2025. The DON stated she expected nurses to document the administration of medications or treatments on the MAR or TAR. During an interview on 04/10/2025 at 3:44 PM, LVN #1 stated he struggled to sign off on the MAR because he would get busy and forget to sign off that the medication was administered. He stated Resident #27 had received all their medications, but he had not documented it on the MAR. During an interview on 04/10/2025 at 2:32 PM, LVN #2 stated he was the nurse assigned to Resident #27 on 04/05/2025. LVN #2 stated the resident went to a memorial service and returned to the facility the same day. LVN #2 stated he administered the resident's medications when they returned to the facility but did not document the administration on the resident's MAR. During an interview on 04/10/2025 at 2:19 PM, the Administrator stated nurses should document on the MAR when medications were administered. 52066 2. An Admission Record revealed the facility admitted Resident #2 on 10/10/2008. According to the Admission Record, the resident had a medical history that included a diagnosis of heart failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/05/2025, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. A handwritten physician's order for Resident #2, dated 03/23/2025, specified an order for Bumex (a diuretic medication) 0.5 milligrams (mg) in the morning and 0.25 mg at 1:00 PM, with instructions to hold the Bumex for a systolic blood pressure reading less than (<) 110 millimeters of mercury (mmHg). Resident #2's Order Summary Report, reflecting active orders as of 04/09/2025, revealed the order for Bumex was transcribed into the EHR as two separate orders. The orders, dated 03/24/2025, specified Bumex 0.25 mg was to be given once a day and held for a systolic blood pressure < 110 mmHg; however, the order for Bumex 0.5 mg once a day was transcribed with instructions to hold for a systolic blood pressure greater than (>) 110 mmHg. An Orders note, effective 03/24/2025, revealed Licensed Vocational Nurse (LVN) #2 transcribed Resident #2's Bumex orders into the resident's EHR. During an interview on 04/10/2025 at 2:33 PM, LVN #2 stated that when he received a new order, he read it and entered it into the EHR. LVN #2 stated that Resident #2's order with parameters to hold the medication for a systolic blood pressure > 110 mmHg was a mistake. LVN #2 stated he had received education regarding transcribing physician's orders, and he was expected to transcribe physician's orders correctly. During an interview on 04/09/2025 at 4:36 PM, the Medical Director stated the staff were to hold Resident #2's Bumex if the resident's systolic blood pressure was < 110 mmHg. The Medical Director stated she thought the order was a typo, and the nursing staff should know not to hold the Bumex for a systolic blood pressure > 110 mmHg, as that would never be appropriate. During an interview on 04/10/2025 at 2:19 PM, the Administrator stated staff were trained and expected to transcribe physician's orders correctly.

Based on observation, interview, and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was free from physical abuse when two Certified Nursing Assistants (CNAs) intentionally held down Resident 1 against his will while performing perineal care (the cleaning and maintenance of the genital and anal areas). This failure resulted in Resident 1 feeling belittled and upset. Findings: A review of Resident 1's admission record indicated he was admitted on [DATE] with a diagnosis of pleural effusion (abnormal buildup of fluid between the lungs and the chest wall). A review of a care plan, initiated on 2/19/25, indicated Resident 1 had an activities of daily living self care performance deficit related to generalized weakness. In order to assist Resident 1 to safely perform grooming, toilet use, and personal hygiene, staff were to conduct the following interventions, [For] toilet use .[Resident 1] requires assistance to .clean self, transfer onto toilet, transfer off toilet, to use toilet .Encourage [Resident 1] to discuss feelings about self-care deficit .Encourage [Resident 1] to participate to the fullest extent possible with each interaction . A review of Resident 1 ' s Minimum Data Set (MDS- a federally mandated assessment tool), dated 2/20/25, indicated the following: -Section C: A Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident's) score of 4, which indicated severe cognitive (relating to processes of thinking and reasoning) impairment. -Section F: Resident 1 notified staff it was very important for him to choose between a tub bath, shower, bed bath, or sponge bath. -Section GG: Facility staff assessed Resident 1 was able to perform toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding, etc.), lower body dressing (the ability to dress and undress below the waist), and toilet transfer (the ability to get on and off the toilet or commode) with partial/moderate assistance (when the helper does less than half of the effort to carry out the activity). -Section H: Facility staff assessed Resident 1 was always continent (had the ability to control bladder function and retain urine until the appropriate time) of urine. A review of Resident 1's Skilled Weekly Review dated 2/24/25 at 6:50 p.m. indicated, .toileting transfer/clothing management min [minimum] assist [when a person needs very little help], peri [perineal] care CG [caregiver]/ min assist .Lb [lower body] dressing mod [moderate] assist [when a person needs help with half of the effort to complete a task] and feeding (I [independent]). A review of Resident 1's Progress Notes, dated 2/27/25, at 7:19 P.M., indicated, According to [Resident 1] he was held down by a female and male CNA while they changed his pants . A review of Resident 1's Progress Notes, dated 2/28/25, at 9:02 A.M., indicated, [Resident 1] reported that two CNAs had physically abused him on 2/26 to the DOR [Director of Rehab] . A review of Resident 1's Interdisciplinary Team (a group of professionals from different disciplines who work collaboratively to provide care to a resident) note dated 2/28/25 at 9:28 p.m. indicated, Resident made allegation to staff member that he was 'forced' to wear a brief during a bed bath that occurred on 2/26/25 .[Resident 1] would like to independently perform peri care in the bathroom with the door closed . A review of Resident 1's behavior note dated 3/3/25 at 2:51 p.m. indicated, Nursing staff has reported behaviors of the following: Throwing personal belongings= 0 [on] all shifts .Making sexual advances= 0 [on] all shifts .Verbal aggression= D [Day shift]= 0 NOC [nocturnal shift]= 0 . During a concurrent observation and interview in Resident 1's room on 3/5/25, at 10:13 A.M., Resident 1 stated, 2 CNAs [CNA A and CNA B], one on each side. They held me down. The larger one put her weight on me . They wanted to put a diaper on me. I told them no . but they put it on me anyway . this is demeaning . I was pissed. While Resident 1 recounted the event, he became teary eyed. During an interview on 3/5/25, at 12:03 P.M., Licensed Nurse (LN) stated CNA A told him Resident 1 refused a brief (an adult diaper) change. The LN stated he, remembered [Resident 1] didn't want females caring for him. During an interview on 3/5/25, at 1:45 P.M., the DOR stated Resident 1 told her, . they held me down, pulled down my pants and put diapers on me. The DOR stated Resident 1 was upset and used the word manhandled in his description of the event. During an interview on 3/5/25, at 1:56 P.M., CNA A stated Resident 1 was not cooperating with his brief change stating he did not want it. The CNA also stated, [Resident 1] started to become aggressive and told us to get out . we each held a hand and put on the brief with our free hands. During an interview on 3/5/25, at 2:35 P.M., the Operations Manager (OM) confirmed the incident occurred and confirmed holding a resident down was a form of abuse. During a record review of facility policy titled Abuse: Prevention of and Prohibition Against, dated 1/2024, indicated, It is the policy of this facility that each resident has the right to be free from abuse . Residents also have the right to be free from . physical abuse .Abuse is willful infliction of . intimidation, or punishment . with resulting . mental anguish.

Based on interview and record review, the facility failed to designate a qualified staff member to function in the role of Infection Preventionist (IP) (individual responsible for the facility's activities aimed at reducing the spread of disease by collecting and analyzing data on healthcare-associated infections, identifying outbreaks, and using appropriate prevention strategies to prevent and control further spread), per the facility's assessment plan. This failure created potential for inability to implement programs and activities to prevent and control infections in a population of vulnerable residents, which placed 33 of 33 Residents at risk for infections. Findings: During an interview on 03/22/23 at 12 p.m., the Director of Nursing (DON) and Licensed Nurse A (LN A) were asked about the IP at the facility. The DON stated the IP had quit working at the facility approximately five to six weeks earlier. During and interview on 03/22/23 at 4:01 p.m., the DON stated the facility did not have a full-time IP Nurse, as the prior IP nurse left her position at the facility in early February, 2023. The DON stated the facility's goal was for LN A (who worked as an IP at another facility) to transition into the IP position in April, 2023. The DON stated two nurses were currently out on medical leave and LN A needed to work the floor (as a charge nurse) until their return. The DON stated the facility was able to, piece (IP duties) together. She stated LN A, Consultant E did some of the work and she (the DON) and other nurses, helped. Review of facility document titled, (Facility Name), subtitled, Facility Assessment, subtitled, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies, further subtitled, Staffing Plan, (dated 1/25/2023) indicated, Nursing Service Staffing Plan . Infection Preventionist: 40 hrs. qwk (hours per week) . Review of the facility's IP job description titled, Infection Preventionist (CA), subtitled, Purpose of Your Job Position (reviewed 01/27/23), The primary purpose of your job position is to plan, organize, develop, coordinate, direct, and implement the facility's Infection Prevention and Control Program (IPCP) and its activities in accordance with current federal, state, and local standards, guidelines, and regulations that govern such programs . to ensure that an effective infection control program is maintained at all times.

Based on observation and interview, the facility failed to ensure the call light system was accessible to residents while lying on the floor in the restrooms for residents in 19 of 21 rooms. This failure created the potential for residents, who fell while using the restroom, from activating the call light system and summoning help. Findings: During an observation and interview on 3/22/23, at 8:50 a.m., with the Director of Maintenance (DM), the restrooms used by residents in 19 of 21 rooms (Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 17, 19, 20, 21, 2, 23, 24 and 25) were inspected. All the restrooms had the call light button located next to the toilet at elbow level from a resident sitting on the toilet. There was no string or cord from the call light button reaching the floor. The DM measured the height of the call light button in all restrooms and stated it was 36 inches from the floor. During a simulation of a fall from the toilet in the restroom used by residents in rooms [ROOM NUMBERS], it was not possible to reach the call light while lying on the floor.

Based on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) frozen vegetables were not sealed, 2) dietary staff did not know quaternary (quat ammonium compounds designed to kill germs) wet time for sanitizer solutions, 3) cook did not sanitize countertop after preparing meat, and 4) the cook was not wearing appropriate aprons for cooking and washing cooking utensils and equipment per the facility's policy/procedure. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal distress, weight loss and in severe instances may result in death. Findings: 1. During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. the frozen corn and frozen peas located in the freezer in the main kitchen area were both stored in unsealed blue bags, which were in open cardboard boxes. During a concurrent observation and interview on 3/22/23 at 8:40 a.m., the frozen corn and frozen cauliflower located in the freezer in the main kitchen area were both stored in unsealed blue bags, which were in open cardboard boxes. The Dietary Supervisor stated the frozen vegetables are delivered in a compressed sealed bag inside a sealed cardboard box, but the frozen vegetables are not tied/sealed after they are opened. The facility Policy/Procedure (P/P) titled, Procedure for Freezer Storage, dated 2018, indicated: Subject: Freezer Storage: Procedure: . 5. Store frozen foods in an airtight moisture-resistant wrapper such as a plastic bag or freezer paper to prevent freezer burn . 2. During an interview on 3/22/23 at 9 a.m., Dietary Aide D stated the procedure for cleaning the dirty kitchen countertops was as follows: First clean the dirty countertops with soapy water located in the green bucket, wipe with the clean water located in the blue bucket, and then sanitize the countertops with the sanitizer located in the red bucket. Dietary Aide D stated the sanitizer wet time (the time that a disinfectant/sanitizer needs to stay wet on a surface to ensure efficacy) for the quat sanitizer wet time was 10 minutes. During an interview on 3/23/23 at 8 a.m., the Dietary Supervisor stated the kitchen countertop needed to be sanitized after preparing meat such as the hamburger and ground turkey to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). During an interview on 3/23/23 at 9:20 a.m., when the Dietary Supervisor was asked what the contact/wet time was for the sanitizer used to sanitize the kitchen countertops, he stated he would have to look up the wet time. When the Dietary Supervisor returned, he stated the sanitizer wet time was 10 minutes. During a concurrent observation, interview and review of Purell's sanitizer directions on 3/23/23 at 9:15 a.m. Dietary Aide C stated she used the Purell spray to sanitize the meal tray carts, which appeared to be made of stainless steel. Dietary Aide C stated she sprayed the sanitizer throughout each cart and then wiped the sanitizer, so the solution was evenly spread throughout the carts, and then she let the sanitizer air dry. When Dietary Aide C was asked what the contact/wet time was for the sanitizer, Dietary Aide C stated she thought 10 seconds. The Purell sanitizer instructions on the back of the Purell (Foodservice surface sanitizer) indicated: Sanitization Directions to Sanitize Hard, Nonporous (a surface, such stainless steel, metal, glass, hard plastic, and varnished wood whereby any kind of liquid and air cannot penetrate the material, and they just remain on the surface) Food-Contact Surfaces: Visible soil must be removed prior to sanitizing. Wash surface and follow with potable water rinse. Spray, pour, or apply this product with a cloth, mop, or sprayer device until surface is thoroughly wet. For spray application, spray 6-8 inches from the surface. Treated surface must remain wet for 60 seconds. Wipe or allow to air dry. No rinse required. To Spot Sanitize Soft Surfaces: Visible soil must be removed prior to sanitizing. Spray this product 6-8 inches from soft surface until wet. Do not saturate. Let stand for 30 seconds. Allow to air dry. During a concurrent interview and review of the Shurguard Ultimate (Food Contact Sanitizer/Disinfectant) on 3/24/23 at 12:08 a.m., the surveyor met with the DON (Director of Nursing), Maintenance Manager, and the Rehabilitation Manager to go over the sanitizer solution dietary staff was supposed to use in the kitchen to clean the kitchen countertops. The Maintenance Manager stated the dietary staff were supposed to use the Purell spray bottle solution for the countertops per oversight with the Infection Preventionist. The Shurguard was supposed to be used for the three-sink compartment (manual procedure for cleaning and sanitizing the dishes). The Rehabilitation Manager stated she trained the dietary staff to use the Purell sanitizer to sanitize the kitchen countertops. The Rehabilitation Manager was asked if she was a qualified Certified Dietary Manager whose duties included training the dietary staff on sanitation procedures. The Rehabilitation Manager stated she was not qualified to act as the Dietary Manager. The Shurguard Ultimate directions were for both sanitizer (a quat solution, reduces the number of germs on a surface, safe for food to come in contact with, and does not need to be rinsed) and a disinfectant (kills most germs, the solution is a stronger concentration, not safe for food to come in contact with, so the surfaces that come in contact with food needed to be rinsed with potable water after using the sanitizer as a disinfectant) use on countertops. The wet time for using the Shurguard Ultimate solution as a sanitizer was 1 minute and use as a disinfectant was 10 minutes. The facility P/P titled, Shelves, Counters and Other Surfaces Including Hand Washing Sinks, dated 2018, indicated: Cleaning Procedure: . 3. Spray or wipe with Quaternary bucket solution containing sanitizer. Read sanitizer directions to learn how long surface is to remain wet. Use enough sanitizer to meet this time. Do not rinse. 3. During an observation on 3/22/23 at 10:25 a.m., Cook B used the soapy water in the green bucket to wipe the countertops off after finishing making the meatloaf with the added ground turkey. Cook B then used the clean water from the blue bucket to wipe the soapy countertops but stopped there and did not sanitize the countertops. During an interview on 3/22/23 at 10:35 a.m., the Dietary Supervisor was asked if Cook B should have sanitized the countertops after he finished preparing the meatloaf, whereby meat particles landed on the countertops. The Dietary Supervisor stated Cook B should have sanitized the countertops, but he forgot to. The Dietary Supervisor then cued Cook B to sanitize the countertops after preparing the meatloaf. Cook B stated he would normally sanitize the countertops, but he got busy with food preparation closer to tray line, his head went in multiple directions and he forgot to sanitize the countertops. The facility job description titled, Cook, revised 10/17, indicated: . Follow established Infection Control and Universal Precautions policies and procedures when performing daily tasks . 4. During and observation on 3/22/23 at 11:30 a.m., Cook B was observed not wearing an apron over his sweatshirt when cooking and/or for washing dirty utensils/equipment. Cook B was observed wearing a sweatshirt while cooking and going back and forth between cooking/the food prep area and the dirty dishwasher area where he was washing his cooking utensils/equipment and then going back to preparing the food/placing the food on the steamtable and plating the food for the residents' lunch. Both dietary aides and the 2nd cook had a cloth apron on while preparing the food/getting trays read for the tray line. During an observation and interview on 3/22/23 at 12:45 p.m., Dietary Aide C stated she used a cloth apron when working with food, when on the tray line and preparing the residents' meal tray. Dietary C stated she used a disposable plastic apron when washing dishes. Dietary Aide C pointed to her cloth apron placed on the hook near the coffee machine and kitchen door leading to the hallway. Cook B was observed washing his cooking utensils/dishes without a disposable apron over his clothes. During an interview on 3/23/23 at 8 a.m., the Dietary Supervisor stated the dietary staff used a disposable apron to wash dishes and a cloth apron while preparing foods such the hamburger and ground turkey and when cooking to prevent cross contamination. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD has never overseen him. The facility P/P titled, Dress Code For Women and Men, dated 2018, indicated: Purpose: Appropriate dress in the Food and Nutrition Department. Personal hygiene and appropriate dress are very important part of the total appearance of Food and Nutrition Services Department. All clothing should be in good repair. Appearance is very important in maintaining a high standard of food service. The following recommendations are made: . Men: . 5. Clean apron, plastic or cloth . The facility job description titled, Registered Dietician (RD), revision 10/2017, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the RD would monitor General Sanitation and Safety: . 17. Competency of the staff is routinely done and documented . Food Preparation: . 18. All food production surfaces are cleaned and sanitized after use. The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . The facility job description titled, Personnel Management, dated 2018, indicated: Policy: A qualified FNS (Food and Nutrition Service) Director, chosen by the Administrator, is responsible for the total operation of the Food and Nutrition Services Department. All Food and Nutrition service is performed under their direction. (Note the Dietary Supervisor was not a Certified Dietary Manger/had not completed the Dietary Management Program). Procedure: If a person is not a RD, he must meet the Federal and State laws and receive regular consultation from the RD or have met equivalent requirements. Responsibilities of FNS Director: . Food and Nutrition service orientation, staffing, supervision, staff training and in-servicing . Maintaining Acceptable standards of Sanitation and food safety. Responsibilities of the Consultant Dietician: . The Dietician will provide staff development programs, (in-servicing) for FNS . that assure the professional food and nutrition service needs of the facility are met. This will include, but is not limited to sanitation inspections . and enforcement/education of State, County and Federal regulations .

Based on observation, interview, and record review, the facility failed to prepare a meal tray with 1) the individual therapeutic portion size for 30 out of 33 residents, when 30 residents' meatloaf portion size was not followed per the residents' lunch meal card, and 2) 13 out of 13 residents on a Fortified diet did not have their mash potatoes fortified with one oz of gravy per Spring 2023 Week 3 Fortified Lunch. These failures to ensure nutritional content could result in decreased dietary intake and resulted in less calories and protein, which may result in weight loss and further compromise resident medical status. Findings: 1) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. Cook B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When the Dietary Supervisor was asked how Cook B was going to meet the portion size for 30 residents with six pounds of hamburger, the Dietary Supervisor stated he went to the store to buy the hamburger and did not buy enough. The Dietary Supervisor stated cook B would add the one pound of ground turkey, which was going to be used to make a meatloaf for the residents who did not like beef. Cook B then added the pound of ground turkey to the hamburger mix. This occurred after surveyor had to cue the Dietary Supervisor about there not being enough hamburger. The Dietary Supervisor was overseeing Cook B. Cook B had prepared the meatloaf following the recipe for 24 servings. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:15 a.m., Cook B added the one pound of ground turkey to the already mixed meatloaf. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:25 a.m. and 10:30 a.m., Cook B stated he had made two hamburger patties because one resident was allergic to onions and one resident could not have gluten (protein found in the wheat plant and some other grains). There were four loaves of meatloaf in a baking pan placed on the bottom oven rack, and the two hamburger patties were each in a baking dish placed on the top oven rack, baking at 400 degrees Fahrenheit. During an observation on 2/22/23 at 11:45 a.m., Cook B had placed a slice of meatloaf on a medal spatula and placed the spatula with the meat on the food scale. He was measuring the meat for the pureed diets. Cook B then pureed the meat using low sodium broth. During an observation during tray line on 2/22/23 at 12:20 p.m., one slice of meatloaf ( regular portion size) was seen on the shelf above steamtable. During a concurrent observation and dietary record on 3/22/23 at 12:30 p.m., the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the small portion of meatloaf should weigh three oz and the regular or large portion of meatloaf should weigh 4 oz. Plating the residents lunch meal ended at 12:30 p.m. and there was one of four loaves of meatloaf in the baking pan, which was full of grease. Grease had not been drained from then baking pan before plating the meatloaf. There was six pound (96 oz) of hamburger and one pound (16 oz) of ground turkey, total of 112 oz of meat used to serve 30 residents. A review of the residents Lunch Meal Card, indicated 118 oz of meat was needed to serve 30 residents, based on portion size. Cook B was short 6 oz of meat before he started plating the meatloaf and hamburger patties. There was a loaf of meatloaf leftover after the last slice of meatloaf was plated. During an interview on 3/23/23 at 8:00 a.m., the Dietary Supervisor stated he did not see Cook B weigh the meatloaf periodically. The Dietary Supervisor stated Cook B did have a slice of meatloaf on the shelf above the steam table for an example of the portion size he needed to slice. The Dietary Supervisor stated Cook B was slicing the meatloaf as he was periodically eyeballing the portion size example of meatloaf. The Dietary Supervisor stated to accurately weigh meat Cook B should have used cellophane to cover the scale, placed the slice of meat on the scale, and then weigh the meat. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. When asked how the Dietary Supervisor measured out meat, the Dietary Supervisor stated he usually sliced and measured a few pieces of meat. The Dietary Supervisor stated he would then eyeball the slices of meat he sliced against the meat he had weighed for his portion size example to make sure he was plating the correct portion size. The Dietary Supervisor stated if he felt he had not sliced enough meat he would remeasure a slice of meat to make sure he was slicing the correct portion size. The Dietary Supervisor stated Cook B felt rushed because he had to place the meatloaf back in the oven because it was not cooked. The Dietary Supervisor stated Cook B did not measure the meat out like he would normally. The facility Policy/Procedure titled, Food Preparation: Portion Control, dated 2018, indicated: Policy: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food . 3. A diet scale should be used to weigh meats . It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy. 2) During an observation on 3/22/23 at 12:20 p.m., Cook B was fortifying the meatloaf with gravy and extra liquid butter on the spinach for residents on a Fortified diet. During an interview on 3/22/23 at 1:20 p.m., Cook B stated the gravy on the meatloaf was for the Fortified diets. Cook B stated per the Fortified instructions, he should have fortified both the meatloaf and the mashed potatoes with gravy and fortified the spinach with additional butter. Cook B stated he missed putting gravy on the mash potatoes. A review of the dietary document titled, Fortified Lunch dated Spring 2023 Week 3, indicated for Wednesday's lunch, the mashed potatoes needed 2 oz of gravy and the Spinach needed 1/2 oz melted margarine. A review of the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the Garden Fresh Meatloaf for Regular, Mechanical Soft (includes foods that are soft and do not take a lot of effort to chew or swallow), Pureed and CCHO (Controlled Carbohydrate include sugars, fibers and starches) diet were supposed to have gravy on the meatloaf, not just the fortified diets. The facility P/P titled, Fortified Diet, dated 2020, indicated: Description: The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional Breakdown: The goal is to increase the calorie density of the foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day . Sample Fortified Meal Plan: . Lunch: Extra sauce or gravy on meat, extra margarine on potatoes, rice or paste . The facility P/P titled, Section 1: Purpose, dated 2018, indicated: .Therapeutic diets shall be prepared and served in accordance with the physician diet order . The facility job description titled, Registered Dietitian, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Monitor dietary services to assure that all residents' dietary needs are being met . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the Registered Dietician would monitor: Food Preparation: 1. Recipes and instructions for food preparation are being followed. 2. Spreadsheets are used for service of the correct food and portion. 4. Fortified foods guides used and are prepared and severed accordingly The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . The facility job description titled, Cook, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to prepare meals in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with established policies and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided at all times. Essential Functions and Responsibilities: . Ensure that all dietary procedures are followed in accordance with established policies . Review menus prior to preparation of food . Serve meals in accordance with established portion control procedures . Ensure that food and supplies for the next meal are readily available .

Based on dietary observation, interview, and dietary record review, the facility failed to ensure staff possessed required competency as evidenced by dietary staff members were not: 1) following recipes for a.spinach and b. meatloaf 2) following therapeutic diets when a. portion sizes were not plated correctly, meat needing to be pureed (texture-modified diet with the consistence of pudding for people who have difficulties with chewing and swallowing) was not weighed properly, and b.mash potatoes were not fortified 3) qualified to oversee the day-to-day operations of the kitchen and 4) qualified to evaluate cooks for competences. Failure to ensure staff competency could result in decreased food distribution and food production systems to ensure food palpability and nutritional content, which could result in decreased dietary intake that did not meet individual resident nutritional requirement. This could result in weight loss and further compromise resident medical status. Findings: 1a) During an observation on 3/22/23 at 9:05 a.m. Cook B placed two frozen bags of spinach in a pot of water and started cooking the frozen spinach on the stovetop. During an observation on 3/22/23 at 9:15 a.m., the two bags of spinach were submerged in boiling water. During an observation on 3/22/23 at 10:10 a.m., the spinach was still cooking on the stovetop. During a concurrent observation and interview on 3/22/23 at 11:20 a.m. the spinach with added margarine and Swiss cheese was on the steam table. When Cook B was asked if he had baked the Spinach after adding the margarine and Swiss cheese per the Spinach Au Gratin recipe, Cook B stated, No, he first drained the spinach, added the spinach to the pan, placed the pan on the steam table and then added the margarine and Swiss cheese while in the pan on the steam table. The spinach had been cooking in boiling water for over two hours prior to placing the spinach on the steam table. During an observation during tray line on 3/22/23 at 12:20 p.m., Cook B was using a slotted serving spoon (spoon with holes) to plate the Spinach Au Gratin, which was very watery. Cook B tapped the spoon on the side of the serving pan five times to drain off the excess water before plating the spinach. A review of the recipe titled, Spinach Au Gratin, indicated: 1. Cook spinach in enough water to cover. Drain well. Place in baking pan, 2. Add margarine and cheese and mix well, 3. Bake at 325 degrees Fahrenheit for 10-15 minutes, until cheese is melted . 1b) During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 9:45 a.m., Cook B chopped carrots, onions and celery, but did not chop the mixed colored bell peppers, one of the ingredients needed. Cook B placed the carrots, celery and onions in the Robot Coupe (food processor used to dice, mince, grind, puree, slice, shred, etc.), blended the vegetables, and drained the excess water. When Cook B was asked why he blended the vegetables, Cook B stated it made it easier to mix all the ingredients together. The recipe indicated: Heat margarine or oil in skillet and saute vegetables and Italian seasonings until vegetables are tender, approximately 3 to 5 minutes. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10 a.m., there was six pounds of hamburger to serve 30 residents. The Garden Fresh Meatloaf recipe indicated six pounds of hamburger would serve 24 residents. Cook B stated there was one vegetarian, two residents who did not like beef, and thirty residents who would be having the hamburger either in the form of meatloaf or a hamburger patty. When the Dietary Supervisor was asked how Cook B was going to meet the portion size for 30 residents with six pounds of hamburger, the Dietary Supervisor stated he went to the store to buy the hamburger and did not buy enough. The Dietary Supervisor stated Cook B would add the one pound of ground turkey, which was going to be used to make a meatloaf for the residents who did not like beef. Cook B then added the pound of ground turkey to the hamburger mix. This occurred after the surveyor had to cue the Dietary Supervisor about not having enough hamburger to serve 30 residents. The Dietary Supervisor was overseeing Cook B. Cook B had prepared the meatloaf following the recipe for 24 servings. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:15 a.m., Cook B added the one pound of ground turkey to the already mixed meatloaf. Cook B added chopped carrots, celery and onion. When Cook B was asked why he did not put the additional raw chopped vegetables in the food processor, Cook B stated to give the meatloaf a variation of cut vegetables. When Cook B was asked what additional ingredient he added to the bowl, which had the meatloaf mix, ground turkey, and raw vegetables, he stated he added a 1/4 cup of Italian seasoning. When asked if the recipe asked for a 1/4 cup of Italian seasoning, Cook B said, Yes. Surveyor asked Cook B to look at the recipe. Cook B stated he read the Garden Fresh Meatloaf recipe wrong. Cook B stated he was supposed to add 1/4 teaspoon (tsp) to the one pound of additional ground turkey. Cook B was observed taking a handful of the Italian Seasoning off the top of the ground turkey with his gloved hand. During a concurrent observation, interview, and review of the Garden Fresh Meatloaf recipe on 3/22/23 at 10:25 a.m. and 10:30 a.m., Cook B stated he had made two hamburger patties because one resident was allergic to onions and one resident could not have gluten (protein found in the wheat plant and some other grains). There were four loaves of meatloaf in a baking pan placed on the bottom oven rack, and the two hamburger patties, each in a baking dish, placed on the top oven rack, baking at 400 degrees Fahrenheit. When Cook B was asked why he was cooking the meat at 400 degrees instead of following the recipe, which indicated: Bake at one and a half hours to two hours at 325 degrees, Cook B stated to speed up the process. During a concurrent observation and interview on 3/22/23 at 11:25 a.m., Cook B pulled the meat out of the oven to check the temperature. Cook B stated the meatloaf temperature was at 135.4 degrees. Cook B placed the meatloaf back in the oven to continue cooking. During a concurrent observation and interview on 3/22/23 at 11:30 a.m., when Cook B was asked what the other pan on the top oven rack was, Cook B stated a veggie patty. The two 4-ounce hamburger patties had been cooking on the top oven rack for one hour. The facility Policy/Procedure (P/P) titled, Food Preparation, dated 2018, indicted: Policy: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedure: . 2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. The facility P/P titled, Menu Planning, dated 2020, indicated: . Procedures: . 4. Standardized recipes adjusted to appropriate yield shall be maintained and used in food preparation. 2a) During an observation on 3/22/23 at 11:45 a.m., Cook B had placed a slice of meatloaf on a medal spatula and placed the spatula with the meat on the kitchen food scale. He was measuring the meat for the pureed diets. Cook B then pureed the meat using low sodium broth. During an observation during tray line on 3/22/23 at 12:20 p.m., one slice of meatloaf (regular portion size) was seen on the shelf above steamtable. During a concurrent observation and dietary record review on 3/22/23 at 12:30 p.m., the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated a small portion of meatloaf should weigh three oz and a regular or large portion of meatloaf should weigh 4 oz. Plating the residents lunch meal ended at 12:30 p.m. and there was one of four loaves of meatloaf left in the baking pan, which was full of grease. The grease had not been drained from the baking pan before plating the meatloaf. There was six pounds (96 oz) of hamburger and one pound (16 oz) of ground turkey, total of 112 oz of meat used to serve 30 residents. A review of the residents Lunch Meal Cards, indicated 118 oz of meat was needed to serve 30 residents, based on portion size. Cook B was short six oz of meat before he started plating the meatloaf and hamburger patties.There was a loaf of meatloaf left over after the last slice of meatloaf was plated. During an interview on 3/23/23 at 8:00 a.m., the Dietary Supervisor stated he did not see Cook B weigh the meatloaf periodically. The Dietary Supervisor stated Cook B did have a slice of meatloaf on the shelf above the steam table for an example of the portion size he needed to slice. The Dietary Supervisor stated Cook B was slicing the meatloaf as he was periodically eyeballing the example of meatloaf portion size. The Dietary Supervisor stated to accurately weigh meat Cook B should have used cellophane to cover the scale, placed the slice of meat on the scale, and then weigh the meat. During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. When asked how the Dietary Supervisor measured out meat, the Dietary Supervisor stated he usually sliced and measured a few pieces of meat. The Dietary Supervisor stated he would then eyeball the slices of meat he sliced against the meat he had weighed for his portion size example to make sure he was plating the correct portion size. The Dietary Supervisor stated if he felt he had not sliced enough meat he would remeasure a slice of meat to make sure he was slicing the correct portion size. The Dietary Supervisor stated Cook B felt rushed because he had to place the meatloaf back in the oven, because it was not cooked. The Dietary Supervisor stated Cook B did not measure the meat out like he would normally. The facility P/P titled, Food Preparation: Portion Control, dated 2018, indicated: Policy: To provide specific portion control information. Procedure: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food . 3. A diet scale should be used to weigh meats . It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy. The facility job description titled, Cook, revised 10/2017, indicated: Position Summary: The primary purpose of your job position is to prepare meals in accordance with current applicable federal, state, and local standards, guidelines, and regulations, with established policies and procedures, and as may be directed by the Director of Food Services, to assure quality food service is provided. Essential Functions and Responsibilities: . Ensure that all dietary procedures are followed in accordance with established policies . Review menus prior to preparation of food . Serve meals in accordance with established portion control procedures . Ensure that food and supplies for the next meal are readily available . 2b) During an observation on 3/22/23 at 12:20 p.m., Cook B was fortifying the meatloaf with gravy and extra liquid butter on the spinach for residents on a Fortified diet. During an interview on 3/22/23 at 1:20 p.m., Cook B stated the gravy on the meatloaf was for the Fortified diets. Cook B stated per the Fortified instructions, he should have fortified both the meatloaf and the mashed potatoes with gravy and fortified the spinach with additional butter. Cook B stated he missed putting gravy on the mash potatoes. A review of the dietary document titled, Fortified Lunch dated Spring 2023 Week 3, indicated for Wednesday's lunch, the mashed potatoes needed 2 oz of gravy and the Spinach needed 1/2 oz melted margarine. A review of the therapeutic Spring Cycle Menus for lunch, dated 3/22/23, indicated the Garden Fresh Meatloaf for Regular, Mechanical Soft (includes foods that are soft and do not take a lot of effort to chew or swallow), Pureed and CCHO (Controlled Carbohydrate include sugars, fibers and starches) diet were supposed to have gravy on the meatloaf, not just the fortified diets. The facility P/P titled, Fortified Diet, dated 2020, indicated: Description: The Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional Breakdown: The goal is to increase the calorie density of the foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day . Sample Fortified Meal Plan: . Lunch: Extra sauce or gravy on meat, extra margarine on potatoes, rice or paste . The facility P/P titled, Section 1: Purpose, dated 2018, indicated: .Therapeutic diets shall be prepared and served in accordance with the physician diet order . The facility job description titled, Registered Dietitian, undated, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Monitor dietary services to assure that all residents' dietary needs are being met . 3) During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. there was no Dietary Supervisor overseeing the kitchen. The Rehabilitation Manager stated she was overseeing the kitchen. The Rehabilitation Manager stated the Dietary Supervisor was on the way. During a concurrent interview and dietary record on 3/22/23 at 8:40 a.m., the Dietary Supervisor stated he had worked at the facility for a year, started as a cook and has been the Dietary Supervisor for the past six months. The Dietary Supervisor stated he was not yet qualified to be a Dietary Supervisor. He had his California Food Handlers Card, but he was not a Certified Dietary Manager (CDM). The Dietary Supervisor stated he was still taking the Certified Dietary Manager course. The Dietary Supervisor was asked to show where the carton of liquid eggs was kept. The Dietary Supervisor stated there was no liquid eggs used to cook omelets and scrambled eggs. The Dietary Supervisor stated he did the ordering for the kitchen but had missed ordering the cartons of liquid eggs. The dietary menu titled Good For Your Health Menus, dated 3/20/23-3/26/26, indicated the residents were going to be served a Denver Omelet on Thurs (3/23/23) and scrambled eggs on Friday (3/24/23). When the Dietary Supervisor was asked how the scrambled eggs for Friday was going to be made, the Dietary Supervisor stated he would normally go to the grocery store and buy a cartoon of liquid eggs. During an interview on 3/22/23 at 3:45 p.m., the Dietary Supervisor stated he was trained by the Rehabilitation Manager, the Dietary Supervisor from the facility's sister facility located in a nearby town, who was a Certified Dietary Manager, and the corporate Registered Dietician (RD) consultant, who came to the facility every few months. The Dietary Supervisor stated he could e-mail and call the corporate RD consultant as well. The Dietary Supervisor stated he trained Cook B. The Dietary Supervisor stated he had no training by the facility RD, who came every Thursday. The Dietary Supervisor stated the Dietary Supervisor oversaw the kitchen. The Dietary Supervisor stated he had never seen the RD oversee the kitchen and observe tray line. During an interview on 3/23/23 at 8:00 a.m. the Dietary Supervisor stated the Dietary Supervisor from the facility's sister facility and the Rehabilitation Manager taught him how to purchase food service supplies/kitchen supplies. The Dietary Supervisor stated there was hamburger in the freezer for the meatloaf, but the cook forgot to pull the hamburger out to thaw in time to make the meatloaf. The Dietary Supervisor stated he did not catch Cook B not cutting up mixed colored bell peppers for the Garden Fresh Meatloaf. The Dietary Supervisor stated the RD came every Thursday mainly to do her resident assessments. The Dietary Supervisor stated he could not recall the RD overseeing the kitchen in the past six months, since the Dietary Supervisor went from being a cook to being the Dietary Supervisor. The Dietary Supervisor stated the RD was new. During an interview on 3/23/23 at 8:50 a.m., the Dietary Supervisor stated he oversaw the cooks and when he went on vacation the Rehabilitation Manager would be checking on the kitchen and dietary staff. The Dietary Supervisor stated the Rehabilitation Manager hired him in this position, and when he was first hired in the cook position. The Dietary Supervisor started the Dietary Supervisor from the facility's sister facility did the dietary staff competencies. The Dietary Supervisor stated he worked as the Dietary Supervisor Monday through Thursdays and a cook on Fridays. During an interview on 3/24/23, at 1:26 p.m., the Administrator stated the facility had been without a certified dietary manager (CDM) since July 2021. Since then, the Administrator stated, the facility had not been able to hire a CDM. The Administrator stated around October 2022 the facility started training a cook (the Dietary Supervisor) to take on the role as CDM. A review of the dietary training document titled, Food and Nutrition Service In-Service, dated 1/19/23, indicated the Dietary Supervisor, who was not a CDM, had given an In-Service (training) on Review of Spread Sheets. A review of the dietary training document titled, Dietary In-service, dated 12/5/22, indicated the Dietary Supervisor, who was not a CDM, had given an In-Service on Menu Changes and Substitutions. A review of the Dietary Supervisor's employee file indicated Dietary Supervisor was hired as a cook on 9/23/21 and started in the job position of Director of Food Services on 10/1/22. The facility job description titled, Director of Food Services, signed by the Dietary Supervisor on 10/1/22, indicated: Purpose of Your Job Position: The primary purpose of your job position is to assist the Dietician in planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations, governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Equipment and Supply Functions: . Ensure that stock levels of staple/non-staple food, supplies, equipment, etc. are maintained at adequate levels at all times . Assist in the purchase of food services supplies, equipment, etc., as required. Education: . Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association . Handwritten next to qualification: In Training, signed and dated, 10/1/22 . Specific Requirements: Must be registered as Food Service Director in this state . 4) During an interview on 3/23/23 at 8:39 a.m., the Dietary Supervisor stated the RD had never overseen him. The Dietary Supervisor stated he did in-services for the dietary staff, one per month. The Dietary Supervisor stated the Dietary Supervisor from the facility's sister facility would do an in-service when she came up to the facility. The Dietary Supervisor stated he would do the competencies on the dietary staff including the cooks as did the Dietary Supervisor from the facility's sister facility. The Dietary Supervisor stated if he had questions, he would e-mail the Dietary Supervisor from the sister facility. The Dietary Supervisor stated he would watch Cook B to see if he was doing the dietary processes correctly, such as following a recipe, in order to see if Cook B was competent in meal production, amongst other things. The Dietary Supervisor stared Cook B came in one day before being hired and shadowed (observed) him. The Dietary Supervisor stated Cook B shadowed him for two weeks while the Dietary Supervisor did the cooking. The Dietary Supervisor stated during those two weeks, he would ask Cook B to do various kitchen tasks. The Dietary Supervisor stated he oversaw Cook B for one to two months. During an interview on 3/23/23 at 2 p.m., the Rehabilitation Manager stated she was [NAME] a support for the kitchen. The Rehabilitation Manager stated she was the Director of the Rehabilitation Department. The Rehabilitation Manager stated in her scope she would be looking at the resident's diet orders, advising the dietary staff in changes to a resident's therapeutic diet, advising if the texture of the resident's pureed diet was not prepared correctly, amongst other things. A review of the Dietary Supervisor's Equipment Competency-Complete with New Employees and Annually, dated 3/1/22, indicated the Rehabilitation Manager signed off on the Dietary Supervisor's competencies, whose dietary position was a cook at the time, under DSS (Dietary Service Supervisor)/Manager signature title. A review of the Dietary Supervisor's Verification of Job Competency Demonstration - Cook, dated 7/27/22, indicated the Rehabilitation Manager signed off on the Dietary Supervisor's competencies, who was in the Dietary Supervisor In Training position. During a concurrent interview and review of dietary staff competencies on 3/24/23 at 3:45 p.m., the DON (Director of Nursing) was shown and asked why Cook B's, competencies titled, Verification of Job Competency Demonstration - Cooks, in his employee file had no date of completion of competencies for the Cook position. but the same competency document for Cook B handed to surveyor on 3/23/23, was dated 10/13/22, indicated Cook B was signed off on all competencies for Cooks in one day. The DON stated she saw the issue but did not have an answer. She said, I see that. A review of the Rehabilitation Manager's employee file indicated she was hired on 12/20/10 in the job position of Speech-Language Pathologist and hired on 12/20/12 in the job position of Director of Rehabilitation. The facility job description titled, Director of Food Services, undated, indicated: . Personnel Functions: . Review and check competencies of dietary personnel and make necessary adjustments/corrections as required or that may become necessary . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . Conduct departmental performance evaluations in accordance with the facility's policies and procedures . The facility job description titled, Registered Dietitian, revised 10/2017, indicated: . Make written and oral reports/recommendations to the Food Service Supervisor and/or administrator as necessary/required concerning the operations of the Dietary Department . Develop and participate in the planning, conducting, and scheduling of timely in-services training that ensure a well educated competent dietary services department, as well as for other facility departments . The facility Sanitation and Food Safety Checklist, revised 6/17, used by the RD in her monthly kitchen inspections, indicated the Registered Dietician would monitor General Sanitation and Safety: . 17. Competency of the staff is routinely done and documented . 29. Fulltime FNS (Food and Nutrition Service Manager) credentials meet Title 22/CMS regulations, posted. 30. FNS manager has a current food safety certificate and is posted . Food Preparation: 1. Recipes and instructions for food preparation are being followed. 2. Spreadsheets are used for service of the correct food and portion. 4. Fortified foods guides used and are prepared and severed accordingly .

Based on food production observation, dietary staff interview, and dietary document review, the facility failed to ensure a Registered Dietician (RD) was overseeing the operations of the facility's Food Service Department and a qualified Dietary Supervisor or fulltime RD was overseeing the day-to-day operations of the kitchen, and evaulating dietary staff for competencies (cross reference F 812). These failures resulted in issues with safe and effective food storage, meal production (cross reference F 804) correct therapeutic diets being plated (cross reference F803) and infection control (cross reference F 812). Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness. Findings: During the initial tour of the kitchen on 3/20/23 at 11:20 a.m. there was no Dietary Supervisor overseeing the kitchen. The Rehabilitation Manager stated she was overseeing the kitchen. The Rehabilitation Manager stated the Dietary Supervisor was on the way. A review of the facility job descriptions titled, Director of Rehabilitation, and Speech-Language Pathologist indicated the Rehabilitation Manager was hired as the Director of Rehabilitation on 12/20/2012. On 12/10/2010, the Rehabilitation Manager was hired in the position of Speech-Language Pathologist. During a concurrent interview and dietary record on 3/22/23 at 8:40 a.m., the Dietary Supervisor stated he had worked at the facility for a year, started as a cook and has been the Dietary Supervisor for the past six months. The Dietary Supervisor stated he was not yet qualified to be a Dietary Supervisor. He had his California Food Handlers Card, but was not a Certified Dietary Manager (CDM). The Dietary Supervisor stated he was still taking the Certified Dietary Manager course. During an interview on 3/22/23 at 3:45 p.m., the Dietary Supervisor stated he was trained by the Rehabilitation Manager, the Dietary Supervisor from the facility's sister facility located in another town, who was a Certified Dietary Manager, and the corporate Registered Dietician (RD) consultant, who came to the facility every few months. The Dietary Supervisor stated he could e-mail and call the corporate RD consultant as well. The Dietary Supervisor stated he trained Cook B. The Dietary Supervisor stated he had no training by the facility RD, who came every Thursday. The Dietary Supervisor stated the Dietary Supervisor oversaw the kitchen. The Dietary Supervisor stated he had never seen the RD oversee the kitchen and observe tray line. During an interview on 3/23/23 at 8:50 a.m., the Dietary Supervisor stated the Dietary Supervisor from their sister facility did one inspection of kitchen but technically it did not count because she was not the RD, not part of her job description. The Dietary Supervisor stated the Dietary Supervisor oversaw the cooks. The Dietary Supervisor stated when he was on vacation the Rehabilitation Manager would be checking on the dietary staff to make sure everything was flowing well. The Dietary Supervisor stated the Rehabilitation Manager hired him in the Dietary Supervisor position, and when he was first hired in the cook position. The Dietary Supervisor stated he worked as the Dietary Supervisor on Monday through Thursday, and as a cook on Fridays. During an interview on 3/23/23 at 11:05 a.m., the RD stated she started working at the at the end of August or September 2022. The RD stated she was at the facility once per week and was also available by e-mail and/or phone. The RD stated when she first started, she mainly was in orientation and in October 2022, she started overseeing the operations of the facility's Food Service Department, by doing her monthly inspection of kitchen, and tray line and dining observations. The RD stated she was supposed to do a kitchen inspection monthly, starting October 2022, but she did not know if she had done many kitchen inspections. The RD stated the Rehabilitation Manager was overseeing the kitchen while the RD was orientating. The RD stated she understood and agreed the Dietary Supervisor was not qualified yet to oversee the kitchen. The RD stated she had never met and oversaw Cook B and verified Cook B's competencies as a cook by demonstration. The RD stated she did not oversee the ordering of food supplies. During a concurrent interview and review of the RD's monthly inspections of the kitchen from 1/2022 through 3/23/23, on 3/23/23 at 11:45 a.m., the Administrator was able to show a kitchen inspection took place by a RD six times. The current RD inspected the kitchen on 11/3/22, 1/27/23, and 2/27/23, the facility's corporate RD consultant inspected the kitchen on 5/2-5/3/22 and another RD inspected the kitchen on 1/21/22 and 8/6/22. The Administrator stated the RD, who inspected the kitchen on 1/21/22 and 8/6/22, used to be the facility's RD for a while and when she left, she was still helping at times. The Administrator stated the current RD started on 8/23/22. The Administrator stated it has been difficult to find a qualified RD to oversee the operations of the facility's Food Service Department and qualified Dietary Supervisor or fulltime RD to oversee the day-to-day operations of the kitchen. During an interview on 3/23/23 at 1:45 p.m., the Administrator stated she hired the Dietary Supervisor in 10/2022 as the Director of Food Services in training. The Administrator stated the corporate RD consultant has been helping at the facility at times. The Administrator stated the RD started in August/September 2022 and was mainly learning the computer, resident assessments and physician dietary orders at first. During an interview on 3/23/23 at 2 p.m., the Rehabilitation Manager stated she was mainly a support for the kitchen. The Rehabilitation Manager stated she was the Director of the Rehabilitation Department. The Rehabilitation Manager stated in her scope of practice, she would be looking at the resident's diet orders, advising the dietary staff in changes to a resident's therapeutic diet, advising if the texture of the resident's pureed diet was not prepared correctly, amongst other things. During an interview on 3/24/23, at 1:26 p.m., the Administrator stated the facility had been without a certified dietary manager (CDM) since July 2021, when the CDM quit. Since then, the Administrator stated, the facility had not been able to hire a CDM. The Administrator stated around October 2022 the facility started training a cook (the Dietary Supervisor) to take on the role as CDM. A review of the RD's New Hire/Employment Record Transfer Form, indicated the RD's hire date was 8/23/22, she was part-time, and her scheduled weekly hours was 16 hours. The facility job description titled, Registered Dietitian, undated, indicated: Position Summary: The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Dietary Department in accordance with the current federal, state, and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to ensure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean , safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: . Plan, develop, organize, implement, evaluate, and direct the Dietary Department, its programs and activities . Make written and oral reports/recommendations to the Food Service Supervisor and/or administrator as necessary/required concerning the operations of the Dietary Department . Develop and participate in the planning, conducting, and scheduling of timely in-service training that ensure a well-educated competent dietary services department . Monitor dietary services to assure that all residents' dietary needs are being met . A review of the Dietary Supervisors New Hire/Employment Record Transfer Form, indicated the Dietary Supervisor was hired on 9/23/21 and his job title was cook. A review of the facility job description titled, Director of Food Services, indicated the Dietary Supervisor took the title as Director of Food Services on 10/1/22, and under Education, written next to qualifications, the Dietary Supervisor was In Training, dated and signed on 10/1/22. The facility job description titled, Director of Food Services, signed by the Dietary Supervisor on 10/1/22, indicated: Purpose of Your Job Position: The primary purpose of your job position is to assist the Dietician in planning, organizing, developing, and directing the overall operation of the Dietary Department in accordance with current applicable federal, state, and local standards, guidelines and regulations, governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the dietary department is maintained in a clean, safe, and sanitary manner . Duties and Responsibilities: Administrative Functions: Assist in planning, developing, organizing, implementing, evaluating and directing the Dietary Department, its programs and activities . Personnel Functions: . Review and check competence of dietary personnel and make necessary adjustments/corrections as required or that may become necessary . Make daily rounds to assure that dietary personnel are performing required duties and to assure that appropriate dietary procedures are being rendered to meet the needs of the facility . Conduct departmental performance evaluations in accordance with the facility's policies and procedures . Equipment and Supply Functions: . Ensure that stock levels of staple/non-staple food, supplies, equipment, etc. are maintained at adequate levels at all times . Assist in the purchase of food services supplies, equipment, etc., as required . Education: . Be a graduate of an accredited course in dietetic training approved by the American Dietetic Association . Handwritten next to qualification: In Training, signed and dated, 10/1/22 . Specific Requirements: Must be registered as Food Service Director in this state . Note there has not been a qualified certified dietary manager (CDM) since July 2021. The facility job description titled, Personnel Management, dated 2018, indicated: Policy: A qualified FNS (Food and Nutrition Service) Director, chosen by the Administrator, is responsible for the total operation of the Food and Nutrition Services Department. All Food and Nutrition service is performed under their direction. (Note the Dietary Supervisor was not a Certified Dietary Manger/had not completed the Dietary Management Program). Procedure: If a person is not a RD, he must meet the Federal and State laws and receive regular consultation from the RD or have met equivalent requirements. Responsibilities of FNS Director: . Food and Nutrition service orientation, staffing, supervision, staff training and in-servicing . Maintaining Acceptable standards of Sanitation and food safety. Responsibilities of the Consultant Dietician: . The Dietician will provide staff development programs, (in-servicing) for FNS . that assure the professional food and nutrition service needs of the facility are met. This will include, but is not limited to sanitation inspections . and enforcement/education of State, County and Federal regulations .

Based on observation, interview, and record review, the facility failed to ensure discontinued medications were removed from stock according to facility policy and procedure (P&P), medications were appropriately labeled with a pharmacy label identifying which resident they were for, and expired medications were not available for resident use. The deficient practices had the potential to result in medications being administered not in accordance with physician's order and residents receiving medications with unsafe or reduced potency from being used past their discard date. Findings: On 3/20/23 at 11:14 a.m., an inspection of the Medication Storage Room alongside Licensed Nurse 1 (LN 1) identified two Mounjaro (an injectable medication used to treat diabetes) 2.5 milligram/0.5 milliliter (mg/ml, a unit of measurement) pens. One pen was inside a clear bag with a pharmacy label on the outside for Resident 4. The second pen was unlabeled with a pharmacy label and was not in any other packaging identifying which resident it was for. LN 1 stated all medications should have a pharmacy label affixed to the medication or packaged inside a bag with a label on the outside to identify which resident it was for. She stated Resident 4's order for Mounjaro had been discontinued and the pen should have been discarded in the discontinued medications bucket (DC bucket, a container designated for discontinued or expired medications). Further inspection identified two amber prescription vials sitting on top of the counter for Resident 27. One vial contained omeprazole (a medication used to treat acid reflux) 20 mg capsules and the second contained nitrofurantoin (an antibiotic used to treat infection) 100 mg capsules. LN 1 stated both vials should have been placed in the DC bucket because the resident was no longer taking those medications. During the same inspection, one Eliquis (a medication used to prevent blood clots) 2.5 mg tablet inside plastic strip packaging expired 9/19/22, was identified inside a cabinet. LN 1 stated the tablet was expired and should have been discarded in the DC bucket. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 8/2019, indicated, All medications dispensed by the pharmacy are stored in the box, bag or other container with the pharmacy label . During a review of the facility's P&P titled, Disposal of Medications and Medication-Related Supplies, dated 8/2014, indicated, If a medication expires, or a prescriber discontinues a medication, the discontinued drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose . An inspection of Medication Storage Cart 1, on 3/20/23 at 12:15 p.m., alongside LN 1 identified one calcitonin salmon (a medication used to prevent osteoporosis) 200 units/ml nasal spray, opened 2/5/23. LN 1 reviewed the manufacturer's labeling on the product packaging and stated the nasal spray expired 35 days after opened. LN 1 confirmed the nasal spray had expired 7 days prior. During an interview on 3/21/23, at 10:36 a.m., with Director of Nursing (DON), DON stated the expectation of nursing staff was to remove expired medications from stock and replace with new supply. She stated discontinued medications were to go in the DC bucket and their disposal documented by signatures of two licensed nurses. During a review of the facility's P&P titled, Medication Storage in the Facility, dated 8/2019, indicated, Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of accorder to procedures for medication, and reordered from the pharmacy, if a current order exists.

Based on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for two out of three residents (Resident 8 and Resident 26) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. This failure resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications. Findings: The controlled medication CDR for three random residents receiving as needed controlled medications were requested for review during the survey. During an interview on 3/21/23, at 9:44 a.m., with Licensed Nurse 2 (LN 2), LN 2 stated whenever a controlled medication was administered to a resident, the dose was to be documented in both the CDR and the MAR. He stated it was important for documentation to be in both places to know when a dose was last administered. During an interview on 3/21/23, at 10:22 a.m., with Director of Nursing (DON), DON stated the expectation of nursing staff was whenever a controlled medication was administered to a resident, they were to validate the tablet count, then document the given dose on the CDR and the MAR. 1a. Resident 26 had a physician's order for hydrocodone/APAP (a medication used to treat pain) 5/325 milligram/milligram (mg, a unit of measurement), dated 2/28/23. During a concurrent interview and record review on 3/21/23, at 10:25 a.m., with DON, a review of Resident 26's 3/2023 MAR indicated nursing staff removed 1 tablet on 3/13/23 from the medication cart and documented on the CDR without documenting the respective administration on the MAR. DON verified the finding. 1b. Resident 8 had a physician's order for lorazepam (a medication used to treat anxiety) 0.5 mg, 1 tablet every 4 hours as needed for anxiety, dated 2/11/23. During a concurrent interview and record review on 3/21/23, at 10:27 a.m., with DON, a review of Resident 8's CDR for lorazepam and 2/2023 through 3/2023 MARs indicated nursing staff removed the following from the medication cart and documented on the CDR without documenting the respective administration on the MAR: 1 tablet on 2/23/23, 1 tablet on 3/6/23, and 1 tablet on 3/19/23. DON confirmed the findings and stated, I don't see anything charted. During a review of the facility's policy and procedure titled, Preparation and General Guidelines, dated 10/2019, indicated, When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and/or the medication administration record (MAR): 1. Date and time of administration. (MAR, Accountability Record) 2. Amount administered. (Accountability Record) 3. Remaining quantity (Accountability Record) 4. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from supply 5. Initials of the nurse administering the dose, completed after the medication is actually administered (MAR).

Based on observation, interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 6) received the necessary care, consistent with professional standards of practice, to prevent pressure ulcers when the facility did not implement a frequent turning and repositioning program to prevent pressure ulcers for Resident 6, whom it had assessed to be at a very high risk for developing pressure ulcers; failed to consistently accurately assess pressure ulcers; and failed to implement the Registered Dietician's initial recommendation for a multivitamin supplement for Resident 6, whom the facility had assessed to be in poor nutrition and at a very risk for pressure ulcers. Resident 6 developed two pressure ulcers, including a Stage 4 pressure ulcer. Findings: According to the National Pressure Ulcer Advisory Panel (NPUAP), a pressure injury/ulcer is localized damage to the skin and underlying soft tissue usually over a bony prominence . the injury can present as intact skin or an open ulcer . the injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (shear is stress/deformation of the skin from movement). Pressure injuries/ulcers are classified or staged according to the degree of injury to tissue, from Stage 1 (least injury) to Stage 4 (greatest injury). Stage 2 pressure injuries/ulcers involve the loss of the first skin layer (epidermis), thus exposing the second skin layer (dermis). The wound appears pink and moist. Stage 3 pressure injuries/ulcers involve a wound with total loss of the skin, revealing the layer of fat underneath. Stage 4 pressure injuries/ulcers involve the total loss of the skin and the underlying fat tissue, revealing muscle, bones and other tissues. A pressure injury/ulcer may also be classified as unstageable, which occurs when the wound is covered by slough or eschar (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ (2016) and www.npuap.org/wp-content/uploads/2012/02/Shear_slides.pdf). Review of Resident 6's Admission Record, dated 7/11/17, indicated Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6's Initial Admission Record, dated 9/27/16, indicated Resident 6 was admitted on hospice care (terminal prognosis), had no open skin injuries but had very fragile skin. During an interview on 7/12/17 at 4 p.m., Resident 6's family member and responsible party stated Resident 6 was immobile and needed complete assistance to turn and reposition but had no skin injuries at the time she was admitted to the facility. The family member stated Resident 6 lived with her prior to admission and family frequently turned and repositioned her at home to prevent skin injuries. A nursing Admission Note for Resident 6, dated 9/27/16 at 2:15 p.m. stated: The resident came from home. The resident has very fragile skin, though in very good shape r/t (related to) the families (sic) ongoing care for her . No open areas noted. The Braden Scale for Predicting Pressure Sore Risk assessment (a pressure ulcer assessment scale) dated 9/27/16, indicated Resident 6 was bedfast (confined to bed), completely immobile, did not make even slight position changes in body or extremity without assistance and had very poor nutrition. The assessment indicated a score of 9, corresponding to a very high risk of developing pressure ulcers. Resident 6's record contained a care plan, dated 9/27/16, for Resident 6's potential for skin injuries related to her fragile skin and poor nutrition. The goal of the care plan was to keep Resident 6 free of skin injuries. The care plan contained interventions such as the use of an alternating pressure mattress and the application of barrier creams to at risk areas. The care plan did not contain interventions to turn and reposition Resident 6. A second care plan for Resident 6, dated 9/28/16, focused on self-care performance of activities of daily living related to Resident 6's disease processes, limited mobility, pain and dementia. This care plan noted Resident 6 was totally dependent on staff for repositioning and turning in bed. This care plan did not include any intervention for turning and repositioning Resident 6. A review of Resident 6's physician orders, the Order Summary Report, for September 2016 through April 2017, revealed no physician orders for turning and repositioning Resident 6. Resident 6's Admission MDS (Minimum Data Set - an assessment tool), dated 10/3/16, indicated Resident 6 had no pressure ulcers but was at risk for developing them. In the Admission MDS the facility selected pressure reducing device for bed (pressure redistribution mattress) and application of ointments/medications as interventions for preventing/treating skin injuries. The facility did not select turning and repositioning Resident 6, an available intervention in the MDS. On 10/4/16, at 8:22 a.m., the IDT (Interdisciplinary Team) convened to review Resident 6's conditions and care plans. The IDT/Care Conference Note dated 10/4/16, documented Resident 6 had poor food intake, ate 35-40% of meals, and needed extensive staff assistance with bed mobility. The IDT team made no recommendation to update Resident 6's care plans to include turning and repositioning Resident 6. According to the Wound, Ostomy and Continence Nurses Society, avoidable pressure ulcers can occur when the provider does not define and implement interventions consistent with individual needs, individual goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. (Wound, Ostomy and Continence Nurses Society, 2017. WOCN Society Position Paper: Avoidable vs. Unavoidable Pressure Ulcers/Injuries. Mt. Laurel, NJ: Author.) According to the U.S. National Library of Medicine Pubmed Health Service, frequent repositioning is a key intervention in preventing pressure ulcers: Even if certain mattresses and overlays have been shown to lower the risk of pressure sores . reducing pressure through movement and repositioning is still the most important way to prevent pressure ulcers. (https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH 09/). The facility's policies and procedures recommended repositioning to prevent pressure ulcers. The policy titled Pressure Ulcers - Care and Treatment, revised 05/2016, indicated, under Prevention Measures: B. Repositioning. Licensed Nurse A documented in a Progress Note, dated 10/4/16 at 11:48 p.m., Resident 6 had a skin injury to her right hip classified as a possible deep tissue injury (a form of pressure ulcer where the outer skin is intact but the underlying tissue is injured) measuring 3 centimeters (cm) length by 1 cm width. A Nursing Summary - Weekly, dated 10/5/16, contained documentation that Resident 6 had a pressure ulcer to the right hip area. There was no documentation of the stage or a measurement of the pressure ulcer. On 10/11/16 Registered Dietician G completed Resident 6's admission nutrition assessment. In the RD - Nutrition Risk Review - Admission assessment, dated 10/11/16, Registered Dietician G documented Resident 6 ate 50% of her meals, had a pressure injury to the right hip and had insufficient recorded (food) intake to support healing of wound and maintain weight. Registered Dietician G recommended Resident 6 receive a multiple vitamin with minerals supplement. A review of physician orders for Resident 6, Order Summary Report, for October, November, and December 2016, revealed no orders for a multiple vitamin with minerals supplement for Resident 6. Vitamin supplements for Resident 6 were ordered starting on 1/19/17. During an interview on 7/13/17 at 9:45 a.m., Registered Dietician H stated the dietician's recommendations were usually communicated to the resident's physician the same day. Registered Dietician H also stated a multiple vitamin with minerals supplement would have assisted in the prevention and healing of pressure ulcers for Resident 6. On 7/14/17 at 8:25 a.m., Resident 6's nutrition assessments, physician orders and other clinical records were reviewed with the Director of Nursing (DON). The DON verified the dietician's recommendation on 10/11/16 for a multiple vitamin with minerals supplement for Resident 6 was not followed. She stated she believed the reason was Resident 6 was on hospice care with a terminal prognosis. The DON verified Resident 6's clinical condition eventually improved and Resident 6 was subsequently taken out of hospice care in November 2016. The DON stated after Resident 6 was taken out of hospice care in November 2016 a multiple vitamin with mineral supplements would have helped improve Resident 6's nutrition and prevent skin wounds. The National Pressure Ulcer Advisory Panel (NPUAP) recommends vitamin supplements to people at risk for or with pressure ulcers and nutritional deficiencies. According to the NPUAP providers should provide/encourage an individual assessed to be at risk of a pressure ulcer to take vitamin and mineral supplements when dietary intake is poor or deficiencies are confirmed or suspected. The NPUAP has the same recommendation for individuals with confirmed or suspected pressure injuries. (National Pressure Ulcer Advisory Panel, Prevention and treatment of [REDACTED].npuap.org/). The facility's policies and procedures recommended improved nutrition for pressure ulcer prevention and treatment. Facility policy titled Pressure Ulcers - Care and Treatment, revised 05/2016, indicated Maintain or improve nutrition or hydration status as a pressure ulcer preventing and treatment measure. A Change of Condition MDS assessment for Resident 6, dated 11/11/16, indicated Resident 6 had no current pressure ulcers, but was at risk for developing them. In the MDS the facility selected several interventions for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS. The IDT documented in the IDT/Care Conference Note dated 11/16/16, Resident 6 needed extensive assistance with bed mobility. The IDT Team did not recommend or update Resident 6's care plans to include frequent turning and repositioning. A Braden Scale for Predicting Pressure Sore Risk assessment, dated 11/25/16, noted Resident 6 had a score of 12 corresponding to a high risk for developing pressure ulcers. A Change of Condition note, dated 1/10/17 at 6:33 a.m., contained documentation that Resident 6's right hip wound had reappeared. No staging or measurements of the wound were documented. A Nursing Summary - Weekly, dated 1/11/17, documented Resident 6's right hip wound was a pressure ulcer, but there was no documentation of the staging or measurement of the wound. On 1/17/17, Physician C wrote treatment orders for Resident 6's right hip pressure ulcer. Resident 6's Order Summary Report, dated 1/31/2017, contained the following order, dated 1/17/17: Cleanse pressure injury to right hip with DWC ([MEDICATION NAME] Wound Cleanser), and pat dry. Apply Santyl (an ointment) to necrotic/slough (dead tissue) to wound bed (indicating at least a Stage 3 pressure ulcer per NPUAP). Cover with calcium alginate and foam dressing as needed for pressure injury if soiled or dislodged. In a Change of Condition note, dated 1/21/17 at 9:53 p.m., Licensed Nurse J documented Resident 6 had a sheared (stress / deformation of the skin from movement) area to right buttock area. In an Incident Note, dated 1/24/17 at 10:29 p.m., Licensed Nurse A documented Resident 6 had a reddened skin tear to her right buttock measuring 3 cm x 2 cm. A new skin care plan, dated 1/24/17, noted Resident 6 Has actual impairment to skin integrity r/t (related to) Stage 4 pressure injury on right ischial tuberosity (the sit bone). The new skin care plan did not include turning and repositioning interventions for Resident 6. During an interview on 7/12/17 at 4:25 p.m., Licensed Nurse B stated Resident 6's right buttock pressure ulcer was first identified by the facility as a Stage 4 pressure ulcer in the last week of January 2017. She stated the wound evolved very quickly from a skin tear to a Stage 4 pressure ulcer. She stated the wound location had been referred by facility staff as either right buttock or right ischial tuberosity, with both names referring to the same pressure ulcer. A review of Resident 6's nutrition assessments revealed no assessments of Resident 6's nutritional status by a Registered Dietician following the detection of her Stage 4 pressure ulcer on 1/24/17. During a review of Resident 6's records on 7/13/17, at 9:45 a.m., Registered Dietician H verified Resident 6 had been assessed by a Registered Dietician on 1/18/17 and again on 3/30/17. She stated, in her professional opinion, a new assessment of Resident 6's nutritional status should have been made by a registered dietician following the identification of Resident 6's Stage 4 pressure ulcer on 1/24/17. The facility policy, Nutrition, revised 1/2014, stated: Each resident's nutritional status is assessed by the Registered Dietician or his/her designee on admission and at least quarterly thereafter, and following a change in condition. A Skin Pressure Ulcer Weekly assessment, dated 2/3/17, noted Resident 6's right buttock wound as an unstageable pressure ulcer (unable to determine the stage due to the presence of dead tissue covering the wound) measuring 1.9 cm length x 2.9 cm width. The assessment documented bone was visible in the wound bed. During an interview on 7/14/17, at 8:25 a.m., the Director of Nursing (DON), who stated she was a wound certified nurse, stated pressure ulcers in which it was possible to visualize bone in the wound bed were categorized as Stage 4 pressure ulcers. The Skin Pressure Ulcer Weekly assessment, dated 2/3/17, documented Resident 6's right hip wound was a Stage 2 pressure ulcer measuring 0.7 cm x 0.9 cm. A quarterly MDS assessment, dated 2/7/17, indicated Resident 6 had pressure ulcers and was at risk for developing them. In the MDS the facility selected several interventions for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS. The IDT - Care Plan Review, dated 2/7/17, contained no documentation of recommendations to update Resident 6's care plans to include turning and repositioning Resident 6. A Skin Pressure Ulcer Weekly assessment, dated 3/13/17, documented Resident 6' right buttock ulcer was an unstageable pressure injury and Resident 6's right hip pressure injury was healed. Skin Pressure Ulcer Weekly assessments, dated 4/13/17 and 5/2/17, documented Resident 6's right buttock wound as a Stage 4 pressure ulcer. A second quarterly MDS assessment, dated 5/2/17, indicated Resident 6 had pressure ulcers and was at risk for developing them. The MDS contained several interventions which were selected for Resident 6 for preventing/treating skin injuries. The facility did not select turning and repositioning the resident, an available intervention in the MDS. A physician's order, dated 5/3/17, directed staff to Turn and reposition resident a minimum of every 2 hours for pressure redistribution. On 5/16/17, Resident 6's care plan for potential skin impairment related to fragile skin and poor nutrition was updated to include the following intervention: Turn and reposition resident a minimum of every 2 hours for pressure redistribution. During interview and concurrent record review, on 7/13/17 at 5:50 p.m., Resident 6's care plans were reviewed with the Director of Nursing (DON). The DON verified the turn and repositioning intervention for Resident 6 was not present in any of Resident 6's care plans until it was added on 5/16/17. The DON stated given Resident 6's high risk for developing pressure ulcers, identified by the facility on 9/27/16, Resident 6's care plans should have included turning and repositioning interventions starting on the day Resident 6 was admitted to the facility on [DATE]. Review of Skin Pressure Ulcer Weekly assessments, dated 6/13/17 and 7/11/17, noted Resident 6' right buttock injury were classified as a Stage 4 pressure ulcer. During an observation, on 7/13/17 at 2:50 p.m., Licensed Nurse B completed a dressing change and wound measurement of Resident 6's Stage 4 right buttock pressure ulcer. The wound measured 2.1 cm length, 2.1 cm width, 2.1 cm depth, and 4.6 cm of tunneling. During interview and concurrent record review, on 7/14/17 at 8:25 a.m., Resident 6's record was reviewed with the Director of Nursing (DON). The DON was asked which interventions the facility implemented to prevent pressures ulcers for Resident 6 after the facility determined Resident 6 to be very high risk for pressure ulcers on 9/27/16. The DON stated the facility implemented all the interventions listed in the care plans plus turning and repositioning Resident 6 every two hours. She stated the facility had continuously turned and repositioned Resident 6 every two hours starting from admission on 9/27/16 until the present day. The DON was asked to provide evidence that Resident 6 had been turned and repositioned every two hours. The DON provided copies of Resident 6's Treatment Administration Record for May, June and July 2017. The turning and repositioning documentation in these reports consisted of a check mark next to each shift - a.m., p.m., and night - confirming Resident 6 had been turned and repositioned every two hours during each shift. These reports did not specify the times Resident 6 had been turned and repositioned during each shift. The DON was asked for this information. During interview and concurrent record review, on 7/14/17 at 12 p.m., the DON and Registered Nurse Consultant K provided facility reports titled, Follow Up Question Report, dated September 27, 2016 to July 14, 2017, which contained documentation of Resident 6's turning and repositioning by the facility's Certified Nursing Assistants (CNAs). These reports contained the question Did you turn and reposition? followed by the response, Yes and the CNA's name, date and time. Registered Nurse Consultant K stated the date and time recorded on the reports was not necessarily the date and time Resident 6 was turned and repositioned, but the time the CNA recorded it on the computer system. She stated CNAs did not always record care immediately after providing care. Registered Nurse Consultant K was asked if, from the documentation provided, it was possible to determine the times Resident 6 had been turned and repositioned. Registered Nurse Consultant K replied it was not possible to know, stating it was only possible to know the turning and repositioning had been done sometime during the CNA's shift. A review of the turning and repositioning documentation provided by the facility, the Follow Up Question Reports, from 9/27/16 to 6/30/17, revealed documentation Resident 6 was turned and repositioned an average of once every 8 hours. On several days during the period, such as on 9/28/16, 10/2/16, 11/13/16, 12/11/16, 1/1/17, 2/6/17, 3/3/17, 4/28/17, 5/31/17 and 6/5/17, there were gaps of more than 12 hours without documentation of Resident 6 being turned and repositioned. The Follow Up Question Report for July 2017 documented on 7/11/17 Resident 6 was turned and repositioned a total of three times: at 6:39 a.m., at 11:17 a.m. and at 9:47 p.m On 7/11/17 Resident 6 was observed in her room at 9:15 a.m., at 11:15 a.m., at 2 p.m. and at 4 p.m. In all four instances Resident 6 was observed asleep lying on her right side. The Follow Up Question Report for July 2017 documented on 7/13/17 Resident 6 was turned and repositioned a total of three times: at 2:10 a.m., at 8:52 a.m., and at 9:51 p.m. On 7/13/17 Resident 6 was observed in her room at 9:10 a.m., and at 11:10 a.m. In both instances Resident 6 was observed asleep lying on her left side. According to the American Association of Family Physicians, Pressure ulcers may develop in as little as four to six hours and, there is also no evidence to suggest an optimal interval at which to reposition patients, although every two hours is recommended based on expert opinion. http://www.aafp.org/afp/2015/1115/p888.html. The National Database of Nursing Quality Indicators, a national nursing quality measurement program, recommends, as pressure injury prevention interventions, turning immobile patients every 2 hours while in bed as this is a common practice for patients unable to turn/reposition themselves . Patients who are at higher risk will likely need to be turned/repositioned more frequently than every 2 hours. https://members.nursingquality.org/ndnqipressureulcertraining/Module3/PressureULcerSurveyGuide_16.aspx. The U.S. National Library of Medicine MedlinePlus Service recommends changing a patient's position in bed every 2 hours to prevent pressure ulcers. https://medlineplus.gov/ency/patientinstructions/ 6.htm.