Every finding on record at Pebblebrook Health Center at Park Springs

Based on observations, staff interviews, and review of the facility's policy titled Storage of Food and Supply Products, the facility failed to ensure proper dating of food and to ensure food items and hydration were not available for resident consumption past their expiration date. These deficient practices had the potential to place the 42 residents receiving food from the kitchen at risk of contracting a foodborne illness.Findings Include:Review of the facility's policy titled Storage of Food and Supply Products, last reviewed 03/03/2017 documented, All foods and supply items will be stored in a safe and sanitary manner. The policy included procedures: .4. All foods items must be properly covered or tightly wrapped when stored in a refrigerator or freezer. Leftovers items should be labeled with the name of the food product, production date and the use-by-date. Clear cling wrap is preferred over aluminum foil, so that food times can be seen more easily. 10. When placing new products in storage, always put them behind the older products on the shelf so that they will be used first. Rotating food products will ensure that there will be no outdated products. This is called the First-in, First-out (FIFO) system.During an initial kitchen tour on 07/28/2026 at 9:20AM, with the Kitchen Manager (KM) revealed that the items in the freezer which included, japanese vegetable blend and carrots and in the refrigerator pasteurized cheese, were not labeled with open and discard dates. Food items in the refrigerator included sweet and unsweet tea, almond milk, and opened sliced ham and on the dry storage shelf were cereal, mustard, mayonnaise, and saltine packets that had exceeded expiration dates. The emergency water supply had 90 cases of emergency water which included six one-gallon jugs that were expired.During an interview on 07/28/2026 at 10:44AM, the KM confirmed the food items in the freezer, dry storage and emergency supply were expired and not properly dated. She stated that her expectation was for the chefs to ensure that all food items are labeled and rotated when new food items are delivered and that expired food items be discarded.

Based on observation, staff interviews, and review of the facility's policy titled, Handwashing Guideline for Dietary Employees, the facility failed to perform hand hygiene between residents during meal pass in one of two dining halls (Lodge Dining Hall) observed. The deficient practices had the potential to increase the potential for cross-contamination and spread of infection. The facility census was 34. Findings include: Review of the facility's policy titled Handwashing Guideline for Dietary Employees dated 1/2025 under the section titled Policy revealed, Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illness. Dietary employees shall clean their hands in a handwashing sink or an approved automatic handwashing facility and may not clean hands in a sink for food preparation, ware washing, or in a service sink used for the disposal of mop water or similar waste. Under the section titled Compliance Guidelines: revealed, 1. Dietary employees shall keep their hands and exposed portions of their arms clean. During an observation on 4/29/2025 at 12:13 pm in the Lodge Dining room revealed Dietary Aide CC brought out four covered meal trays on a cart and proceeded to place each meal tray in front of the residents without performing hand hygiene in between the residents. During an interview on 4/29/2025 at 12:18 pm with the Dietary Aide CC stated the kitchen has hand sanitizer dispensers and she sanitized in the kitchen before bringing the meal cart out to the dining room. She confirmed she did not sanitize her hands in between residents while passing out their trays and asked if that was something she should do. During an interview on 5/1/2025 at 1:08 pm with the Dietary Manger (DM) revealed the staff should be washing hands if visibly soiled and when handling dirty food or plates. DM continued to state she expects her staff to sanitize when handling dirty plates and that she was unsure of the policy related to handling meal trays. During an interview on 5/1/2025 2:34 pm with Infection Preventionist (IP) revealed, the Dietary Aides were supposed to prepare the plates, and Certified Nurse Assistants (CNA) were supposed to deliver the trays to the residents. She stated she expects for staff to perform proper hand hygiene in between residents.

Based on observations, staff interviews, and review of the facility policies titled, Nutritional Lifestyles, Inc., Food Safety Requirements, and Foods Brought in from Outside Sources, the facility failed to ensure food items were properly stored, labeled with expiration dates, and expired foods were disposed of for one of one coolers (Main kitchen) and two of four pantries (Main kitchen and Coastal Hall) observed. In addition, the facility failed to ensure food items was properly labeled in the refrigerator/freezer and failed to ensure cleanliness for one of four refrigerators (Rehab Hall) observed. This deficient practice had the potential to cause foodborne illness for all residents. The deficient practice had the potential to affect 34 of 34 residents (R) who consume an oral diet. Findings include: Review of the facility's policy titled, Nutritious Lifestyle, Inc. dated [DATE] under the section titled Policy: revealed, The consultant dietitian will monitor the storage of foods to ensure that all food served by the facility is of good quality and safe consumption. All food will be stored according to the state and Federal Food Codes. The following guidelines should be followed. Under the section titled Guidelines: revealed, 1. Dry storage rooms .To ensure freshness, opened and bulk items are stored in tightly covered containers. All containers are labeled and dated. Review of the facility's policy titled, Food Safety Requirements, dated ,d+[DATE] under the section titled Policy revealed, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Under the section titled Policy Explanation and Compliance Guidelines revealed, 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. C.iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by-date, or frozen (where applicable)/discarded. Review of the facility's policy titled Foods Brought in from Outside Sources, dated [DATE] under section titled Procedure revealed, 6. (C.) The food item(s) should be labeled with a. The resident's name, b. The date the item(s) was purchased or prepared and c. The name of the item. Perishable food items that require refrigeration will be discarded after 72 hours (3 days) if the food is not consumed by the resident. 1. Observation of the Main kitchen cooler on [DATE] at 9:11 am revealed a pan of meat that was stored above a filled pot of turkey soup and tomato soup. Observation of the Main kitchen cooler on [DATE] at 9:13 am revealed the following items in the cooler opened without an expiration date on the container: stir fry sauce, ranch dressing, and two opened containers of sour cream. 2. Observation of the Main kitchen pantry on [DATE] at 9:18 am revealed the following opened foods with no date as to when they were opened or when they will expire: brown gravy mix (powder, wrapped in aluminum foil) and macaroni noodles. Interview with the Dietary aid (DA) EE on [DATE] at 9:18 am revealed she was unsure of why the items in the main kitchen were not dated properly with the expiration date. She further revealed she did not know why the bottles of sauce and dressing were not dated and she was unsure of when the items were actually opened. Observation of the Coastal kitchen pantry on [DATE] at 11:25 am revealed the following foods that were expired and/or had no label displaying the date which the package was opened: two packages of grits, a re-packaged bag of parsley (labeled par) with a use by date of [DATE] written on the sandwich bag, a container of an unknown seasoning, multiple bags of open pasta, croutons, peanut butter with ,d+[DATE] written on the top and grape jelly. 50803 3. An observation on [DATE] at 12:40 pm of the unit refrigerator and freezer located in the Rehab Hall revealed four applesauce cups with expiration dates that read [DATE], one unlabeled bag of food with a handwritten date of ,d+[DATE], one unlabeled and undated bag of food, and two 1.5-quart containers of opened and undated ice cream. An observation on [DATE] at 12:40 pm of the unit refrigerator located in the Rehab Hall revealed multiple black substances on the water spout and drip tray of the fridge. In an interview on [DATE] at 12:31 pm with the Dietary Manager, she revealed that she has been working at the facility for three months. She stated that her dietary staff do not use the kitchen in the Rehab Hall for functional kitchen purposes, but the fridge was used for residents only and possibly activities. She stated that her dietary staff checked the temperatures and dates of the food in the refrigerator daily and that the fridge was cleaned when visibly dirty. She confirmed the unlabeled bag of food dated ,d+[DATE] in the fridge, two opened and undated 1.5-quart containers of ice cream, one unlabeled and undated bag of food, four containers of apple sauce with expiration dates of [DATE]. She further confirmed the black substances on the fridge water dispenser drip tray and water spout. The Dietary Manager stated that she expects the refrigerator to be monitored daily, food dated upon opening, deep cleaned once a week, and sanitized when visibly soiled. She further stated that the potential negative outcomes can lead to potential food poisoning, outbreaks, and foodborne illnesses. In an interview with the Administrator on [DATE] at 1:10 pm, she stated that she expects the residents and family to be able to use the fridge, but they do ask the residents and family to label and date or have the nursing staff label and date. She further stated that potential negative outcomes of not meeting those expectations include sickness and someone getting the wrong food. Regarding the cleanliness of the fridge, she expects housekeeping to clean daily and negative outcomes of a fridge not being clean could risk residents drinking water with black substances. The Administrator further confirmed that residents were able to access this water as they please. Interview with the Dietary Manager on [DATE] at 1:15 pm revealed that she had in serviced the kitchen staff regarding labeling food products once they were opened and put away.

Based on observations, staff interviews, record review, and review of the facility's policy titled Incidents and Accidents, the facility failed to ensure the environment was free from potential accident hazards by not ensuring sharps container was locked, failed to ensure the sharps lid was not left open and failed to ensure the correct size sharps container was secured within the placement holder for one of two medication carts (Coastal Hall). Additionally, the facility failed to ensure two of 34 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) were free from exposure to harmful chemicals and aerosols. Findings include: Review of the facility's policy titled, Incidents and Accidents dated 1/2025 under the section titled Policy Explanation revealed, The purpose of the incident reporting can include: Assuring all appropriate and immediate interventions and implanted and corrective actions are taken to prevent recurrence and improve the management of resident care. Under the section titled Compliance Guideline revealed, 5. The following incidents/accidents report but not limited to: .housekeeping products. 1. Observation on 4/30/2025 at 5:28 pm of Costal Hall revealed an unlocked, open sharps lid, and an oversized shaped container attached to medication cart. Observation on 4/30/2025 at 5:28 pm through 5:48 pm revealed the medication cart with an unlocked, open sharp container that remained in the hall that was unattended. Interview and observation on 4/30/2025 at 5:48 pm with the Director of Nursing (DON) confirmed the medication cart was not supposed to be like this. She also confirmed the sharp container should be a smaller box to fit inside the placement and should be locked. During an interview on 4/30/2025 at 5:58 pm with the Administrator revealed, the sharps container should be removed and replaced with a sharp container that ensures a safe cover. 2. During an observation on 4/29/2025 at 10:33 am revealed there was a can of aerosol spray in room [ROOM NUMBER] bathroom. During an observation on 4/30/2025 at 9:39 am and 4/30/2025 at 5:16 pm revealed room [ROOM NUMBER] had a can of aerosol spray in the bathroom During an interview and observation on 4/30/2025 at 5:25 pm with Licensed Practical Nurse (LPN) AA confirmed aerosol spray was not supposed to be in the resident's room. 3. During an observation on 4/29/2025 at10:58 am revealed, cleaning supplies and aerosol spray in room [ROOM NUMBER] bathroom. During an observation on 4/30/2025 at 9:46 am revealed, cleaning supplies and aerosol spray in room [ROOM NUMBER] bathroom. During an observation and interview on 4/30/2025 at 5:52 pm with the DON confirmed the cleaning products were not supposed to be in the rooms. She stated the interdisciplinary team (IDT) were assigned rooms and responsible along with all the staff to make sure there were no cleaning products in the rooms. During an interview on 4/30/2025 at 5:58 pm with the Administrator revealed the cleaning products were brought in by family members and she will inform the families about bringing in outside cleaning products into the facility.

Based on observations and staff interviews the facility failed to follow a recipe when preparing puree food. This deficient practice had the potential to result in inconsistent texture modification, nutritional imbalance, and increase risk of aspiration for three of three residents receiving a puree diet. Findings include: Observation and interview on 4/30/2025 at 5:32 pm of pureed foods being prepared in the Coastal kitchen by the Coastal Homemaker DD revealed, there was no recipe being followed when pureeing the dinner meal of baked beef steak, broccoli, and mashed potatoes. Homemaker DD was observed placing three pieces of baked beef steak in the blender then started the blender. She took an ice cream scoop with the broth from the beef steak pan and put it in the blender. When asked what the serving size of the meat was Homemaker DD responded, about 3 ounces per piece she was not able to answer how much broth was added nor the size of the scoop that was used. Observation and interview on 5/1/2025 11:47 am in the Coastal kitchen revealed, Homemaker DD pureeing green peas and baked chicken for a resident. There was no recipe being followed while the food was being pureed. When adding the peas to the blender, she did not measure the amount of peas. When adding the vegetable broth with the ice cream scoop to the blender with the peas, Homemaker DD did not measure the amount. Homemaker DD pureed a piece of baked chicken in the blender. When asked what the serving size was she responded, three or four ounces. She proceeded to use another ice cream scoop to add the broth from the pan of chicken to the chicken being blended without measuring it. When asked about a recipe, Homemaker DD stated she had a recipe book for non-puree foods but knew how to prepare the puree foods because she had been doing it so long. Homemaker DD confirmed she did not go by a recipe when pureeing meals. Interview on 5/1/2025 at 1:15 pm with the Dietary Manager (DM) revealed she did not have recipes for residents who were on puree diets and did not have a reason for not having one. She revealed when the homemakers prepare food, the expectation was to provide them with recipes and for them to follow the recipes. The DM further stated this could negatively impact residents because they could run into the issue of not getting the correct consistency of food or cause choking. A request for the facility's policy regarding food accommodations from the Dietary Manager revealed that the facility did not have a policy for puree food accommodations.

Based on record review, staff interviews, and review of the facility's policy titled, Resident's Rights Regarding Treatment and Advance Directives the facility failed to ensure one out of 24 sampled Residents (R) (R145) advance directive was documented accurately throughout the medical record. Findings include: Review of the facility's policy titled, Resident's Rights Regarding Treatment and Advance Directives dated January 2025 under the section titled Policy Explanation and Compliance Guideline: revealed, 1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive . 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff . 9. Any decision making regarding the resident's choice will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of the Electronic Medical Records (EMR) revealed, R145 was admitted to the facility on [DATE] with diagnoses that included but not limited to adult failure to thrive, anorexia (restrictive eating behavior), vitamin B12 deficiency anemia due to intrinsic factor deficiency, hypothyroidism (lack of thyroid hormones), and essential hypertension (blood pressure). Review of the most recent Quarterly Minimal Data Set (MDS) for Section C (Cognitive Pattern) revealed R145 had a Brief Interview for Menal Status (BIMS) of 14 indicating little to no cognition impairment. Review of R145's care plans dated 4/25/2025 revealed that a code status was not included in the care plan. Review of R145's physicians orders dated 4/14/2025 revealed, a code status of full code. Review of R145 dashboard in the electronic health record (EHR) is documented do not resuscitate (DNR) Review of Advance Directive dated 4/18/2025 revealed R145 had an allow natural death (and) - do not attempt resuscitation code status. During an interview on 5/1/2025 at 10:03 am with the Social Worker (SW) revealed the advanced directives were given to the family members in the admission packet and once the advanced directives was signed, they would follow up with the physician, and the documentation would be uploaded in the medical record. The SW confirmed that R145 was a DNR, and her physicians orders were documented as a full code status. She acknowledged that the nurses did not change R145's order to the correct status. During an interview on 5/1/2025 at 2:36 pm with the Director of Nursing (DON) revealed when a resident is admitted , they come in as a full code until the documentation for advanced directives is submitted to the Admission Director. Once the documentation is submitted then it should be communicated to the nursing department for the order to be changed in the clinical record. The DON confirmed R145's code status order was not documented correctly. During an interview on 5/1/2025 at 2:41 pm with the Administrator revealed, she expects audits checks for the new admission to ensure all orders match the medication administration record (MAR) and paperwork. She also revealed, the DON was responsible for making sure those orders were correct.

Based on observations, staff and resident interviews, record reviews, and review of the facility's policy titled, Administering Medications the facility failed to adequately assess two out of 24 sampled residents (R) (R12 and R141) for self-administration of medication. This failure had the potential to place the residents at risk for adverse consequences. Findings include: Review of the facility's policy titled, Administering Medications dated April 2019 under the section titled Policy Statement revealed, Medications are administered in a safe and timely manner, and as prescribed. Under the section titled Policy Interpretation and Implementation revealed, 27. Resident may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary (IDT) team, has determined that they have the decision-making capacity to do so safely. 1. Review of the Electronic Medical Record (EMR) revealed R12 was admitted to the facility with a diagnoses that included but not limited to unspecified dementia, psychotic disturbance, mood disease, and rash and other nonspecific skin eruption. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed R12 had a Brief Interview of Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of the care plan with last review date of 4/24/2025 revealed that R12 was not care planned for self-administration of medication. Review of the physician's order dated 11/17/2027 revealed an order for triamcinolone 0.1% (percent) ointment (skin cream). Only ointment topically twice daily to body rash (groin, under arms, and back side). During an observation on 4/29/2025 at 11:21 am revealed triamcinolone acetonide cream on R12's bathroom counter. During an observation on 4/30/2025 9:33 am and 4/30/2025 at 5:14 pm revealed triamcinolone acetonide cream on R112's bathroom counter. During an interview and observation on 5/20/2025 at 5:18 pm with Licensed Practical Nurse (LPN) AA confirmed the triamcinolone acetonide cream was not supposed to be on her bathroom counter and that the nurses were supposed to put it back in the locked medication cabinet. 50803 2. Review of the EMR revealed R141 was admitted to the facility with pertinent diagnoses that included but was not limited to acute respiratory failure with hypoxia, chronic obstructive pulmonary disease with (acute) exacerbation, and other pulmonary embolism with acute cor pulmonale, chronic kidney disease stage 3, and need for assistance with personal care. Review of R141's Admission MDS assessment dated [DATE] for Section C (Cognitive Patterns) revealed a BIMS of 15, which indicated R141 was cognitively intact; Section N (Medications) revealed, R141 was taking an antidepressant, anticoagulant, antibiotic, diuretic, antiplatelet, and hypoglycemic medication. Review of R141's care plan dated 4/30/2025 indicated a focus of bleeding related to anticoagulant use. Goals included but were not limited to R141 taking the anticoagulant as ordered without serious complications. Interventions included but were not limited to administer anticoagulants as ordered. Review of R141's physician's orders included but was not limited to an order dated for 4/17/2025 for cefadroxil 500 milligrams (mg) every 12 hours, an order dated 4/23/2025 for clopidogrel 75 mg once a day, an order dated 4/19/2025 for apixaban 5 mg twice a day, an order dated 4/17/2025 sacubitril-valsartan 24-26 mg twice a day, an order dated 4/23/2025 for dapagliflozin propanediol 5 mg once a day, an order dated 4/17/2025 for metoprolol succinate 25 mg twice a day, an order dated 4/17/2025 for probenecid 500 mg three times a day, and an order dated 4/23/2025 for sertraline 100 mg once a day. However, there was no order for self-administration of medication. An observation on 4/29/2025 at 9:59 am revealed a cup of pills in front of R141 on the bedside table. There was no staff member present for supervision. An interview on 4/29/2025 at 9:59 am with R141 revealed that she recently moved into the facility and had been at the facility for about a week. When asked if she gets assistance with medications, she stated no and explained that staff just bring it to her. When asked about the pills observed on her bedside table, she stated that those were part of her 9:00 am medications. In an interview on 4/29/2025 at 10:08 am with LPN AA, she confirmed that R141 normally self-administers her own medication. An interview on 5/1/2025 at 1:30 pm with the Director of Nursing (DON) revealed that residents would have to be deemed appropriate before self-administering meds by going through an observation with the floor nurse. This observation would be upon being informed about the desire to self-administer and an assessment would be completed to assess the resident's abilities and cognition. The DON further stated that there should be an order for it as well. When asked about R141, she confirmed that the facility did not have a self-administration assessment completed for her. When showed the photo of the medications left at the beside, the DON stated that should not be the case and that R141 does not self-administer at this facility. The DON further stated that potential negative outcomes of medications left at the bedside without a self-administration of medication assessment include that the resident could potentially not take the meds, the resident could drop them, and, depending on the type of medication, timing could also be an issue.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled, Nutritional Assessment, the facility failed to provide care and services to prevent significant weight loss and impaired nutritional needs for four of seven Residents (R) (R3, R17, R20, and R21) reviewed for nutrition and weight loss. The facility failed to provide ongoing, consistent Nutritional Assessments, with accurate documentation, provided the correct diet as ordered for R17, and develop a Nutritional Care Plan for R21. The deficient practice had the potential to place the residents at risk for unmet care needs and a diminished quality of life. Findings included. Review of the facility's policy titled, Nutritional Assessment, dated October 2017 revealed, .As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .The dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicted by a change in condition that places the resident at risk for impaired nutrition .As part of the comprehensive assessment, the nutritional assessment will be a systematic process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition.,, The Nutritional Assessment policy further revealed, .Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences .Individualized care plans shall address to the extent possible .The identified causes of impaired nutrition .The resident's personal preferences .Goals and benchmarks for improvement .Time frames and parameter for monitoring and reassessment . 1. Review of the Face Sheet located in the Face Sheet tab of the Electronic Medical Record (EMR) revealed R3 was admitted with diagnoses that included vascular dementia, congestive heart failure, and rheumatoid arthritis. Review of the Weights located in the Vitals tab of the EMR revealed the following weights: 3/6/2023: 103.2 lbs. 4/4/2023: 108.0 lbs. 5/2/2023: 94.6 lbs. Review of the annual Minimum Data Set (MDS) assessment located in the RAI (Resident Assessment Instrument) tab of the EMR with an Assessment Reference Date (ARD) of 6/1/2023 revealed R3 had a Brief Interview of Mental Status (BIMS) score of eight out of 15 which indicated she was moderately impaired in cognition, required extensive assist of one staff person for eating, weighed 95 lbs. and had sustained no weight loss. Review of an 6/2/2023Nutritional Status and Swallowing Care Plan, updated on 8/23/2023, located in the RAI tab of the EMR revealed R3 was receiving a mechanically altered diet and is at risk of weight loss r/t (related to) declining cognition. The 6/2/2023 Approach to the Nutritional Status and Swallowing Care Plan revealed, Diet and supplements as ordered 1/19/2021 Care Plan Meeting: Member Reports that she does not want supplements of any kind Record intake of meals and report change in appetite to RD [Registered Dietician] Provide assistance during mealtimes as needed. Weight as ordered. RD to monitor and implement interventions if appropriate with goals of care. The Nutritional Status and Swallowing Care Plan did not reveal any further Approaches to R3's nutrition and weight loss. Review of the Weights located in the Vitals tab of the EMR revealed the following weights: 6/2/2023: 88.0 lbs. 7/11/2012: 87.2 lbs. 8/8/2023: 88.2 lbs. Review of the current Physician Orders located in the Orders tab of the EMR revealed on 8/18/2023, R3 had a Mechanical soft diet, chopped meats. Review of the quarterly MDS assessment located in the RAI tab of the EMR with an ARD of 9/1/2023, revealed R3 had a BIMS score of eight out of 15 which indicated that she was moderately impaired in cognition, required extensive assistance with meals, weighed 89 lbs. and had no weight loss. Review of the quarterly Nutritional assessment dated [DATE] located in the Observations tab of the EMR revealed the RD did not complete the assessment until 10/30/2023 (41 days later). The RD documented that R3's current body weight was 89.4 lbs. her BMI [body mass index-a value derived from the mass and height of a person] was 16.35 [normal BMI is between 18.5 to 24.9] and her IBW [ideal body weight] was 110 lbs. The Nutritional Assessment further revealed despite a 1.6% weight gain in the last 92 days, R3 had a 13.4% weight loss in the last 180 days which was significant. The RD further documented that her diet is mechanical soft, chopped meats, ate greater than 75% at most meals, and was able to feed herself. In addition, the RD documented that No updated labs available for review and to continue the current plan of care. Staff were to continue to offer high calorie snacks and desserts. Review of the 9/15/2023 Lab located in the Resident Documents tab of the EMR revealed the following laboratory results: RBC [red blood count-a type of blood cell that is made in the bone marrow and contains a protein called hemoglobin, which carries oxygen from the lungs to all parts of the body and is a test that looks for malnutrition]: 3.39 (3.92 to 5.13) L (low) HBG [hemoglobin]: 9.0 (11.7 to 13.8) L HCT [hematocrit-measures the amount of RBCs in the blood]: 29.0 (36 to 48) L NA [Sodium]: 135 (136 to 145) L Total Protein [measures the total amount of proteins such albumin and globulin in the blood]: 5.3 (6.0 to 8.0) L. Albumin was 3.3 (3.4 to 5.4) L. Review of the Weight Review Nutritional Assessment, dated 10/24/2023 completed on 10/30/2023 and located in the Observation tab of the EMR revealed the RD had documented that her current body weight was 95.8 lbs. with a BMI of 17.52. The Weight Review further showed that despite weight gains in 30 and 90 days, R3 still had a weight loss of 11.3% in the last 180 days. The Weight Review Nutritional Assessment revealed that R3's diet was mechanical soft, chopped meats, had variable intake but ate greater than 75% at most meals. She was able to feed herself and there were no updated labs available for review. The RD recommended, based on the weight gain, to continue the current plan of care, offer high calorie snacks and desserts. Review of the Lab located in the Resident Documents tab of the EMR revealed the following laboratory results: RBC: 3.64 L HGB: 9.4 L HCT: 30.6 L Total Protein: 5.6 L Albumin: 3.3 L During an initial observation on 10/30/2023 at 10:03 am, R3 was observed with contracted fingers on both the right and left, with the right hand being more pronounced. During observation at the breakfast table on 10/31/2023 at 9:24 am, R3 was observed to have eaten less than 25% of her meal but accepted a banana from staff. There was a staff person at the table encouraging her to eat. During observation at the lunch table on 11/1/2023 the following was observed: At 12:43 pm, staff were serving bowls of soup, however, R3 did not receive one. At 12:49 pm, R3 was given liquids in a cup with a handle, lid, and straw. At 12:54 pm R3 was served her lunch, she was observed to use her fingers to pick up the food and feed it to herself. At 12:59 pm, Staff sat down next to R3 to assist her to eat. During an interview on 11/2/2023 at 9:56 am, the RD was asked if she had sat in the dining room to watch R3 eat her meals. She stated, Maybe a few months ago. The RD was asked if Occupational Therapy (OT) had been in to evaluate R3 for adaptive silverware due to her finger contractures. The RD stated, No, I don't recall having the need to have her evaluated. RD was asked why her Nutritional Assessments were not completed timely. She stated, I completed an audit and found her assessment had not been completed, so it was done late. The RD was asked how you determined that there were no laboratory results to review, per your documentation on the assessments, when there were labs drawn on two occasions between each assessment. The RD stated, I do not have access to the lab section of the EMR. The RD confirmed that she did not ask for copies of the labs from nursing staff or from HIM to determine there were no current labs to review before documenting on the Nutritional Assessments. 2. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed R17 was admitted to the facility with diagnoses of vascular dementia, psychotic disorder, and major depressive disorder. Review of the annual MDS assessment located in the RAI tab of the EMR with an ARD of 3/20/2023 revealed R17 had a BIMS score of 10 out of 15 which indicated she was moderately impaired in cognition, required limited assistance of one staff for eating, weighed 121 lbs. and had no weight loss. Review of the Nutritional Care Plan dated 3/22/2023 located in the Care Plan tab of the EMR revealed an update on 10/11/2023 which showed, R17 is receiving a regular, pureed diet d/t [due to] dx [diagnosis] of dysphagia [difficulty swallowing] .Her BMI is 25.29, overweight, continues with variable intakes, 50% consumed at most meals, occasionally noted with less than 25% consumed. Rt [resident] is at risk for nutritional decline d/t medical comorbidities. The documented Approaches on the Nutritional Care Plan dated 3/22/2023 revealed the following: 3/22/2023: Meal tray set-up: uncover plate, assist with opening containers, pouring liquids, cutting up food etc., as needed or desired. 3/22/2023: Monitor weight as ordered. Notify MD [Medical Doctor], RD if weight loss or gain occurs. 3/22/2023: Observe/document/report to MD prn [as needed] s/sx [signs/symptoms] of malnutrition (cachexia, weight loss, muscles wasting) significant weight loss (> 5% in 30 days, 7.5% in three months, or 10% in six months. 3/22/2023: OT to screen and provide adaptive equipment for feeding as needed. 3/22/2023: Provide and serve diet as ordered. 3/22/2023: Provide and serve supplements as ordered (if applicable.) 3/22/2023: RD to evaluate and make diet change recommendation PRN. 9/12/2023: Offer supplements if <50% of food was consumed. Review of the Weights located in the Vitals tab of the EMR revealed the following: 4/03/2023: 123.0 lbs. 5/01/2023: 118.2 lbs. 6/03/2023: 107.8 lbs. 7/03/2023: 115.0 lbs. 8/07/2023: 110.6 lbs. 9/02/2023: 106.4 lbs. Review of the quarterly Nutritional assessment dated [DATE] located in the Observations tab of the EMR which showed a completed date of 10/30/2023, revealed R17's current body weight was 106.4 lbs. and that she sustained a 3.8% weight loss in the last 26 days, not significant, 1.3% weight loss in 91 days, not significant, and a 12.1% weight loss in 180 days, which was significant. The RD further documented that R17 was on a regular, pureed diet with thin liquids, intake was variable with less than 50% consumed at most meals, occasionally consumed 51-76%. She received Ensure Plus three times a day with meals, had occasional meal refusals and her personal sitter helped with meals, has a history of pocketing food and liquids and there were no labs to review. Review of the quarterly MDS located in the RAI tab of the EMR with an ARD of 9/20/2023 revealed R17 had a BIMS score of 10 out 15, which indicated R17 was moderately cognitively impaired, required extensive assistance of one staff person for eating, weighed 106 lbs., and had weight loss. During an observation on 10/31/2023 at 9:22 am, R17 was sitting at the breakfast table, with her personal care giver next to her. She was given chopped up bacon and scrambled eggs. R17 was observed chewing and chewing her food and needed reminders to swallow. No choking was observed. During an interview on 11/01/2023 at 9:38 am, Licensed Practical Nurse (LPN) 1 was asked to confirm the diet order for R17. LPN 1 checked the computer and stated, Regular-Pureed texture. LPN1 was told about the observation on 10/31/2023 of the regular diet with chopped meat. LPN 1 stated, Someone must have put regular on the diet sheet and not pureed. LPN1 further stated that she was getting the Ensure when she did not eat all of her meal. LPN1 went to the dining room kitchenette and asked the aide for R17's diet sheet. LPN1confirmed that the pureed was crossed out and only regular was listed. LPN 1 reviewed the Nursing Progress Notes and confirmed that there was no reason documented for the change in the diet order. During an interview on 11/1/2023 at 9:50 am, the Certified Dietary Manager (CDM) stated, I am not sure who crossed out the pureed. The CDM asked the Dietary Aide (DA) 1 what he served R17 for breakfast. The DA stated, Mechanical soft, chopped meats. The DA further stated, R17 complained this morning she didn't like the little pieces cut up. During an interview on 11/1/2023 at 11:30 am, the Director of Nursing (DON) confirmed that R17 was on a Regular-pureed diet as she wrote the order herself due to her difficulty swallowing. During an interview on 11/2/2023 at 10:05 am the RD was asked if she was aware of the change with R17's diet order. She stated, I was not aware of the diet error. The RD was asked if she had referred R17 to OT for evaluation of adaptive equipment. The RD stated, I am not sure when the last time she was evaluated. 3. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed that R20 was admitted with diagnoses that included vascular dementia, congestive heart failure, and irregular heart rhythm. Review of the current Physician Orders located in the Orders tab of the EMR revealed that R20 had an order, dated 12/1/2022 for a Cardiac mechanical soft, chopped meats with fortified foods. In addition, R20 had a supplement order, dated 12/16/2022, for Ensure 237 ml [milliliters] twice daily. Review of the Nutritional Status and Swallowing Care Plan, dated 11/2/2022 revised on 10/15/2023 revealed, R20 is at risk for nutritional decline aeb [as evidenced by] poor intake, consuming less than 50% at most meals, and 6 lbs. weight loss x 30 days. Review of the Approaches to the Nutritional Status and Swallowing Care Plan, dated 11/2/2022 revealed the following: 11/1/2022: Meal tray set up: uncover plate, assist with opening containers, pouring liquids, cutting up food etc., as needed, or desired. 11/1/2022: Monitor weights as ordered. Notify MD, RD if weight loss or gain occurs. 11/1/2022 Observe/document/report to MD prn s/sx of malnutrition (cachexia [weakness or wasting of the body] weight loss, muscle wasting) significant weight loss (>5% in one month, >7.5% in 3 months, >10% in 6 months). 11/1/2022 Obtain lab work as ordered. Report results to MD and follow up as indicated. 11/1/2023 OT to screen and provide adaptive equipment for feeding as needed. Review of a significant change MDS assessment located in the RAI tab of the EMR with an ARD of 12/8/2022 revealed, R20 had a BIMS score of four out of 15 which indicated she was severely impaired in cognition, required supervision for eating, weighed 111 lbs. and had weight loss. Review of the Weights located in the Vitals tab of the EMR revealed the following: 3/6/2023: 122.2 lbs. 4/3/2023: 123.4 lbs. 5/3/2023: 121.4 lbs. 6/2/2023: 119.4 lbs. 7/4/2023: 115.6 lbs. Review of the quarterly Nutritional assessment dated [DATE] located in the Observations tab of the EMR revealed the assessment was completed on 10/30/2023 (94 days later). The Nutritional Assessment revealed that R20's current body weight was 115.8 lbs., BMI was 19.84 and her ideal body weight should be 120 lbs. The assessment further showed that she had sustained a 3.2% weight loss in 32 days which was not significant, 6.3% weight loss in 92 days which was not significant and did not calculate the weight loss/gain in the last 180 days. The assessment showed that she was on a Cardiac, Mechanical Soft Chopped Meats with Fortified Foods meal intake was variable but at 75% overall, was receiving Ensure twice daily and consumed at least 50% of this overall. R20 was able to feed herself and was likely meeting her estimated goals with the current plan. Review of the Weights located in the Vitals tab of the EMR revealed the following: 8/07/2023: 118.2 lbs. 9/02/2023: 124.1 lbs. Review of the quarterly MDS assessment located in the RAI tab of the EMR with an ARD of 9/8/2023 revealed R20 had a BIMS score of seven out of 15 which indicated she was severely impaired in cognition, required set-up and supervision of one staff for eating, weight 124 lbs. and had no weight loss. Review of the Nursing Progress Notes located in the Progress Notes tab of the EMR revealed R20 was administered Lasix (a diuretic medication) from 9/13/2023 to 9/19/2023 related to edema and chest congestion. The Nursing Progress Notes further showed that on 9/20/2023 to 10/4/2023 R20 was COVID-19 positive. Review of the Weights located in the Vitals tab of the EMR revealed the following: 10/2/2023: 114.8 lbs. 10/24/2023: 116.1 lbs. Review of the 10/16/2023 Lab located in the Resident Documents tab of the EMR revealed the following: Albumin 3.1 (L) Total Protein 5.9 (L) Review of the quarterly Nutritional Assessment, dated 10/30/2023 located in the Observations tab of the EMR revealed that R20 had a current body weight of 114.8 lbs. which was a 7.5% weight loss in the last 30 days which was significant. The RD further documented that her intake was variable, consumed 75% of her meals overall, and no chewing or swallowing issues reported, and was able to feed herself. There was no updated lab to review. During an initial interview on 10/30/2023 at 2:15 pm, the RD was asked how often she was at the facility. The RD stated, I come two times per week. The RD was asked why there was no documentation on the Nutritional assessment dated [DATE]. The RD stated, I just did her evaluation today. The RD was asked why she documented there were no labs to review when on 10/16/2023 R20 had labs drawn. The RD stated, I don't have access to labs, I only have the progress notes and if the nurses' don't address it there, then I don't see it. During an observation on 10/31/2023 at 9:27 am, R20 was observed seated at the breakfast table. She was slow, but able to feed herself. At times, she would require the use of her other hand to hold the fork to her mouth. During an observation on 11/1/2023 at 9:15 am, R20 was at the breakfast table. She was not using utensils but using her fingers to pick up the food to feed herself. No staff assistance was observed. During an observation on 11/1/2023 at 12:44 pm, R20 was at the lunch table. A bowl of soup was placed in front of her, she used a spoon, however, most of it spilled onto her lap before getting it to her mouth. There was no staff assistance observed. After R20 continued to finish her bowl of soup, she then used her fingers to scoop the soup off the napkin in her lap to feed herself. During a follow-up interview on 11/2/2023 at 9:50 am, the RD was asked about the Nutrition Care Plan approach for an OT evaluation, as needed back in April 2023 and if she had observed R20 in the dining room during meals. The RD stated, I have watched her in the past, but not recently. I do not remember the last time I watched her eat. I would have wanted to know about her inability to consistently feed herself, but I don't recall anything being discussed regarding adaptive silverware. The RD was asked about the statement in the Nutritional Assessment regarding the lack of labs to review. Since there were labs done on 10/16/2023, why did you not obtain copies from nursing staff or HIM to review them for your assessment. The RD stated, I can ask for labs, but I did not. The RD was asked when the resident was positive for COVID-19 at the end of September and was administered Lasix due to edema and chest congestion, which she then sustained a 10 lb. weight loss, did you review her in the nutritional risk meetings or assess her for additional nutritional needs. The RD stated, I don't recall if I had reviewed her when she was sick. The RD was asked how the physician was updated regarding weight loss. She stated, I give my information to the Director of Nursing (DON), and she will tell the physician. 4. Review of the Face Sheet located in the Face Sheet tab of the EMR revealed R21 was admitted with diagnoses that included alcohol induced dementia, irregular heart rhythm, and major depressive disorder. Review of the 11/8/2022 admission Nutritional assessment dated [DATE] located in the Observations tab of the EMR revealed that R21 was at high risk for nutritional impairment and to continue with the current POC (Plan of Care.) Review of the admission MDS assessment located in the RAI tab of the EMR with an ARD of 11/10/2022 revealed R21 was assessed by staff to be severely impaired in cognition, was independent with eating and weighed 151 lbs. Review of the Care Plan' tab of the EMR did not show a Nutrition Care Plan was developed, at the time of the comprehensive assessment, for R21. Review of the Weights located in the Vitals tab of the EMR revealed the following: 11/4/2022: 151.1 lbs. 11/7/2022: 143.4 lbs. (a decline of 7.7 lbs.) 11/14/2022: 144.8 lbs. 12/6/2022: 139.0 lbs. 1/2/2023: 145.0 lbs. 2/3/2023: 149.8 lbs. No March 2023 weight was recorded. 4/3/2023: 168.0 lbs. (an increase of 19 lbs.) Review of the quarterly Nutritional assessment dated [DATE] completed on 10/30/2023 revealed, Resident continues to eat very well and often receives seconds from the kitchen. He shares no nutrition complaints at this time. With no weight loss and good intake, recommend current plan of care. Review of the quarterly Nutritional assessment dated [DATE] completed on 10/30/2023 revealed that R21's current body weight was 179#, ate 76-100% of meals, no updated labs were reviewed .continue with current plan of care. During an interview on 11/2/2023 at 9:31 am, the RD was asked what her responsibilities are when she comes to the facility. The RD stated, I would see new admission, attend care plan meetings on Tuesdays and on Thursday, and send information remotely. The RD further stated, I do kitchen audits one time per month, and review weights if they trigger for weight loss. The RD was asked who was involved in evaluating and addressing any underlying causes of nutritional risk or impairment. The RD stated, I would be the main person. The RD was asked when a resident is admitted to the facility how often are weights to be done. The RD stated, They are done on admission, then the following week, and if there were no issues, monthly after that. The RD was asked if she was aware that the March 2023 weight had not been obtained and when the April 2023 weight was obtained the resident had gained 20 lbs. The RD did not answer the question. The RD was asked why the May 2023 and August 2023 Nutritional Assessments were not completed until 10/30/2023. The RD stated, I did an audit on Monday and found the assessments were not completed. I don't know why they were not completed in a timely manner. The RD was asked if the Ensure was discontinued in January 2023 due to weight gain and consuming 76-100% of his meals, why was he still getting fortified foods. The RD stated, I typically try not to remove many things, recently his intakes have been variable. The RD was asked what examples of fortified foods are. The RD stated, cheese in the eggs, cream on the cereal. The RD was asked if she was the person responsible for developing the Nutrition Care Plan. The RD stated, Not anymore, that stopped about two months ago. The CDM [Certified Dietary Manager] is now responsible. The RD was asked, at the time of R21's admission, was she responsible for the Nutrition Care Plan. She stated, Yes. The RD was asked if she was aware that R21 did not have a Nutritional Care Plan developed at the time of admission. The RD stated, I was not aware the Care Plan was not developed. During an interview on 11/2/2023 at 11:54 am, the CDM was asked if he was responsible for the Nutritional Care Plan. The CDM stated, I am not, as far as I know, responsible for the Nutritional Care Plan. The CDM was asked if he was aware that R21 did not have a Nutritional Care Plan. He stated, No.

Based on staff interview and record review, the facility failed to ensure a physician ordered laboratory test was obtained in a timely manner for one of one Resident (R) (R21) reviewed for laboratory testing. The deficient practice had the potential to prevent R21 from receiving laboratory results as ordered by the physician. Findings included. Review of R21's Face Sheet located in the Face Sheet tab of the Electronic Medical Record (EMR) revealed R21 was admitted with diagnoses that included alcohol induced dementia, irregular heart rhythm, and mood disorders. Review of the Minimum Data Set (MDS) located in the RAI (Resident Assessment Instrument) tab of the EMR with an Assessment Reference Date (ARD) of 8/10/2023 revealed R21 had a Brief Interview of Mental Status (BIMS) score that was assessed by staff to be severely impaired in cognition for decision-making. Review of an 8/15/2023 Note to Attending Physician/Provider located in the Resident Documents tab of the EMR revealed a pharmacist recommendation to physician which stated, The resident is receiving medications which need routine lab work. Please check all that you would like ordered: CMP [comprehensive metabolic panel] and Lipids. The physician checked both laboratory tests and signed the form on 8/15/2023. Review of the EMR under the Lab section in the Resident Documents tab of the EMR revealed no labs were done in August, September, or October 2023. During an interview on 11/1/2023 at 2:17 pm, Licensed Practical Nurse (LPN) 1 was asked if there was a copy of the laboratory test results as it was not located in the EMR. LPN 1 reviewed the lab book, located in the top cabinet of the nurses' station for the month of August, reviewed the physician orders, and the pharmacy recommendations and stated, I don't see that it had been done however, I will speak with my supervisor. LPN 1 was asked when the physician signs a pharmacy recommendation how is the order processed, so that the physician's order is carried out. LPN 1 stated that the Registered Nurse (RN) supervisor is responsible for this. During an interview on 11/1/2023 at 3:42 pm, the Director of Nursing (DON) stated, The lipids were not done as the form gave us a Medicare Warning stating they were not going to pay for this test, however, she confirmed that the CMP was not done either, in August 2023, as ordered.

Based on observations, staff interviews, and policy review, the facility failed to label, and date opened food items; failed to discard food items by use by dates; failed to have appropriate garbage receptacle at hand washing sink; and failed to properly sanitize dishware, to prevent cross contamination. The census was 20. 1. Review of the policy titled Food Safety and Sanitation created 3/17, revealed First In, First Out is to pay close attention to the use by dates and be sure to label and date all opened containers or leftover food items. Continued review of the policy revealed that all leftover food items must be properly covered, labeled with the contents, and dated with a use-by date. The policy also revealed to Prevent Cross Contamination is the transfer of harmful micro-organisms from one food to another by means of a nonfood surface such as cutting boards, utensils, human hands, aprons, or rags. Observation on 7/15/22 at 9:02 a.m. of the walk-in refrigerator revealed two opened one-gallon containers of peeled garlic with a best used by ([NAME]) date of 7/4/22. Interview on 7/15/22 at 9:02 a.m. with the Certified Dietary Manager (CDM) revealed that she did not realize that the peeled garlic containers had a [NAME] date of 7/4/22. She stated that she thought the garlic had 30 days to use after the [NAME] date. The CDM was unable to obtain documentation from food source provider to support the statement. 2. Review of the policy titled Storage of Food and Supply Products created 3/17, revealed procedure 4. All food items must be properly covered or tightly wrapped when stored in a refrigerator or freezer. Leftover items should be labeled with the name of the food product, production date and the use-by date. Observation on 7/15/22 at 9:05 a.m. of the walk-in freezer revealed an open bag of French Fries that was wrapped but had no open date on the bag. Interview on 7/15/22 at 9:05 a.m. with the CDM, confirmed that the opened bag of French Fries was not dated. She stated that staff should have placed an open date on the bag of French Fries, before placing in the freezer. 3. Review of the policy titled Handwashing created 3/17, revealed procedure 2.6. Dry hands thoroughly with a new sanitary, single service towel. Turn the faucet off with the towel you just used to dry your hands. Shutting the water off with your clean hands would re-contaminate them. Do not touch anything that re-contaminates the hands before returning to work. Observation on 7/15/22 at 9:15 a.m. at the hand washing sink in the Coastal kitchen, revealed the only garbage receptacle available to dispose of paper towels used after hand washing was a 50-gallon garbage can with a lid. Continued observation revealed Dietary Cook AA washing his hands at the hand washing sink, using a paper towel to dry hands, then trying to use the paper towel to lift the garbage can lid to dispose of the paper towel. Interview on 7/15/22 at 9:15 a.m. with the CDM revealed that staff are to use a clean paper towel to lift the lid of the 50-gallon garbage receptacle to dispose of their used paper towels after washing their hands. 4. Review of the policy titled Washing and Sanitizing Dishes, Utensils and Pots and Pans created 3/17, revealed procedure 1. Sanitization is a process by which an agent or substance is applied to a clean surface to destroy any micro-organisms that may cause illness. This process may be accomplished either by machine washing or hand washing, as long as all procedures follow food sanitation standards. Procedure 3. Hand Washing - if the commercial dishwasher is not working properly, dishes will need to be washed by hand or transported to the other kitchen for proper washing. If they are washed by hand in the kitchen, the following guidelines must be followed: - Scrape an/or pre-rinse large particles of food from the dishes, utensils, and pots and pans. - Use a 3-compartment sink. Fill the first sink with hot soapy water and wash items. - In the second sink have clear, hot water, and rinse the items. - In the third sink have a sanitizing solution of 1 tablespoon of household bleach to 1 gallon of water or a sanitizing solution of a quat sanitizer or iodine solution. - All dishes, utensils and pots and pans must air dry, do not stack any items while still wet. Do not use towels for drying since they can spread contamination. Observation on 7/16/22 at 11:30 a.m., Dietary Cook BB was observed washing the food processor bowl, lid, and blade between pureeing food items in a one compartment sink in the Coastal Kitchen. Dietary Cook BB rinsed the food that remained on the food process bowl, lid, and blade with water. She then used a scrub pad with soap and washed the food processor items and then rinsed with water. Dietary Cook BB took a white towel and dried the food processor items and placed the bowl, lid, and blade back on the food processor base unit and began to puree additional food. The observation revealed that Dietary Cook BB did not sanitize the food processor bowl, lid, or blade before preparing additional puree food for resident lunch meal. Interview on 7/16/22 at 11:30 a.m. with Dietary Cook BB revealed that she washes the food processor bowl, lid, and blade like that all the time and has been doing it that way for a long time. Interview on 7/16/22 at 12:15 p.m. with the CDM revealed that she expects the dietary staff to properly clean and sanitize the food processor bowl, lid, and blade between uses when multiple food items are to be pureed. Continued interview with the CDM revealed that staff are not to dry dishware with a towel.

Based on observations, staff interviews, policy review and review of dietary recipe and menu cycle, the facility failed to ensure staff followed food recipes for preparing pureed foods to avoid compromising the nutritive value for peas and meatloaf for two of 20 residents, who received a puree diet. Findings include: Review of the policy titled Standardized Recipes, revised April 2007, revealed the food service manager will maintain the recipe file and make it available to food services staff as necessary. Review of the recipe for Glazed Meatloaf 3 oz PU Number 13. Prepare slurry. Number 14. Process until smooth adding 1 oz (ounce) slurry per portion. Number 16. Reheat to a minimum temperature of 165F (Fahrenheit) or higher for 15 seconds. Hold at 140F or higher for services. Continued review of the recipe revealed measurements as: Food Thickener Bulk - 2 tablespoon 1 1/2 teaspoon and water or stock 1 1/4 cup. Review of the Day 8 Menu Cycle for regular diet revealed portion sizes were indicated. The cycle menu for regular diets did not specify any other diets or diet consistency portion sizes. Observation on 7/15/22 at 11:30 a.m. with Dietary Cook BB, in the resident unit kitchen, preparing puree foods for lunch service. Dietary Cook BB took a large metal spoon and placed four unmeasured spoonful of cooked peas into the food processor and blended to puree. After blending, she opened the lid and added another unmeasured spoonful of cooked peas and blended. She then took an ice cream type scoop and placed one scoop of pureed peas onto two separate plates. Continued observation at this time revealed Cook BB pureed meatloaf by placing four slices of unweighed/unmeasured meatloaf into the food processor and blended to puree. She added an unmeasured amount to chicken stock to the puree meatloaf and continued to blend. Dietary Cook BB took an ice cream type scoop and placed one scoop of pureed meatloaf on each plate next to the puree peas. Interview on 7/15/22 at 11:30 a.m. with Dietary Cook BB, revealed she did not have a recipe or cycle menu to use as a reference or portion size guidance. She revealed that she was not aware of any recipes for pureed food items but then stated that puree recipes are kept in the main kitchen. Dietary Cook BB stated that they add broth or gravy to puree food items until proper consistency and does not measure the liquid added. Interview on 7/15/22 at 12:15 p.m. with the Certified Dietary Manager (CDM) revealed that the main kitchen has a recipe book with the recipes for puree foods. Continued interview with the CDM, revealed that the cook can look at the recipe for puree food items in the main kitchen, then prepare that pureed food item in the unit kitchen location. The CDM stated that she expects staff to follow recipes for puree food items. Interview on 7/15/22 at 1:45 p.m. with the CDM revealed that a binder containing recipes for puree foods was found in a cabinet in the unit kitchen for staff to review, when pureeing foods. During further interview with the CDM, she stated that there is no actual cycle menu for puree diets for staff to view the portion sizes to serve residents receiving puree diet.

Based on observation, interview, review of facility hot water policy, and review of provided facility forms titled Corrective Daily Temperature Checks, the facility failed to ensure safe water temperatures in sixteen (16) resident rooms at the hand washing sink. The census was 45 residents. The sample size was 30. Findings include: Review of the Corrective Daily Temperature Checks (temperature logs) for the months of (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 to date, revealed the facility recorded daily water temperatures taken in random rooms in resident rooms on five (5) resident neighborhoods. Review of the facility Incident Logs for the months of (MONTH) 2019, (MONTH) 2019 and (MONTH) to date, revealed there were no accidents related to high water temperatures in the facility. A brief interview was conducted on 9/3/19 at 1:45 p.m. with Resident (R) R#1 in her room while she was visiting with her family. Resident is alert with a pleasant affect. Resident #1 complained that the water in her bathroom was too hot sometimes. She confirmed the water was hot when she washed her hands. The family confirmed that the resident could do many things independently. A review was conducted of R#1's Minimum Data Set (MDS) admission assessment dated [DATE] that indicated a Brief Interview for Mental Status was conducted (BIMS). In the MDS Section C, the resident was assessed to have a BIMS of 15, indicating no cognitive impairment. The MDS documented resident was admitted initially 1/25/19 with a re-entry date of 8/26/19. On 9/3/19 starting at 2:00 p.m. hot water temperature checks were conducted by the surveyor for hot water in resident rooms. A subsequent walking tour with the Maintenance Supervisor verified hot water temperatures in the following rooms using a facility calibrated thermometer as follows: room [ROOM NUMBER] 136.0 degrees Fahrenheit (F) maintenance verified at 141.0 degrees F at 3:42 p.m. room [ROOM NUMBER] 116.8 degrees F maintenance verified at 116.7 degrees F at 3:49 p.m. room [ROOM NUMBER] 127.4 degrees F maintenance verified at 127.5 degrees F at 3:58 p.m. room [ROOM NUMBER] 112.0 degrees F maintenance verified at 113.0 degrees F at 4:00 p.m. room [ROOM NUMBER] 137.0 degrees F maintenance verified at 114.0 degrees F at 4:02 p.m. room [ROOM NUMBER] 111.9 degrees F maintenance verified at 111.5 degrees F at 3:56 p.m. room [ROOM NUMBER] 110.8 degrees F vacant room, maintenance verified at 113.0 degrees F at 3:58 p.m. room [ROOM NUMBER] 93.8 degrees F (no recheck conducted) room [ROOM NUMBER] 110.6 degrees F maintenance verified at 111.1 degrees F at 4:00 p.m. room [ROOM NUMBER] 110.1 degrees F room [ROOM NUMBER] 108.5 degrees F room [ROOM NUMBER] 90.2 degrees F (no recheck conducted) On 9/3/19 starting at 1:10 p.m. hot water temperature checks were conducted by another surveyor for hot water in resident rooms as follows: 9/3/19 at 1:10 p.m. room [ROOM NUMBER] hot water 112.6 degrees F 9/3/19 at 1:16 p.m. room [ROOM NUMBER] hot water 111.4 degrees F 9/3/19 at 1:18 p.m. room [ROOM NUMBER] hot water 110.9 degrees F 9/3/19 at 1:20 p.m. room [ROOM NUMBER] hot water 131.1 degrees F 9/3/19 at 1:22 p.m. room [ROOM NUMBER] hot water 113.3 degrees F 9/3/19 at 1:23 p.m. room [ROOM NUMBER] hot water 113.9 degrees F 9/3/19 at 1:25 p.m. room [ROOM NUMBER] hot water 112.8 degrees F 9/3/19 at 1:26 p.m. room [ROOM NUMBER] hot water 111.4 degrees F On 9/3/19 at 6:05 p.m. an additional recheck of hot water temperatures was conducted by a Maintenance Technician with the surveyor using a facility calibrated thermometer in the following rooms: room [ROOM NUMBER] maintenance recheck 106.2 degrees F room [ROOM NUMBER] maintenance recheck 106.0 degrees F room [ROOM NUMBER] maintenance recheck 127.0 degrees F, readjusted to 101.8 degrees F verified with a second recheck room [ROOM NUMBER] maintenance recheck 100.0 degrees F no recheck conducted room [ROOM NUMBER] maintenance recheck 99.6 degrees F no recheck conducted On 9/3/19 at 4:07 p.m. during a walking tour with the Maintenance Supervisor with another surveyor present, he verified hot water temperatures using the facility's calibrated thermometer as follows: 9/3/19 at 4:07 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 113.3 degrees F 9/3/19 at 4:08 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 111.4 degrees F 9/3/19 at 4:10 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 113.9 degrees F 9/3/19 at 4:11 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 132.2 degrees F 9/3/19 at 4:13 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 114.1 degrees F 9/3/19 at 4:15 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 115.2 degrees F 9/3/19 at 4:17 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 113.5 degrees F 9/3/19 at 4:19 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 113.1 degrees F On 9/3/19 at 6:06 p.m., the water temperatures were adjusted by the Maintenance Supervisor. Random room checks were as follows: 9/3/19 at 6:08 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 115.0 degrees F, re-adjusted and then down to 102.0 degrees F 9/3/19 at 6:09 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 104.0 degrees F 9/3/19 at 6:13 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 101.4 degrees F 9/3/19 at 6:14 p.m. hot water temperature with facility thermometer: room [ROOM NUMBER] = 103.0 degrees F An interview was conducted on 9/3/19 at 6:15 p.m. with the Maintenance Supervisor who stated that he works in two (2) of the continuing care facilities, and has two (2) Maintenance Technicians who check the water temperatures every day. He stated that they pick random rooms and mark the temperatures on the log sheet. The log sheets are kept at the front desk. A review was conducted on 9/6/19 of the facility policy titled, Hot Water Policy that documented the facility should insure that plumbing fixtures that supply hot water and are accessible to the residents, shall be thermostatically controlled so the water temperature at the fixture does not exceed one hundred and ten degrees Fahrenheit (110.F). The water should be at a temperature range of one hundred five degrees Fahrenheit to one hundred ten degrees Fahrenheit (105 degrees F-110 degrees F). This is done weekly or more often if needed. If having some readings where the temps are out of range, especially over 120 degrees, you need to check them as often as necessary. There are circumstances that require that they be checked every hour for a day or so. There are others that need to be done daily for a couple of weeks to make sure that the temperatures stay within range.

Based on observation, policy review and staff interview, the facility failed to ensure opened food items in the dry storage area were securely covered, labeled and dated and failed to discard food items by expiration date. In addition, the facility failed to maintain sanitary conditions of the cookware by not stacking wet cookware and ensuring the cleanliness of kitchen equipment. The census was 45 and the sample size was 30. Findings include: 1. Review of the facility policy titled Storage of Food and Supply Products dated 3/2/17, revealed the policy for all food and supply items will be stored in a safe and sanitary manner. Procedure 8. The dry storage pantry is for foods that are non-perishable, such as canned goods, box mixes, flour, sugar, salt, cereals, condiments,etc. Once opened, food that has been stored in dry storage should either be either refrigerated or sealed in airtight containers or well wrapped with clear wrap. All items should be labeled and dated with date of opening and use by date. During initial tour on 9/3/19 at 9:55 a.m., revealed one 128 ounce bottle of red wine vinegar with no open date or use by date, a styrofoam cup labeled Olive Oil with use by date of 6/22/19, one 12.9 ounce bottle of Balsamic vinegar with no open date or use by date and a clear plastic storage bin labeled thickener unsealed with a stainless steel cake pan as the top to the bin. These items were verified by the Director of Food and Beverage. Observation on 9/3/19 at 10:50 a.m. in the Coastal Neighborhood kitchen, revealed a 12 ounce bag of opened grits, unsealed and with no open date or use by date. In the resident refrigerator in the Coastal neighborhood kitchen and one 12 ounce bottle of salad dressing with no open date and no resident name on it. 2. Review of the facility policy titled Washing and Sanitizing Dishes, Utensils and Pots and Pans dated 3/3/17, revealed the policy is all dishes, utensils and pots and pans must be washed and sanitized according to established procedures and in compliance with regulatory guidelines. Procedure 2. Always let dishes, utensils and pots and pans air dry, do not stack any items while still wet. Never use towels to dry these items. Observation on 9/3/19 at 10:00 a.m. revealed stainless steel table in the back of the kitchen, revealed on bottom shelf varying sizes of stainless steel pans stacked on top of each other with wet moisture on the inside of the pans. These items were verified by the Director of Food and Beverage. During follow-up visit to kitchen on 9/5/19 at 12:49 p.m. revealed four large stainless steel bowls and three medium sized stainless steel deep pans stacked with moist condensation noted inside bowls and pans. Interview on 9/5/19 at 12:53 p.m. with Dietary Manager (DM) stated that she had started an in-service on kitchen sanitation, including wet nesting, so she does not know why the pots and pans were stacked when they were not completely dry. 3. Observation on 9/3/19 at 10:00 a.m. revealed cake pans and muffin pans on stainless steel table in back of kitchen, with dried food particles on them. Observation on 9/3/19 at 10:03 a.m. revealed food slicer with dried food particles on the sliding tray and large mixer bowl had dried food particles inside the bowl. Both items were sitting on stainless steel table in the back of the kitchen. Observation on 9/5/19 at 11:55 a.m. during puree process with Cook/Homemaker EE, revealed that she placed the food processor items in the high temperature dishwasher after use and did not allow the bowl, blade or lid to air dry completely before using the items for continued puree items. Interview on 9/5/19 at 12:02 p.m. with Cook/Homemaker EE, stated she has the food processor and also a blender that she could use to puree the foods, but the blender has three blades spiraling the agitator bar and it doesn't blend the foods as well as the food processor does. She stated that she didn't think about using it instead of using the food processor when it was still wet with dish water. She stated that she knows she should have waited for the food processor to dry completely, or she should have use the blender.

Based on record review, staff interviews anf policy review titled Behavior Assessment, Intervention and Monitoring, the facility failed to monitor and document behaviors and side effects for four (4) of four (4) residents (R) R#17, R#24, R#26 and R#34 reviewed who were receiving [MEDICAL CONDITION] medications. The sample size was 30. Findings include: Review of the facility policy titled Behavior Assessment, Intervention and Monitoring revised (MONTH) (YEAR), revealed the policy is to comply with regulatory requirements related to the use of medication to manage behavioral changes. Management 2. The care plan will incorporate findings from the comprehensive assessments and be consistent with current standards of practice. Management 8e. How the staff will monitor for effectiveness of the interventions. Management 10h. Monitoring for efficacy and adverse consequences. Monitoring 4. The nursing staff and the Physician will monitor for side effects and complication related to psychoactive medications. 1. Review of the clinical record for R#17 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 8, indicating moderate cognitive impairment. Review of Physician Orders (PO) for R#17 dated 9/2019 revealed an order for [REDACTED]. Review of the Medication Administration Records (MAR) for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, revealed [MEDICATION NAME] 25 milligram (mg) was administered daily without evidence that behaviors or medication side effects were monitored or documented. 2. Review of the clinical record for R#24 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 3, indicating severe cognitive impairment. Review of Physician Orders (PO) for R#24 dated 9/2019 revealed an order for [REDACTED]. Review of the Medication Administration Records (MAR) for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, revealed [MEDICATION NAME] 1 milligram (mg) was administered as needed without evidence that behaviors or medication side effects were monitored or documented. 3. Review of the clinical record for R#26 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating moderate cognitive impairment. Review of Physician Orders (PO) for R#26 dated 9/2019 revealed an order for [REDACTED]. Review of the Medication Administration Records (MAR) for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, revealed [MEDICATION NAME] 12.5 milligram (mg) was administered daily without evidence that behaviors or medication side effects were monitored or documented. Also during the month of (MONTH) and (MONTH) 2019, as needed [MEDICATION NAME] was administered seven (7) times in (MONTH) and two (2) times in (MONTH) without evidence that behaviors or medication side effects were monitored or documented. 4. Review of the clinical record for R#34 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating moderate cognitive impairment. Review of Physician Orders (PO) for R#34 dated 7/2019 revealed an order for [REDACTED]. Review of the Medication Administration Records (MAR) for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, revealed [MEDICATION NAME] 0.5 milligram (mg) was administered daily without evidence that behaviors or medication side effects were monitored or documented. Also during the month of (MONTH) and (MONTH) 2019, as needed [MEDICATION NAME] was administered three (3) times in (MONTH) and one (1) time in (MONTH) without evidence that behaviors or medication side effects were monitored or documented. Interview on 9/6/19 at 1:41 p.m. with Licensed Practical Nurse CC, stated that when she administers [MEDICAL CONDITION] medications, the computer prompts her to the behavior monitoring screen. She further stated there is an administration note section that she can document additional information if needed. Interview on 9/6/19 at 7:17 p.m. with Interim Director of Nursing, stated that her expectation is that the nurses perform behavior monitor for residents receiving [MEDICAL CONDITION] medications.

Based on observation, record review and staff interview, the facility failed to implement the individualized care plan for behavior monitoring for four residents (R) R#17, R#24, R#26 and R#34, who were receiving [MEDICAL CONDITION] medications. The sample size was 30. Findings include: 1. Review of the clinical record for R#17 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 8, indicating moderate cognitive impairment. Review of Physician order [REDACTED]. Review of the care plan initiated on 8/29/19, revealed that resident is receiving antidepressant and antianxiety medications and is at risk for undesired side effects. Interventions listed include monitor for side effects of medication and notify Physician if side effects noted, provide quiet atmosphere with one-on-one support during periods of increase anxiety, allow resident time to talk about anxiety and record behaviors on Behavior Tracking Record, observe for changes in sleep patterns, fatigue, appetite, ability to concentrate, participation in activities and crying. 2. Review of the clinical record for R#24 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 3, indicating severe cognitive impairment. Review of Physician order [REDACTED]. Review of the care plan initiated on 7/15/19, revealed that resident is receiving antianxiety drugs on as needed (PRN) basis for anxiety/restlessness. Interventions include engage resident in group/social activities, encourage resident to abstain from alcohol, monitor for side effects of medications, provide quiet atmosphere with 1:1 support during periods of anxiety, record behavior on behavior tracking form, observe for episodes of anxiety. 3. Review of the clinical record for R#26 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating moderate cognitive impairment. Review of Physician order [REDACTED]. Review of the care plan initiated on 1/8/19, revealed that resident requires the use of antipsychotic medications, is receiving antianxiety drugs on a regular basis and has targeted behaviors of yelling at others, becoming agitated such points her finger and raises her hand like she will hit. Interventions include administer medications as ordered and monitor for side effects, assist to reduce anxiety level by providing reassurance and comfort, ongoing observation and documentation for delusions, hallucinations or mood/behavior disturbances, medication reviews per pharmacy consultant and Physician to assess for dose adjustments, continuation, or discontinuation, monitor for behaviors and notify Physician and record behaviors on Behavior Tracking Form. 4. Review of the clinical record for R#34 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating moderate cognitive impairment. Review of Physician order [REDACTED]. Review of the care plan initiated on 8/9/19, revealed that resident is receiving antianxiety and antidepressant drugs on a regular basis and has behavioral response of yelling at others and refusing medications. She has spit and attempted to hit member due to progression of [MEDICAL CONDITION] and is at risk for continued behavioral responses. Interventions include administer as needed [MEDICAL CONDITION] medication per Physician order [REDACTED]. Interview on 9/6/19 at 1:41 p.m. with Licensed Practical Nurse CC, stated that when she administers [MEDICAL CONDITION] medications, the computer prompts her to the behavior monitoring screen. She further stated there is an administration note section that she can document additional information if needed. Interview on 9/6/19 at 7:17 p.m. with Interim Director of Nursing, stated that her expectation is that the nurses follow the care plan for behavior monitor for residents receiving [MEDICAL CONDITION] medications. Cross refer 757

Based on observation, record review, staff and resident interview, it was determined the facility failed to have a physician's order and medical justification for the use of an indwelling catheter for one (1) resident (R)(R#50) of nine (9) residents with catheters present upon admission. The census was 45 and the sample size was 30. Findings include: Review of the resident's clinical record revealed an admission from an acute hospital with a [DIAGNOSES REDACTED]. Record review of R#50's physician orders for treatments, documents that starting on 8/15/19, the resident is ordered to have a regular renal diet, check for abnormal involuntary movement scale (AIMS) vital signs every shift, crush medications as needed. On 8/16/19 monitor for behaviors sad facial expressions, have a resident summary each month, to be weighed once weekly for four weeks, to have checks each shift for side ¼ side rails for positioning, skin checks once weekly, fall precautions, admit to skilled care, Physical Therapy to evaluate and treat, Occupational Therapy, PPD once, chest x-ray once 8/24/19, urine culture and sensitivity 8/26/19, (blood sugar testing) accu-check four times daily, order date of 8/28/19, blood pressure each shift; no blood pressure to be done on left arm order date of 8/28/19. No physician order was documented for the use and care of an indwelling catheter that was present upon admission. Review of the resident's Minimum Data Set (MDS) Admission Assessment, dated 8/22/19, documented a Brief Interview for Mental Status (BIMS) was conducted indicating a score of 4, indicating the resident is cognitively impaired. The MDS in Section H, revealed the resident had the presence of a catheter, was always incontinent of bladder and continent of bowel. The MDS in Section H, revealed the resident required extensive assistance one person physical help for toileting and mobility and transfers. In Section 0, for special programs and treatments, reflects the resident is to receive [MEDICAL TREATMENT] services, Physical Therapy and Occupational Therapy. A review was conducted of the resident's Baseline (initial) Care Plan, dated completed 8/16/19, that documents the resident desires to discharge to home. In a section titled Problem Areas documentation reflects that the resident currently has a urinary tract infection, has end stage [MEDICAL CONDITION], with [MEDICAL TREATMENT] on Monday, Wednesday and Friday at a [MEDICAL TREATMENT] center. Also, documents that resident is at risk for altered bladder function, is at risk for actual infection/urinary tract infection. Under the section titled, Intervention, documentation reflects a check mark by physician to review discharge and admission orders [REDACTED]. Areas circled were to confirm all orders with physician, to check bruit/thrill each shift and Foley catheter if indicated per physician order. A review was conducted of the resident's Care Plan Report dated effective 8/15/19 to present. Care areas documented were under sections labeled: Problems, Goals, Interventions, Disciplines and Frequency. Under Problems documentation reflects that resident is at risk for infection related to an indwelling Foley catheter placement, with a goal that resident will remain free of a urinary tract infection during period of catheterization. An observation was conducted on 9/4/19 at 4:36 p.m. of R#50 in his private room. Resident was sitting in his wheelchair, watching television. Resident appeared well groomed with bilateral leg braces in place. A catheter bag was secured to his wheelchair in a privacy bag. The resident voiced no concerns. An observation was conducted on 9/5/19 at 10:15 a.m. with R#50, observed in a wheelchair, a catheter bag attached to his wheelchair in a privacy bag. The resident stated he had no concerns, and confirmed he had a packed lunch to take with him to [MEDICAL TREATMENT] this day. The resident was sitting at the door of his room, appearing well groomed with ankle support braces and shoes on, awaiting transportation pick up for [MEDICAL TREATMENT]. An interview was initiated by the Director of Nursing (DON) on 9/4/19 at 4:57 p.m. where she stated it had been brought to her attention, and made aware that they were missing physician orders for a resident. She confirmed that in-services were started immediately with the nursing staff, and that they were taking care of it. An interview was conducted with the DON on 9/6/19 at 4:00 p.m. where she confirmed in-services had been started on 9/5/19 regarding physician orders. She confirmed that the order process starts during the initial admission process and it is the expectation of the nursing staff to ensure information is documented correctly and that the information is specific to the resident's care needs. A review was conducted of the facility policy titled, Medication and Treatment Orders, dated revised (MONTH) (YEAR). The policy statement documents that orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy interpretation and implementation at No. 2, documents only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners shall be allowed to write orders in the medical record. In the policy section titled, Purpose it is documented that the purpose of procedure is to establish guidelines in the receiving and recording of medication orders. In the section titled, Supervision by a Physician, the policy documents that a current list must be written and maintained in the clinical record of each resident. That orders must be written and maintained in chronological order. In section titled, Recording Orders, No. 6 Treatment Orders, documentation reflects that when recording treatment orders, specify the treatment, frequency and duration of the treatment.

Based on observation, record review, staff and resident interview, it was determined the facility failed to have a physician's order and medical justification for [MEDICAL TREATMENT] services, and an order for [REDACTED]. The census was 45, the sample size was 30. Findings include: A review of the resident's clinical record revealed an admission from an acute hospital with a [DIAGNOSES REDACTED]. Record review of R#50's physician orders for treatments, documents that starting on 8/15/19, the resident is ordered to have a regular renal diet, check for abnormal involuntary movement scale (AIMS) vital signs every shift, crush medications as needed. On 8/16/19 monitor for behaviors sad facial expressions, have a resident summary each month, to be weighed once weekly for four weeks, to have checks each shift for side ¼ side rails for positioning, skin checks once weekly, fall precautions, admit to skilled care, Physical Therapy to evaluate and treat, Occupational Therapy, Purified Protein Derivative (PPD) once, chest x-ray once 8/24/19, urine culture and sensitivity 8/26/19, (blood sugar testing) accu-check four times daily, order date of 8/28/19, blood pressure each shift; no blood pressure to be done on left arm order date of 8/28/19. A physician's order was not found for [MEDICAL TREATMENT] services that the resident is receiving on Monday, Wednesday and Friday at a local outpatient [MEDICAL TREATMENT] center. No order was found for the care, treatment and/or precautions related to the resident's [MEDICAL TREATMENT]. Review of the resident's Minimum Data Set (MDS) Admission Assessment, dated 8/22/19, documented a Brief Interview for Mental Status (BIMS) was conducted indicating a score of 04, indicating the resident is cognitively impaired. The MDS in Section H, revealed the resident had the presence of a catheter, was always incontinent of bladder, and continent of bowel. The MDS in Section H, revealed the resident required extensive assistance one person physical help for toileting and mobility and transfers. In Section 0, for special programs and treatments, this section documents that the resident is to receive [MEDICAL TREATMENT] services, Physical Therapy and Occupational Therapy. A review was conducted of the resident's Care Plan Report dated effective 8/15/19 to present. Care areas documented were under sections labeled: Problems, Goals, Interventions, Disciplines and Frequency. Under Problems documentation reflects that resident is at nutritional risk related to healing needs related [MEDICAL CONDITION] and [MEDICAL TREATMENT] three times weekly. Resident is on [MEDICAL TREATMENT] three times weekly on Monday, Wednesday and Friday due to end stage [MEDICAL CONDITION]. Interventions documented: assess condition following [MEDICAL TREATMENT] for signs and symptoms of complication. Communicate with [MEDICAL TREATMENT] center regarding general condition, weight changes, medication changes and any concerns. Monitor and document shunt site. Educate family and resident on site care. Monitor site daily for redness, swelling, drainage, pain, report abnormal finding to physician, no lab draws or blood pressures in shunt arm, palpate for thrills, auscultate for bruits on daily basis, report abnormal findings to physician. Protect site from moisture during bathing. A review was conducted of the facility's outpatient [MEDICAL TREATMENT] services agreement, dated effective (MONTH) 2, (YEAR). A review was conducted of the facility's communication binder for R#50 with a local outpatient [MEDICAL TREATMENT] center. Information forms found in the communication binder located at the nurse's computer station, indicated that the resident is scheduled weekly for [MEDICAL TREATMENT] on Monday, Wednesday and Friday at the center. Two forms titled [MEDICAL TREATMENT] Communication Form were found in the binder dated 8/30/19 and 9/4/19; no other communication was found between the [MEDICAL TREATMENT] center and the nursing staff. The communication form records information such as vital signs, last meal, significant alerts and facility nurse's name and signature discharging the resident to the [MEDICAL TREATMENT] center. The second part of the form is discharge information from the [MEDICAL TREATMENT] center recording time and date of discharge from the center, fluid removed, medications given, labs drawn, vital signs and an area titled Patient Tolerance to Procedure. The form has an area for the [MEDICAL TREATMENT] nurse name and signature. [MEDICAL TREATMENT] Communication Form dated 8/30/19 post [MEDICAL TREATMENT] documented that the resident received [MEDICATION NAME] 0.75 mcg by mouth (vitamin supplement for [MEDICAL CONDITION]), recorded vital signs, and the resident tolerated procedure well. [MEDICAL TREATMENT] Communication Form dated 9/4/19 documented in the area from the center that the resident had labs drawn and received [MEDICATION NAME] 0.75 mcg, tolerated the procedure without difficulty, but had a mild [MEDICAL CONDITION] post treatment [MEDICATION NAME] less than 10 seconds, that vital signs were within normal limits. That spouse was notified. No new orders. An interview was conducted on 9/6/19 at 12:00 p.m. with Registered Nurse (RN) AA who provided the [MEDICAL TREATMENT] communication book/binder for R#50; she confirmed there are not may communication forms in there that they fill them out but there are not returned from the [MEDICAL TREATMENT] center, explaining that she asks his wife that goes to [MEDICAL TREATMENT] with him most times, and she tells her there is no concerns. She stated if the resident or wife told him there were changes she would then call the center to get information. An interview was conducted with Licensed Practical Nurse (LPN) BB on 9/6/19 at 5:35 p.m. where she explained that [MEDICAL TREATMENT] communication sheets are kept in the resident's [MEDICAL TREATMENT] binder. She confirmed if she doesn't get the communication form back, she calls the center and they fax it to her. The LPN confirmed that the [MEDICAL TREATMENT] center that her patient goes to is good at returning the forms, but she stated she couldn't vouch for other residents that have a different [MEDICAL TREATMENT] center. A review was conducted of the provided facility policy titled, [MEDICAL TREATMENT] Access Care dated revised (MONTH) 2010. The policy is for general information regarding types of access devices used with [MEDICAL TREATMENT].

Based on record review, policy review and staff interview, the facility failed to ensure that [MEDICAL CONDITION] medications including antianxiety and antidepressant medications for four (4) residents (R#17, R#24, R#26, R#34) were not ordered as needed (PRN) beyond 14 days, and failed to document the reason for the extension or the period during which the extended order should be in effect. The sample size was 30. Findings include: 1. Review of the clinical record for R#17 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 8, indicating moderate cognitive impairment. Review of Physician order [REDACTED].#17 dated 9/2019 revealed an order for [REDACTED]. 2. Review of the clinical record for R#24 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 3, indicating severe cognitive impairment. Review of Physician order [REDACTED].#24 dated 9/2019 revealed an order for [REDACTED]. 3. Review of the clinical record for R#26 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating moderate cognitive impairment. Review of Physician order [REDACTED].#26 dated 9/2019 revealed an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. 4. Review of the clinical record for R#34 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating moderate cognitive impairment. Review of Physician order [REDACTED].#34 dated 7/2019 revealed an order for [REDACTED]. Interview on 9/6/19 at 7:17 p.m. with Interim Director of Nursing, stated that she was aware of the stop order regulation for as needed (PRN) [MEDICAL CONDITION] medications and was not aware that they did not have stop order dates for the as needed [MEDICAL CONDITION] medications for R#17, R#24, R#26 and R#34.

Based on observation, staff interview, and policy review, the facility failed to securely wrap, label, and date food items in the dry storage area, food preparation area, walk-in refrigerator, walk-in freezer, and two of four refrigerators located in the food preparation area. The facility also failed to discard food items past the use by date in the walk-in refrigerator; failed to discard prepared food items three day after preparation per policy; and failed to have dietary staff store a personal item away from a food preparation table. This deficient practice had the potential to effect 48 residents receiving an oral diet. Findings include: Observation on [DATE] at 9:20 a.m. of the dry storage room revealed a bag of seafood flour opened and wrapped with plastic wrap however the plastic wrap was not secure and the opening the bag was exposed. Continued observation revealed an open five pound bag of pasta with no date opened. Interview on [DATE] at 9:20 a.m. with the Certified Dietary Manager (CDM) at the time of observation revealed that she expects dietary staff to wrap, label and date items after opening. Continued interview with the CDM revealed that the evening cook completes a walk through of the dry storage area before leaving and they are to ensure that the dry storage area is clean and food items stored correctly. Observation on [DATE] at 9:30 a.m. of large white storage bins containing bread crumbs, white rice, brown rice, rice flour, and sugar revealed they were located in the food preparation area, near the door to the walk-in refrigerator. The storage bins did not have dates of when the food items were placed in the storage bins. Interview with the CDM at the time of the observation revealed that they have not been dating the storage bins. The CDM did confirm that those bulk food items were removed from the original package. The CDM stated that she had not told dietary staff that they need to date the storage bins. Observation on [DATE] at 9: 35 a.m. of the walk-in refrigerator revealed two, five pound containers of cottage cheese with a use by date of [DATE]; one, five pound container of cottage cheese with a use by date of [DATE]; two, five pound containers of cottage cheese with use by date of [DATE]. Continued observation revealed a one gallon container of Hickory Smoked Barbeque Sauce that was opened with no date. There was a circular clear container that contained corn on a rack in a cart revealed it had a date of [DATE]. Further observation revealed fours stalks of celery that were clean and prepared, wrapped in plastic wrap and not labeled or dated. Interview with the CDM at the time of the observation revealed that the cottage cheese was delivered on the last food delivery and the use by date was not checked. Further interview with the CDM revealed that she excepts staff to date food items after opening. The CDM revealed that cooked protein food items have a three day discard date and with other food items is a seven day discard date after the date that is placed on the food item. Observation on [DATE] at 9:40 a.m. of the walk-in freezer revealed an opened bag of asparagus that was not dated. CDM confirmed at time of observation that it was dated and should have been. Observation on [DATE] at 9:45 a.m. of the stand up refrigerator in the food preparation area, near the grill, revealed an open package of sliced bacon with no date. The CDM confirmed the bacon was not dated and should have been. Observation on [DATE] at 9:47 a.m. of the food preparation table near the coffee machine revealed a set of keys with a pink fob (hardware attached to a set of keys). There were ten pitchers ice tea on the same counter as the key set. Interview with the CDM at the time of the observation revealed she confirmed that the keys were on the food preparation table and expects dietary staff to store personal items in the dietary office. Observation on [DATE] at 9:50 a.m. of the refrigerator with two glass sliding doors near the coffee maker revealed a tray containing stacked 4 ounce containers of apple juice, another tray with stacked 4 ounce containers of prune juice, tray of stacked 4 ounce containers of orange juice, and a tray of stacked 4 ounce containers of cranberry juice with no date. Interview with the CDM at the time of the observation revealed all of the 4 ounce juices are delivered frozen and are thawed for use. The CDM revealed that she at one time had staff date when the juice containers were taken from the freezer and placed in the refrigerator but no longer requires staff to date. When asked how would staff know when the juice would expire after having been thawed and the CDM stated that she did not know. Observation on [DATE] at 1:48 p.m. of the large white bulk storage bins in the food preparation area revealed that the bread crumbs and rice flour continue to have no date. Observation of the white rice, brown rice, sugar all had dates of ,[DATE]. Interview with the CDM at the time of the observation revealed that the bread crumbs and the rice flour were not dated due to the cook unable to recall when items were placed in the bins. Observation on [DATE] at 1:50 p.m. of the walk-in refrigerator revealed a pan of cook flank steak with a date prepared of [DATE] and discard date of [DATE]. Continued observation of the leftover prepared item rack revealed a pan labeled Tomato Basil soup, prepare date of [DATE] and discard date [DATE]. Interview with the CDM at the time of observation revealed that the discard date was written on the grilled flank steak incorrectly and was a mistake. Continued interview with the CDM regarding the Tomato Basil soup she stated will be discarded today, when asked why it was not discarded, she stated that they have not gotten to yet. The CDM stated that staff know not to use, they would look at the date. Review of the policy with subject: Storage of Food and Supply Products date created [DATE], stated Procedures as follow: 4) All food items must be properly covered or tightly wrapped when stored in a refrigerator or freezer. Leftover items should be labeled with the name of the food product, production date and the use by date. 8) Dry storage panty is for foods that are non-perishable, such as canned food, box mixes, flour, sugar, salt, cereals, condiments, etc. Once opened, food that has been stored in dry storage should be either refrigerated or sealed airtight containers or well wrapped with clear wrap. All items should be labeled and dated with date of opening. 12) All left over food items must be properly held following standard procedures: all foods must be wrapped tightly with clear wrap or a container lid. Foods should be labeled with the name of the food item, the date it was prepared, and the use-by date, generally within 3 days for perishable items. Review of the policy with subject: Storage of Personal Items date created: [DATE], revealed policy: The Culinary Team of Pebblebrook will store all personal items away from food production area. Procedures include: 1) Staff must store all personal items in either the department office, a locker or in any designated spot away from food production. 2) Personal items such as cell phones, charges, radios, and keys may not be in the area of food production to avoid the opportunity for cross contamination. Review of as in-service dated [DATE] titled Survey Readiness with purpose of: Prepare for CMS and Health Department revealed 11 dietary staff attended. The Summary of the presentation: discuss recent health inspections. Provide information to all staff to be better prepared for survey. Review of an in-service dated [DATE] with title Label and Date Inservice revealed In addition to labeling, dating items requires special attention, common name of the food, date the food was made, use by date. Brief interview with the CDM when delivered documents stated this in-service was actually conducted on [DATE] with the other in-service for Survey Readiness. Review of an in-service date [DATE] titled Survey Readiness audience: Homemakers/Culinary Staff revealed ten dietary staff attended and Topics Covered: all items in refrigerators must be labeled and dated, discard expired and out of date items daily. Surveyors will visit kitchens first and will be unannounced-they will check cleanliness, dating, documentation, and labeling.

Based on record review and staff interviews, the facility failed to ensure that yearly dementia care in-services were provided to the Certified Nursing Assistants (CNA). The facility census was 54 residents. Findings include: During interview with the Director of Nursing (DON) on 9/01/18 at 4:30 p.m., she stated that there was no in-services for dementia care. Record review of the In-service notebook revealed that there was not any evidence that the facility had provided any in-services regarding Dementia Care. Interview on 9/2/18 at 8:24 a.m. with CNA II revealed that she has worked for this facility approximately [AGE] years and that she cannot remember if she has had an In-service regarding dementia care. Interview on 9/2/18 at 12:15 p.m. with CNA KK revealed that she has been working for the facility since (MONTH) (YEAR) and that during her orientation they had had in-services regarding contact precaution wearing gloves and how to use the glucometer but that CNA KK could not recall an inservice regarding how to dementia care.