Every finding on record at San Francisco Post Acute

Based on observation, interview and record review the facility did not ensure one freezer temperature in the kitchen was within acceptable range, and one kitchen aid was competent to use the green and red bucket for cleaning kitchen surfaces when:The freezer temperature was 25.4 F The Kitchen Aid did not know how to clean the 3-sink compartment surface with the green and red buckets.These practices have the potential to promote bacterial growth to foods in the freezer, while inadequate cleaning in the kitchen will contaminate food preparation areas resulting to food borne illnesses to the residents in the facility. 1. During the initial tour in the kitchen on 8/24/26 at 9:25 AM with the Dietary Manager (DM) observed the freezer's temperature outside the freezer was 25.4 F. Inside the freezer the thermometer gauge reads 30 F. During an interview with the DM he stated there are meat and dairy products inside. They just opened this freezer, that's why the temperature is high. Let us wait a few more minutes and it will come down. Around 9:50 AM observed the maintenance personnel coming out of the kitchen stating the freezer is fixed.During a review of the facility's policy and procedure titled Refrigerators and Freezers dated 2001, it indicated: Policy Statement. This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The policy interpretation and implementation indicated: 1. Refrigerators and/or freezers are maintained in good working conditions. #3. Monthly tracking sheets include time, refrigerator temperature, temperature of PHF/TCF food, initials, and action taken . #4. Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.Review of Food and Drug Administration Food Code dated 2022 indicates Technical Requirements: The Freezer shall: Have a temperature range at least as wide as -50 C to -86 C (-45.6 F to -65.6 F). General Safe Range: Between -10 F and 0 F (-23 C to -18 C) keeps food safely frozen and protects texture and flavor.2. During a concurrent observation and interview on 8/26/26 at around 10:27 AM observed kitchen aid (KA1) washing the dishes through the washing machine. KA1 stated the three sink compartments are used only for emergencies. Observed the 2 red buckets inside the third sink. KA1 stated I am the one using green and red buckets. I clean when I first come in and . KA1 was asked to demonstrate how he uses the green and red buckets by cleaning just the last surface of the 3 compartment sinks. Observed the DM pour the red bucket water, rinse it and refill the bucket from tube connected to a container of solution on the wall above the sink. The DM stated the company premixes the solution when we receive it. KA1 checked the sanitizer concentration with the strip stating this one I checked for 10 seconds. Observed the green bucket is sitting above the first compartment of the sink. KA1 started to demonstrate cleaning using the red bucket with a washcloth and then stopped. He did not look at or use the green bucket. The DM was asked and he stated, actually the green bucket should be used first, and then the red bucket. I will review the process with him and give him an in-service.During a review the facility's policy and procedure titled: Sanitation with revision date of 2008 indicated: Policy Statement - The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation indicates: 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soil by using manual or mechanical means necessary and sanitized using hot water and or/chemical sanitizing solutions. #6. Between uses, cloth and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least once per shift or if solution becomes cloudy or visibly dirty. #17. The Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. During a review of the facility's policy and procedure titled: Cleaning and Sanitizing - Basics. Infection Control, Nutrition Ink/Nutricopia, dated 2023 indicates: Clean and sanitize in place method (for large food service equipment and worktable surfaces) 1. Clean items with warm water and detergent (green bucket), 2. Rinse with clear warm water. 3. Sanitize surfaces (Red bucket) with chlorine solution containing at least 100 ppm .

Based on observation, interview, and record review, the facility failed to ensure that one out of 13 residents (Resident 35) was free from abuse when the facility did not recognize, report, assess, or follow up on repeated allegations and documented incidents involving physical contact, yelling, screaming, and disruptive behaviors from a roommate (Resident 32). These failures resulted in ongoing fear, sleep disruption, and psychosocial distress for Resident 35.During an observation on 08/24/2026 at 10:59 AM in the shared room of Resident 32 and Resident 35, Resident 32 began yelling and screaming when the surveyor entered the room. Staff used a phone to contact an individual who could communicate with Resident 32, as Resident 32 does not speak English, in an effort to determine the cause of the distress. Resident 35 was observed yelling in Spanish toward Resident 32, telling them to stop yelling, each time Resident 35 vocalized. Resident 32 spoke with the individual on the phone and subsequently stopped yelling. During the episode of yelling and screaming, Resident 32 was observed removing the blanket from over their feet and independently moving from a lying position to sitting up. Resident 32's bed was in the lowest position, and Resident 32 was able to sit upright on the side of the bed while speaking on the phone During a concurrent observation and interview on 08/24/2026 at 12:05 PM in the shared room of Resident 32 and Resident 35, Resident 35 appeared visibly stressed and stated they have been experiencing increased stress due to Resident 32's frequently yelling. Resident 35 reported being unable to sleep at night because of the ongoing disturbances and expressed a desire for the facility to move Resident 32 to another room. During the interview, Resident 32 was observed yelling and screaming.During an observation on 08/24/2026 at 12:30 PM in the shared room occupied by Resident 32 and Resident 35, Resident 32 was yelling and screaming, and Resident 35 appeared visibly disturbed by the behavior.During a concurrent observation and interview on 08/24/2026 at 1:03 PM in the shared room of Resident 32 and Resident 35, Resident 32 was again observed yelling and screaming while the surveyor was interviewing Resident 35. Resident 35 was visibly distressed. Resident 35 stated that they have informed staff that Resident 32's yelling and screaming disturb them, but reported that the facility has not taken any action. During the interview, staff entered the room to attend to Resident 32, but did not attend to Resident 35. Resident 35 further stated that at night, Resident 32 wakes them by pulling on their shirt, which has frightened them and caused their heart to race. Resident 35 added that they are unable to sleep at night because Resident 32 yells and screams unpredictably.During an interview on 08/26/2026 at 9:46 AM with Resident 35 in the shared room occupied by Resident 32 and Resident 35, Resident 35 stated that Resident 32 moves the curtain back and forth and talks throughout the night, preventing them from sleeping. Resident 35 stated they can only sleep when Resident 32 is asleep but still feel nervous. Resident 35 reported that Resident 32 has pulled their blanket, hair, and legs, and that they sometimes cannot sleep because they fear Resident 32 will touch them. Resident 35 stated they feel embarrassed to report these issues and stay quiet to avoid bothering staff. Resident 35 stated the situation causes them stress, and they cannot remember when Resident 32's yelling and screaming began, but that it keeps them from sleeping or resting. Resident 35 stated they have always been in this room and like its proximity to the nurse's station, but that staff have ignored their reports. Resident 35 stated they would feel safer if Resident 32 were moved to another room.During a telephone interview on 08/26/2026 at 10:11 AM with Family Member 1 (FM 1) for Resident 32, FM 1 stated that Resident 32 has dementia, believes they are at home and not in the facility, and has only short term memory. FM 1 stated that Resident 32 is protective of their belongings. During an interview on 08/26/2026 at 10:30 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated they were assigned to Resident 32 that day and last cared for Resident 32 about a month ago. CNA 1 stated Resident 32 has dementia and alternates between being calm and yelling, and at times becomes upset when a new roommate enters the room. CNA 1 stated Resident 32 is very possessive of their belongings and often requires reassurance so staff can provide care to the other two residents in the room. CNA 1 stated the facility implemented fall prevention measures and instructed staff to be patient and meet Resident 32's needs. CNA 1 reported their last dementia training was in July 2026 and included guidance on avoiding agitation, giving residents space, and exercising patience. CNA 1 stated Resident 32's yelling sometimes continues while the roommates sleep, and only one of the roommates is alert. CNA 1 stated Resident 32 was moved to the current room in July 2026 due to fall risk precautions. CNA 1 stated Resident 35 has not directly reported concerns but has told Resident 32 to shut up in Spanish during episodes of yelling, and CNA 1 believes Resident 35 is bothered by the noise. CNA 1 added they sometimes bring Resident 32 out of the room to avoid agitating the roommates. CNA 1 stated they were not aware Resident 32 had pulled on Resident 35's person and had only observed Resident 32 pulling the curtain, but confirmed Resident 32 picks on Resident 35. CNA 1 stated Resident 35 has told staff that Resident 32 tries to open their curtain and frequently tells Resident 32 to shut up in Spanish.During an interview on 08/26/2026 at 10:52 AM with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated they have been assigned to Resident 32 daily for more than two months. LVN 1 stated they have heard Resident 32 scream at times and believe Resident 32 becomes jealous when other residents complete their activities of daily living. LVN 1 stated Resident 32 does not yell during medication administration. LVN 1 stated Resident 32 has been yelling for about one and a half weeks and has expressed wanting to go home. LVN 1 confirmed, after reviewing the record, that Resident 32 has dementia. LVN 1 stated Resident 32 requires attention when yelling and screaming and that CNAs stay with Resident 32 to calm them. LVN 1 confirmed CNAs have reported Resident 32's yelling. LVN 1 stated Resident 32 typically yells in the mornings, after 10:00 AM, or after breakfast. LVN 1 stated Resident 32's roommate Resident 35 has not complained and CNAs have not reported concerns regarding Resident 35. LVN 1 stated Resident 32 was moved to the current room on 06/23/2026.During an interview on 08/27/2026 at 9:09 AM with the Director of Nursing (DON), the DON was asked whether behavioral health care had been provided to Resident 32 in response to the yelling and screaming. The DON confirmed that the facility did not provide behavioral health care for Resident 32 and that Resident 32 received only regular medical visits. The DON stated that Resident 32 had previously been in another room but was moved to the current room-shared with Resident 35 and another resident on hospice-due to Resident 32's fall risk. The DON stated that Resident 32 does not want anyone touching their belongings and that Resident 32 will scream if someone approaches their area. The DON was asked if they were aware that Resident 32 had been pulling on Resident 35. The DON stated they were not aware of this, had not witnessed it, and had not seen Resident 32 go toward Resident 35. The DON added that licensed nurses had not reported any incidents of Resident 35 being pulled by Resident 32 and that no complaints had been received from Resident 35. The DON was asked whether licensed nurses had checked on Resident 35 regarding how they were doing with the yelling and screaming from Resident 32. The DON stated they would check with the licensed nurses after the interview and added that the DON would address the matter immediately if any complaints had been received. The DON confirmed that there were no notes in Resident 35's chart regarding any disturbances caused by Resident 32. The DON stated that Resident 32 had been moved between rooms four times-on 06/18/2026, 06/23/2026, 07/10/2026-and on 07/31/2026 was moved to the current room shared with Resident 35 and another resident on hospice.During a concurrent interview and record review on 08/27/2026 at 9:09 AM with the DON, the Change in Condition Note for Resident 32 dated 08/14/2026 at 3:52 PM was reviewed. The Change in Condition Note indicated that at around 1:00 PM on 08/14/2026, Resident 32 was shouting and disturbing roommates. The Note documented that Resident 32 pulled the blanket off Resident 35 and continued shouting. The Licensed Nurse (LN) and Certified Nursing Assistant (CNA) attempted to stop Resident 32 but were not successful. The Change in Condition Note further stated that at 2:30 PM, Resident 32's physician was notified and advised staff to attempt de-escalation, calm Resident 32, and, if possible, transfer Resident 32 to a quiet room while avoiding crowding. The Note added that Family Member 1 (FM 1) for Resident 32 was contacted and asked to come to the facility to assist in calming Resident 32.During a concurrent interview and record review on 08/27/2026 at 9:09 AM with the DON, the Interdisciplinary Team (IDT) Note for Resident 32 dated 08/15/2026 at 1:46 PM was reviewed. The IDT Note, identified as a draft, indicated that on 08/14/2026 between 12:00 PM and 1:00 PM, Resident 32 experienced an episode of agitation during which Resident 32 was observed screaming, yelling, and kicking staff. The IDT Note stated that despite attempts at de-escalation and redirection, Resident 32 remained agitated and refused assistance from the licensed nurse (LN) and the Certified Nursing Assistant (CNA) to return to bed. The IDT Note further indicated that the LN contacted Family Member 1 (FM 1) of Resident 32 to speak with Resident 32 in an effort to calm them. The Note added that Resident 32 became severely agitated, approached Resident 35's bed, and removed Resident 35's blanket. The IDT Note documented that a drink had spilled on Resident 35's floor, which caused Resident 32 to become upset and begin yelling at Resident 35 and Resident 35's visitor. The LN again contacted FM 1 of Resident 32 and requested they come to the facility in person to assist in calming Resident 32. The IDT Note further stated that Resident 32's physician was aware of the incident and advised that Resident 32 be moved to a quiet room if possible. The IDT Note also documented that Resident 32 is a fall risk due to continuous attempts to stand without assistance, and therefore Resident 32 was assigned to a bed near the nursing station for ongoing monitoring. After reviewing the IDT Note with the DON, the DON was asked whether any follow-up was completed with Resident 35, Resident 32's roommate. The DON confirmed that there were no notes for Resident 35 related to the incident that occurred on 08/14/2026.During a review of the Behavior Note for Resident 32, dated 06/19/2026 at 4:44 AM, the Note indicated that Resident 32 was very combative and agitated with staff. The Behavior Note added that Resident 32 attempted to leave their bed and screamed and yelled. The Note indicated that the licensed nurse (LN) called Family Member 1 (FM 1) for Resident 32, and FM 1 attempted to speak with Resident 32 in Chinese to assist in calming them. The Behavior Note stated that FM 1 informed staff that Resident 32 was confused and upset, and added that FM 1 might come to the facility later in the afternoon or morning to help. At the time the Note was written, Resident 32 was in a wheelchair near the nurses' station for safety. A follow up Change in Condition Note or an Interdisciplinary Team (IDT) Note had not been written after this incident.During a review of the 72-Hour Nursing Progress Note for Resident 32, dated 06/22/2026 at 4:16 PM, the 72-Hour Nursing Progress Note indicated Resident 32 had screaming and yelling episodes, and that Family Member 1 (FM 1) for Resident 32 was at the bedside. During a review of the Behavior Note for Resident 32, dated 08/09/2026 at 2:11 AM, the Note indicated that Resident 32 had uncontrollable agitation. The Behavior Note added that Resident 32 has a language barrier, and the licensed nurse (LN) called an interpreter to assist in calming Resident 32. The Note further indicated that another LN from a different section of the facility also assisted in speaking with Resident 32. The Behavior Note documented that Resident 32 believed someone had stolen their money or personal items. The Behavior Note stated that Resident 32 requested that staff leave them alone, closed the door, and did not allow staff to reopen it. The Note added that staff explained the door needed to remain open at all times for safety, but Resident 32 did not comply and yelled. The Behavior Note indicated that staff attempted to call Family Member 1 (FM 1) for Resident 32, but there was no answer. The Note documented that Resident 32's physician was contacted and recommended that the Director of Nursing (DON) be called instead. The Behavior Note indicated that at the time the entry was written, Resident 32 had fallen asleep, and staff would continue close monitoring. A follow up Change in Condition Note or an Interdisciplinary Team (IDT) Note had not been written after this incident.During a review of the 72-Hour Nursing Progress Note for Resident 32, dated 08/15/2026 at 11:29 PM, the 72-Hour Nursing Progress Note indicated that Resident 32 continued to exhibit agitation and that extended periods of time and staff were required to redirect Resident 32. The 72-Hour Nursing Progress Note added that periodic visits and phone calls from Family Member 1 (FM 1) appeared to help. The 72-Hour Nursing Progress Note further indicated that nursing staff would continue to position Resident 32 near the nursing station for close monitoring.During a review of the 72-Hour Nursing Progress Note for Resident 32, dated 08/16/2026 at 1:55 PM, the Note indicated that Resident 32 continued to exhibit sporadic agitation and that extended periods of time and staff were required to redirect Resident 32. The 72-Hour Nursing Progress Note added that independent quiet activities had been helpful for Resident 32. The Note further indicated that nursing staff would continue to position Resident 32 near the nursing station for close monitoring.During a review of all Nursing Progress Notes for Resident 35, dated between 03/27/2026 to 08/22/2026, the all Nursing Progress Notes indicated there was no mention of the incident on 08/14/2026 between 12:00 PM and 1:00 PM involving Resident 32 and Resident 35. The Nursing Progress Notes for Resident 35 did not include notes that addressed Resident 32 becoming severely agitated, approaching Resident 35's bed, and removing Resident 35's blanket. The Nursing Progress Notes also did not include documentation that Resident 35 had spilled their drink on the floor that caused Resident 32 to become upset and begin yelling at Resident 35 and Resident 35's visitor. In a previous interview with the DON, the DON confirmed that there were no notes for Resident 35 related to the incident that occurred on 08/14/2026.During a review of the Care Plan for Resident 32, dated 08/25/2026, the Care Plan indicated a focus area related to Resident 32's psychosocial behavior, including striking out and yelling associated with dementia and a history of encephalopathy, which was initiated on 08/24/2026. There were no prior updates to Resident 32's Care Plan related to Resident 32's yelling or screaming behaviors.The facility's policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, last revised 2022, requires that all allegations of abuse, neglect, exploitation, misappropriation of resident property, or injuries of unknown origin be immediately reported to the administrator and to required state and federal agencies. The policy specifies that reports must be made within two hours when abuse or serious bodily injury is alleged, and within 24 hours for all other allegations. It further directs the administrator or reporting individual to notify the state licensing agency, ombudsman, resident representative, adult protective services (as applicable), law enforcement, the attending physician, and the facility medical director. The administrator is responsible for determining and implementing necessary protective measures upon receiving any allegation.

Based on observation, interview and record reviews, the facility did not ensure Resident 47 was provided with dignified care when: CNA 4 was observed standing over the resident at her bedside while feeding her, her lunch.This failure to care for Resident 47 with respect and dignity was not met and will have the potential to have a negative effect on the resident's safety and wellbeing.During a concurrent observation and interview on 8/26/26 at 12:10 PM with CNA 4 at the entrance of Resident 47's room, CNA 4 stated I will be the one to feed resident 47. First, I wash my hands and put on the gown. Observed CNA 4 took a yellow disposable gown from an isolation box drawer outside the door of Resident 47's room and stated yes, I use a gown when feeding a patient. No gloves. Next, she knocked on the door and informed the resident she was going to feed her lunch. Observed the lunch tray is already on the table across the resident's bed. Resident 47 was awake but nonverbal with a blank facial expression. At 12:15 PM observed a male visitor came in who stated husband when greeted. He is Chinese speaking and understands a little English. CNA 4 placed a bib on the resident's chest. Observed no extra chair around the resident's bed. CNA 4 stood on the left side of the resident's bed, took the bed control and stated then, I raised the bed according to my height to feed the resident. CNA 4 started feeding Resident 47 with pureed food while standing. Observed Resident 47 was not opening her mouth.During an interview with CNA 4, she stated yes, I don't sit while feeding the patient I will get back to you to confirm that. The resident's husband was nodding his head when explained that the feeder must be sitting at the resident's level at mealtimes to make her feel safe, comfortable, secure and dignified.During an interview with the Director of Staff Development (DSD- plan, direct, or coordinate the training and development activities and staff of an organization) on 8/26/26 at around 1:05 PM by the nurses' station she stated no, the feeder doesn't need to wear a disposable gown while feeding a resident. The resident is not in isolation. She must be sitting while feeding the resident.During a review of the facility's policy and procedure (P&P) titled: Assistance with Meals (C) 2001, the policy statement indicates: Resident shall receive assistance with meals in a manner that meets the individual needs of each resident. The policy interpretation and implementation of this P&P indicate: Residents requiring full assistance: #2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity. For example: a. not standing over residents while assisting them with meals. All Residents: 3. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling.During a review of P&P titled: Dignity (C) 2001, the policy statement indicated: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life and feelings of self-worth and self-esteem. The policy interpretation and implementation indicate: 1. Residents are treated with dignity and respect at all times. #2. The facility supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. #5. When assisting with care, residents are supported in exercising their rights. For example, residents are: .e. provided with a dignified dining experience. #13. Staff are expected to treat cognitively impaired residents with dignity and sensitivity.

Based on observation, interview and record review the facility did not ensure a safe, sanitary and comfortable environment to help prevent the transmission and spread of communicable diseases and infections when a certified nurse assistant (CNA) did not implement hand hygiene between tasks while feeding Resident 1.Failure to implement infection control practices will promote a widespread substandard transmission-based precaution that will result in added health risk to the residents of the facility.During observation, interview and record review on 8/26/26 at 12:20 PM in Resident 1's room, observed Resident 1 was sleeping but easily arousable when CNA 3 came in to feed him his lunch. Both Resident 1's hands with uncontrollable movements. CNA 3 brought in his tray and informed him his lunch was ready. CNA 3 sanitized her hand, positioned the resident, put the bib on the resident's chest, unfolded the chair and sat at the resident's level. Resident 1 stated my back is too high. CNA 3 stood up, folded the chair and went around the bed, held the bed control and adjusted the head of the bed. CNA 3 went back to the right side of resident 1's bed, unfolded the chair, sat down and started feeding Resident 1. During an interview with CNA 3 she stated, yes, I should have used the sanitizer again after adjusting the head of the bed and folding and unfolding my chair.During an interview with the Director of Staff Development (DSD- plan, direct, or coordinate the training and development activities and staff of an organization) on 8/26/26 at 12:30 PM in the hallway, the DSD stated that's infection control. I will give them another in-service on hand hygiene.During a review of Resident 1's admission record it indicates his diagnoses includes: Atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls) of native arteries on left leg with ulceration of other parts of the foot; sepsis (is a serious condition in which the body responds improperly to an infection); encephalopathy (a disturbance of brain function. It causes confusion, memory loss and coma in severe cases); urinary tract infection (UTI- occurs when bacteria enter the urinary tract through the urethra and begin to spread in the bladder); bacteremia (is when you have bacteria in your blood), among his many diagnoses. During a review of Resident 1's minimum data set (MDS - a powerful tool for implementing standardized assessment and for facilitating care management in nursing homes) his brief interview for mental status score (BIMS - is a 15-point cognitive screening measure that evaluates memory and orientation and includes free and cued recall items) was 00 indicating the interview was not conducted because the resident is rarely/never understood.During a review of the facility's policy and procedure titled: Infection Prevention and Control, dated 2001, with its policy statement: The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections.Review of the facility's policy and procedure titled: Assistance with Meals, dated 2001, indicates: Policy Interpretation and Implementation indicates: Residents Requiring Full Assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity.All Residents: #3. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in prevention of foodborne illnesses, including personal hygiene practices and safe food handling. The policy included procedures for washing hands and applying alcohol-based hand rubs.

Based on observation, interview, and record review, the facility failed to follow disinfection protocols for reusable items which includes durable medical equipment (DME - equipment that is used for a medical purpose, is used in the home, and is expected to last at least three years) for three out of three residents (Residents 18, 29, and 41). This failure puts residents at risk for cross contamination and the possible spread of infection among residents. Findings: During a continuous observation on 12/8/24 from 8:55 a.m. to 9:25 a.m. on unit B, with Registered Nurse 1, (RN1) was observed taking Resident 29's blood pressure, then Resident 41's blood pressure, and finally Resident 18's blood pressure. Each time, RN1 did not disinfect the blood pressure cuff prior to taking the residents' blood pressures. During an interview on 12/09/24 at 1:50 p.m., with RN1, she was unclear about the facility's policy and procedure (P&P) regarding disinfecting resident care equipment, and offered no explanation. RN1 stated she would have to check with the Director of Nursing (DON) & check the P&P. During concurrent interview and record review on 12/10/24 at 2:30 p.m. with the Executive Assistant, the facility policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated July 2014, indicated 1. d. Reusable Items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). The Executive Assistant stated that DME includes bp cuffs

Based on observation, interview and record review, the facility failed to implement pain care plan for 1 of 14 sampled residents (Resident 38) when there was no evidence of pain assessment. This failure had the potential for not meeting Resident 38's nursing needs and goals to attain the resident's highest practicable well-being. Findings: Review of Resident 38's clinical record indicated, Resident 38 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of left femur (broken left thigh bone), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hyperlipidemia (high cholesterol). Review of Resident 38's Minimum Data Set (MDS, resident assessment tool) dated 10/2/24 indicated, Resident 38 was cognitively intact. During a concurrent observation and interview on 12/8/24 at 12:09 p.m., with Resident 38 in front of his room in hallway, he pointed to his abdomen while speaking in Chinese when asked if he had a pain. During a concurrent interview and record review on 12/8/24 at 12:11 p.m., with Registered Nurse (RN) 1, RN 1 stated, she gave Colace (a stool softener) and Miralax powder (an osmotic laxative, a medication that draws water into the stool to soften it and make it easier to pass) to Resident 38 for his abdominal discomfort. But she did not show the evidence of pain assessment of Resident 38 when asked. During a concurrent interview and record review on 12/9/24 at 2:42 p.m., with RN 1, RN 1 still did not show the evidence of pain assessment of Resident 38 when asked again. During an interview on 12/9/24 at 2:44 p.m., with Director of Nursing (DON), DON stated, every shift needs to assess pain when asked. Review of Resident 38's pain care plan initiated on 6/28/23 indicated, . Assess pain every shift and as indicated . During a concurrent interview and record review on 12/10/24 at 2:39 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 38's medication administration record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated December 2024 was reviewed. LVN 1 verified, there was no pain assessment until the night shift on 12/9/24. LVN 1 stated, the facility has 3 shifts which are day, evening, and night shift. LVN 1 stated, Every shift and as needed when asked about the facility's policy and procedure (P&P) regarding pain assessment. Review of the facility's P&P titled, Pain Assessment and Management dated October 2022 indicated, . Assessing Pain . 4. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level . Review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered dated March 2022 indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is . implemented for each resident .

Based on observation, interview and record review, the facility failed to meet professional standards of quality when the facility did not follow doctor's order regarding oxygen for one of 2 sampled residents (Resident 8). This failure could potentially result in negative outcomes for Resident 8. Findings: Review of Resident 8's clinical record indicated, Resident 8 was admitted to the facility with diagnoses including spinal stenosis (the spaces inside the bones of the spine get too small), acute respiratory failure with hypoxia (a serious medical condition that occurs when there is not enough oxygen in the body's tissues), chronic obstructive pulmonary disease (COPD, a lung disease that makes breathing hard), and hypertension (high blood pressure). Review of Resident 8's Minimum Data Set (MDS, resident assessment tool) dated 11/16/24 indicated, Resident 8 was cognitively moderately impaired. Review of Resident 8's H&P (history and physical, a formal assessment of a resident that includes a review of their medical history, a physical exam, and a summary of any tests) dated 11/14/24 indicated, . with history of CHF (congestive heart failure, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), COPD . She used to use home O2 as needed for shortness of breath . she was given . Lasix (diuretic that can treat fluid retention called edema and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) and duonebs (a combination of two medicines called bronchodilators to treat COPD. It works by opening your airways and reducing inflammation in your lungs to help you breathe) on admission with significant improvement and remained stable on room air . During an observation on 12/8/24 at 10:26 a.m., in Resident 8's room, Resident 8 was on oxygen (O2) at 3.5 liters per minute (LPM or L/min, a unit that expresses flow rate) via nasal cannula (a medical device that provides supplemental oxygen to a resident through their nose). Resident 8 did not have shortness of breath (SOB). During a concurrent observation and interview on 12/8/24 at 10:42 a.m., with Registered Nurse (RN) 1 in Resident 8's room, Resident 8 was still on O2 at 3.5 liters per minute. RN 1 stated, the doctor's order was 1-2 liters per minute as needed when asked, then she decreased oxygen from 3.5 to 3 liters per minute. During a concurrent interview and record review on 12/8/24 at 10:45 a.m., with RN 1, the doctor's order titled, Order Details was reviewed. The order details indicated, . CONTINUOUS O2 @ 1-2 LPM VIA NASAL CANNULA PER CONCENTRATOR/TANK TO KEEP O2 SAT (oxygen saturation level, a measurement of how much oxygen the blood is carrying as a percentage) >90% as needed for SOB/COPD . RN 1 did not answer when asked about O2 Sat of Resident 8 in her shift. She acknowledged, O2 was not administered as the doctor's order. During a concurrent interview and record review on 12/8/24 at 11:52 a.m., with Director of Nursing (DON), Resident 8's O2 Sats were reviewed. The O2 Sats indicated, 95% at room air on 12/8/24 at 5:42 a.m., and 96% at 3 liters per minute on 12/8/24 at 10:51 a.m. DON did not answer why Resident 8 was on O2 at this time when asked. During a concurrent interview and record review on 12/10/24 at 1:43 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 8's clinical records were reviewed. LVN 1 stated, There is none unfortunately why they increased it when asked why they applied O2 at 3.5 liters per minute to Resident 8 on 12/8/24 after O2 Sat 95% at room air on 12/8/24 at 5:42 a.m. During an interview on 12/12/24 at 9:47 a.m., with DON, DON acknowledged, O2 at 3.5 liters per minute was a bit of high amount for COPD (For residents with COPD, high oxygen levels is generally considered not recommended and can be harmful, as the target oxygen saturation level for most COPD residents should be between 88% and 92% to avoid complications like oxygen-induced hypercapnia- a condition that occurs when supplemental oxygen increases blood carbon dioxide (CO2) levels in residents with COPD or other conditions that cause chronic hypercapnia), and RN 1 should have followed the doctor's order. Review of Resident 8's care plan indicated, . Monitor oxygen saturation via pulse oximetry (a painless, noninvasive test used to measure the oxygen saturation of the blood) . Review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered dated March 2022 indicated, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is . implemented for each resident . Review of the facility's policy and procedure (P&P) titled, Oxygen Administration dated 2001 indicated, . 1. Verify that there is a physician's order for this procedure. Review the physician's order .

Based on interview, and record review, the facility failed to ensure Resident 25 was free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic [a type of psychiatric medication which are available on prescription to treat psychosis]; (ii) Anti-depressant [prescription medicines to treat depression]; (iii) Anti-anxiety [drugs used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress]; and (iv) Hypnotic [a class of drugs that induce or prolong sleep in people with sleep disorders and are intended to improve the overall quality of sleep]) when: 1.There was no evidence of non-pharmacological intervention for Aripiprazole (antipsychotic), Bupropion (antidepressant), Lorazepam (antianxiety), and Mirtazapine (antidepressant) for Resident 25 2. There was no targeted behavior of Lorazepam for Resident 25. 3. There was no evidence of specific behavioral monitoring for Lorazepam for Resident 25. 4. There is no specific indication for Mirtazepine for Resident 25. These failures could result in unnecessary use of, ineffective and/or lack of monitoring or interventions for psychotropic medications that could negatively affect the residents' highest practicable mental, physical and psychosocial well-being. Findings: Review of Resident 25's clinical record indicated, Resident 25 was admitted to the facility with diagnoses including low back pain, depression (mental health condition that involves a low mood or loss of interest in activities for a prolonged period of time), and PTSD (Post Traumatic Stress Disorder, an anxiety problem after seeing or having a traumatic event). Review of Resident 25's Minimum Data Set (MDS, resident assessment tool) dated 11/6/24 indicated, Resident 25 was cognitively moderately impaired. Review of the document titled, Resident Matrix (a form used by the facility to list all current residents and to note pertinent care categories) dated 12/9/24 indicated, Resident 25 was on antianxiety, antidepressant, and antipsychotic medications. Review of Resident 25's doctors order titled, Order Details dated 11/4/24 indicated, . ARIPiprazole (an antipsychotic medication) Oral Tablet 20 MG (Milligram) . Give 1 tablet by mouth one time a day . Review of Resident 25's doctors order titled, Order Details dated 11/4/24 indicated, . buPROPion (an antidepressant medication) . Oral Tablet Extended Release 24 Hour 300 MG . Give 1 tablet by mouth one time a day . Review of Resident 25's doctors order titled, Order Details dated 11/4/24 indicated, . Mirtazapine (an antidepressant medication) Oral Tablet 15 MG . Give 1 tablet by mouth at bedtime . Review of Resident 25's doctors order titled, Order Details dated 12/4/24 indicated, . LORazepam (an antianxiety medication) Tablet 0.5 MG . Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 Days . During a concurrent interview and record review on 12/10/24 at 10:02 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, No when asked if there was the evidence of non-pharmacological intervention for Resident 25 regarding Aripiprazole, Bupropion, Lorazepam, and Mirtazapine. LVN 1 stated, Unfortunately we don't have a target behavior when asked if there were targeted behaviors for Resident 25 regarding Lorazepam. LVN 1 stated, No. There was not when asked if there was the evidence of behavioral monitoring for Lorazepam for Resident 25. LVN 1 stated, Not in the order when asked if there were the specific indications for Mirtazepine for Resident 25. Review of the facility's policy and procedure (P&P) titled, Psychotropic Medication dated December 2019 indicated, . The facility supports the goal for using psychotropic medications appropriately . 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications . 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident .

Based on observation, interview and record review, the facility failed to ensure communication services were provided for one of 6 sampled residents (Resident 38) who spoke in his native language when there were no interpreter services for Resident 38 on Sunday (12/8/24). This failure has the potential for Resident 38 not to understand and carry out activities of daily living (ADL) to attain the resident's highest practicable well-being. Findings: Review of Resident 38's clinical record indicated, Resident 38 was admitted to the facility with diagnoses including displaced intertrochanteric fracture of left femur (broken left thigh bone), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and hyperlipidemia (high cholesterol). Review of Resident 38's Minimum Data Set (MDS, resident assessment tool) dated 10/2/24 indicated, Resident 38 was cognitively intact. During an interview on 12/8/24 at 11:58 a.m., with Son of Resident 38 via phone, Son stated, Resident 38 speaks Cantonese, Mandarin, and Chinese and does not speak English well. Son stated, Resident 38 had abdominal discomfort. During a concurrent observation and interview on 12/8/24 at 12:09 p.m., with Resident 38 in front of his room in hallway, he pointed to his abdomen while speaking in Chinese when asked if he had a pain. During a concurrent interview and record review on 12/8/24 at 12:11 p.m., with Registered Nurse (RN) 1, RN 1 stated, they are using Chinese-speaking staff or a Chinese-translated book when asked how they can communicate with Resident 38. RN 1 stated, the Chinese speaking staff was off today (Sunday) and she did not know where the book was when asked if interpreter service was available for Resident 38 today which was Sunday. During an interview on 12/9/24 at 2:06 p.m., with Business Office Manager (BOM), BOM stated, Resident 38 speaks Cantonese, and she helps translate when Resident 38 uses Cantonese. BOM stated, Resident 38's abdominal discomfort was due to bowel movements. BOM stated, she works from Monday to Friday. BOM stated, she did not know when asked whether staff use interpreter services on Sundays or nights for Resident 38. During a concurrent interview and record review on 12/9/24 at 2:15 p.m., with RN 1 and BOM, CHINESE COMMUNICATION BINDER was reviewed. The binder indicated, images of health issues, home assist/items, food, utensil, appliances, etc. RN 1 acknowledged, she did not use the binder because she did not know where it was. During an interview on 12/9/24 at 2:21 p.m., with Resident 38, with translation assistance from BOM, Resident 38 stated, he did not like the new binder titled, CHINESE COMMUNICATION BINDER because he was not used to it and the binder had so many pages. Resident 38 stated, he prefers the old binder because that was simple. During an interview on 12/12/24 at 9:45 a.m., with Director of Nursing (DON), DON stated, they should use another Chinese-speaking CNA, binder, or Google interpreter services when asked what to do with Chinese speaking residents on Sundays or at night. DON stated, it is important for residents to communicate in their own language. Review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, dated March 2021 indicated, . 1. The resident's individual needs and preferences are accommodated to the extent possible .

Based on interview and record review, the facility failed to provide, one of three sampled residents (Resident 1), Resident 1's representative with the 7-Day Bed-hold written notice at the time of transfer or within 24 hours of Resident 1's emergency transfer to a higher level of care on [DATE]. This failure resulted in a facility-initiated discharge on [DATE] for Resident 1. Findings: During a review of Resident 1's Summary for Providers, the Summary indicated that Resident 1 had an emergency transfer to the hospital on [DATE], due to a change of condition (COC). During a review of Resident 1's face sheet (FS), the FS indicated that Resident 1 was admitted to the facility on [DATE] and discharged on [DATE] (7 days after an emergency transfer due to a COC). During a concurrent interview and record review on [DATE] at 4:20 PM with Executive Assistant (EA), the EA was unable to locate documented evidence to show Resident 1's representative was provided with the 7-Day Bed-hold written notice at the time of transfer on [DATE] or within 24 hours. The EA verified that Resident 1 was discharged from the facility on [DATE]. The EA stated the facility's social worker should have provided the 7-Day Bed-hold written notice at the time of transfer on [DATE] or within 24 hours. During a concurrent interview and record review on [DATE] at 9:33 AM with Director of Nursing (DON), DON stated that Resident 1's representative was not provided with the 7-Day Bed-hold written notice at the time of transfer on [DATE] or within 24 hours. Review of facility policy and procedure titled Bed-Holds and Returns, dated [DATE], indicated that, 1. All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization s or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g. in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours) . 3. Multiple attempts to provide the resident representative with notice 2 should be documented in cases where staff were unable to reach and notify the representative timely . 7. Residents who seek to return to the facility after the state bed-hold period has expired . are allowed to return . provided that the resident: a. still requires the services provided by the facility; and b. is eligible for Medicare skilled nursing facility or Medicaid nursing facility services . 9. If the facility determines that a resident cannot return, the facility must comply with the requirements for facility-initiated discharges .

Based on observation, interview, and facility document review, the facility failed to maintain the kitchen free of pests. This failure had the potential to result in contamination of food and utensils used by residents leading to pest related disease and/or illness for 51 residents who received food from the kitchen out of a facility census of 51. Findings: An observation and concurrent interview with Dietary Supervisor 1 (DS1), Dietary Supervisor 2 (DS2), and the Maintenance Supervisor (MS) on 10/2/23 at 9:50 a.m., showed a small fly on the wall above the food preparation sink and adjacent to the knife storage area on the wall. Below the food preparation sink was an open cabinet where the sink drain was plumbed into the wall. There were more than 30 alive flies in inside the cabinet space. In addition, two long pieces of sticky tape over four inches in length and 1.5 inches wide were in the cabinet space and were covered with dead flies stuck to the tape. DS1 and DS2 stated they were not aware of the flies. MS stated the flies were not reported to him. In a phone interview with the pest control service technician (PCST) on 10/3/23 at 1:26 p.m., he stated he was called to the facility yesterday and arrived at 7:30 p.m. PCST stated he saw drain flies under the food preparation sink cabinet. He also stated usually when a couple drain flies are observed, there was actually a lot more. He stated his recommendation to the facility was to lift up the floor cabinet to look for a leak or standing water since drain flies were usually attracted to standing water. Review of the policy titled Pest Control revised May 2019, showed the facility shall maintain an effective pest control program. An on-going pest control program will be maintained to ensure the building is kept free from insects and rodents.

Based on observation, interview, and facility document review, the facility failed to have a full-time, qualified, and competent person to supervise food and nutrition services when: 1. The registered dietitian (RD) and the qualified dietary supervisor were at the facility less than full-time defined as 35 hours per week; 2. Food and Nutrition Services (FNS) supervisory staff did not ensure: a resident received food preferences; FNS staff were competent to carry out job duties and tasks they performed; the planned menu was followed; a resident received the appropriate texture food according to the diet order; there was an effective system to maintain food and nutrition services in a safe and sanitary manner; and the kitchen was pest free; and 3. The dietary supervisor did not ensure chicken potstickers were cooked to an appropriate temperature. These failures had the potential to compromise the safety and nutritional status of residents through the potential transmission of foodborne illness, the provision of inadequate nutrients, the provision of food texture that did not meet resident needs, and ineffective interventions for 51 residents who received food from the kitchen out of a facility with a census of 51. Findings: 1. According to the California Code, Health, and Safety Code - HSC S 1265.4: A licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. Subdivision (b) includes the following: The dietetic services supervisor shall have completed at least one of the following educational requirements: (1) A baccalaureate degree with major studies in food and nutrition, dietetics, or food management and has one year of experience in the dietetic service of a licensed health facility. (2) A graduate of a dietetic technician training program approved by the American Dietetic Association, accredited by the Commission on Accreditation for Dietetics Education, or currently registered by the Commission on Dietetic Registration. (3) A graduate of a dietetic assistant training program approved by the American Dietetic Association. (4) Is a graduate of a dietetic services training program approved by the Dietary Managers Association and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (5) Is a graduate of a college degree program with major studies in food and nutrition, dietetics, food management, culinary arts, or hotel and restaurant management and is a certified dietary manager credentialed by the Certifying Board of the Dietary Managers Association, maintains this certification, and has received at least six hours of in-service training on the specific California dietary service requirements contained in Title 22 of the California Code of Regulations prior to assuming full-time duties as a dietetic services supervisor at the health facility. (6) A graduate of a state approved program that provides 90 or more hours of classroom instruction in dietetic service supervision, or 90 hours or more of combined classroom instruction and instructor led interactive Web-based instruction in dietetic service supervision. (7) Received training experience in food service supervision and management in the military equivalent in content to paragraph (2), (3), or (6). Review of the undated job description titled Dietary Supervisor, showed the Dietary Supervisor must be a graduate of an approved dietary managers course that meet the state and federal regulations. In an interview on 10/2/23 at 9:20 a.m. Dietary Supervisor 2 (DS2) stated she was not a not a qualified supervisor. She stated the Certified Dietary Manager (CDM) for this facility worked at two facilities. DS2 also stated there were two registered dietitians for the facility, Registered Dietitian 1(RD1) who was the kitchen RD and Registered Dietitian 2 (RD2) who was the clinical RD. Dietary Supervisor 1 (DS1) stated she was the CDM and was at the facility about three days a week. DS1 also stated RD1 was the RD for the kitchen and was at the facility one day a week. In an interview on 10/2/23 at 12:35 p.m., RD1 stated she was not the regular dietitian for this facility and did not usually come to this facility. She stated she was covering for RD2 for a few days while RD2 was out of state at a conference. In an interview on 10/3/23 at 11:35 a.m., DS1 provided a certificate that showed she was qualified as a Dietary Services Supervisor (DSS). She stated there was no documentation of her hours to show how many hours she came into the facility because she was salary. She stated sometimes she came into the facility for 32 hours a week but mostly she came to the facility 3 days a week for around six to eight hours a day. The Administrator (ADM) stated DS1 came into the facility about 24 hours a week. When the surveyor informed ADM the requirement for a full-time supervisor for Food and Nutrition Services, he stated, but she [DS1] is here 32 hours a week. ADM stated he thought fulltime was defined as 32 hours a week. ADM confirmed there was no documentation of hours for DS1. He also confirmed there was not a full-time RD for the facility. 2. Multiple issues were identified in the kitchen including not providing a resident with food preferences; not ensuring staff competency; not ensuring the planned menu was followed; not ensuring the appropriate texture of food was served according to the diet order; not ensuring food safety and sanitation; and not ensuring the kitchen was free of pests (cross-reference F692, F802, F803, F805, F812, and F925). Review of the undated job description titled Dietary Supervisor, showed the general purpose of the Dietary Supervisor (DS) role was providing supervision to the Dietary Department. The DS was responsible for directing and assisting the preparation and service of regular meals and therapeutic diets, ordering food and supplies, and maintaining the area and equipment in a sanitary condition. Essential duties for this position included, directing and participating in food preparation and service of food that was safe and appetizing and was of quality and quantity to meet each resident's needs in accordance with physicians order in compliance with approved menus; directs and supervises all dietary functions and personnel; trains dietary employees; assures handling of food and supplies complies with current state and federal guidelines; receives resident food preferences; maintains kitchen and food storage areas in a safe, orderly, clean and sanitary manner; transmits orders for appropriate food and supplies; checks trays for accuracy before they are delivered. Review of the undated job description titled Registered Dietitian, showed essential duties included to monitor food services operations to ensure conformance to nutritional, safety, sanitation, and quality standards, as well as state and federal regulations; and to monitor food control systems such as food temperatures, portion control, preparation methods to ensure food was prepared and presented in an acceptable manner. 3. An observation and interview on 10/2/23 at 12:05 p.m., showed DS1 measured the temperature of foods placed on the trayline for food service. A pan of chicken potstickers were removed from the oven. The pan had foil over the top. DS1 placed the probe of a thermometer through to foil to measure the potstickers. Because the probe was placed through the foil covering the pan, it could not be identified where the probe was inserted into a potsticker. The thermometer showed 170 degrees Fahrenheit (F) and DS1 stated they were okay and ready to serve. The surveyor pulled back the foil that covered the pan and measured the temperature of the center of two potstickers with a calibrated thermometer and the temperatures were 106.3 degrees F and 129.0 degrees F. Then DS1 stated the potstickers had to be heated more. When DS1 was asked how she knew her thermometer was inside the potsticker toward the center when she stuck the thermometer probe through the foil, she stated she did not know. When she was asked how many potstickers she should measure temperatures of to ensure they were hot enough, she stated she should take the temperature of at least three potstickers. She also stated the potstickers had to be heated to at least 165 degrees F before serving them. Review of the recipe titled Pot Stickers dated 8/3/23, showed to cook frozen pot stickers to an internal temperature of 165 degrees F. Review of the policy and procedure titled Food Preparation and Service revised 2022, showed poultry was to be cooked to at least 165 degrees F to kill or sufficiently inactivate pathogenic microorganisms. Also, previously cooked food that was to be reheated to an internal temperature of 165 degrees F. In addition, ready to eat foods that require reheating were to be cooked to at least 135 degrees F for holding for hot service.

Based on observation, interview, and facility document review, the facility failed to ensure the competency of Food and Nutrition Staff when: 1. A cook did not know the steps for cooling Time Temperature Control for Safety (TCS, foods more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) food; 2. A cook did not follow recipes when preparing food for the planned menu; 3. A diet aide did not know how long to submerge items in the sanitizer solution when washing manually using the 2-compartment sink; 4. A diet aide did not follow manufacturer's instructions for a sanitizer test strip when testing the surface sanitizer. These failures had the potential to compromise the safety and nutritional status of residents through the transmission of foodborne illness and the provision of inadequate nutrients and/or decreased quality of food for 51 residents who received food from the kitchen out of a census of 51. Findings: 1. Review of the Cooldown Temperature Log dated October 2023, showed instructions which read Food must be cooled from 140 degrees Fahrenheit (F) to 70 degrees F within first 2 hours, 70 degrees F to 41 degrees F within next 4 hours . In addition, the directions showed potentially hazardous foods (also known as TCS food) prepared from room temperature ingredients such as salads and sandwich fillings, including tuna salad, are to be cooled to 41 degrees F within 4 hours. Documentation on this log dated 10/2/23 showed salad start temperature was 140 degrees F at 10 a.m. and 68 degrees F at 11 a.m. These documented temperatures were the same as the example provided on the log for the cooling of potato salad. During the recertification survey from 10/2/23-10/6/23, it was identified Food and Nutrition staff were not documenting cooling of TCS food which was cooked and stored for later use (Cross-reference F812). In an interview and observation with Cook 1 on 10/4/23 at 9:32 a.m., the October cooldown log was reviewed. Cook 1 confirmed he documented green salad on the cooldown log on 10/2/23. He stated he did not know why he documented green salad on the log, and he stated the temperatures of 145 degrees Fahrenheit at 10 a.m., and 68 degrees at 11 a.m., were mistakes. He also stated food should be cooled from 135 degrees F to somewhere around 68 to 72 degrees F in two hours and between 41 and 45 degrees F for an additional four hours. In an interview with DS2 on 10/4/23 at 1:22 p.m., she stated she did not know tuna salad made from room temperature ingredients had to be cooled and she did not expect it to be documented on the cooldown log. Review of the policy and procedure titled Food Preparation, Cooking and Holding Time/Temperatures revised 2019, showed potentially hazardous foods (also known as time temperature control for safety (TCS) foods, foods more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) are to be cooled rapidly from 135 degrees Fahrenheit (F) to 70 degrees F within two hours and then to a temperature of 41 degrees F or below within the next four hours. The total cooling time between 135 degrees F and 41 degrees F is not to exceed 6 hours. 2. Review of the Daily Cook's Menu dated 10/2, showed Beef and Broccoli was served to regular textured diets and the pureed diet received pureed Beef and Broccoli. Review of the recipe titled Beef and Broccoli dated 8/3/23, showed directions on how to prepare the Beef and Broccoli. The recipe showed to prepare the pureed texture Beef and Broccoli, to place prepared portion of Beef and Broccoli into a blender and blend until a smooth consistency. During an observation and concurrent interview with Registered Dietitian 1 (RD1) on 10/2/23 at 1:06 p.m., a regular texture and puree texture test tray was tasted. The regular texture Beef and Broccoli was a mixture of beef and broccoli in a sauce. The pureed test tray showed a scoop of pureed beef and a scoop of pureed broccoli. When tasted, the regular Beef and Broccoli mixture had a different flavor to the separate pureed beef and broccoli. RD1 stated the pureed beef and broccoli should not be separate and the cook should have pureed portions of the prepared Beef and Broccoli mixture. Review of the Daily Cook's Menu dated 10/3/23, showed the entree for lunch that day was steamed fish and the vegetable was stir-fried Peking cabbage. An observation and concurrent interviews with Cook 1, Dietary Supervisor 1 (DS1), and the RD1 on 10/3/23 at 10:30 a.m., showed Cook 1 preparing food for the lunch meal. DS1 told Cook 1 to make sure to follow the recipes. Cook 1 opened the recipe binder to the nutritional analysis page which was a spreadsheet of the nutrient provided for the weekly menu. Cook 1 looked at the nutrient analysis then placed a one teaspoon of chicken base into a container of water. Cook 1 stated he looked at the nutrient analysis to find out how much sodium use to make the broth. Cook 1 stated the broth was for the pureed cabbage. Cook 1 filled a blender with a cooked cabbage mixture and added two, 6-ounch ladles of broth. He blended the cabbage and the broth for about 3 seconds and added another ladle and a half of broth and blended the mixture more. He poured thin mixture into a pan. Review of the recipe titled Cabbage Stir-fry, Peking dated 10/3/23 showed directions for preparing the stir-fry. The directions for the pureed stir-fry showed to place the number of portions needed of prepared stir-fry in a blender and gradually add 1 -1/2 teaspoons of thickener for each portion. Blend until smooth until pudding like consistency is met. In a concurrent observation and interview with Cook 1 on 10/3/23 at 10:40 a.m., a pan containing fish and water was on the stove. Cook 1 removed the fish from the pan and placed it in the blender. Then he removed water from the pan using a 6-ounce ladle. He blended the mixture and poured the mixture into a pan. The texture was runny and Cook 1 added thickener using a half cup measuring cup. Cook 1 stated he followed the recipe for the pureed because he used the same ingredients as the regular fish which he baked in the oven. The recipe titled Fish, steamed dated 10/3/23, showed to prepare the fish by added ingredients and steaming the fish in a steam pan. For the pureed steamed fish, the directions showed to add prepared portions of steamed fish to a blender and add one tablespoon of milk or vegetable broth for each portion, then blend until smooth. Review of the policy and procedure titled Standardized Recipes revised April 2007, showed standardized recipes shall be developed and used in the preparation of foods. 3. In an observation, interview, and document review on 10/3/23 at 11:05 a.m., Diet Aide 1 (DA1) demonstrated how to use the two-compartment sink for manual dish washing. She stated the last sink filled with a sanitizer solution to sanitize items. She stated the sanitizer used was dispensed from a hose above the two-compartment sink. The label on the sanitizer container connected to the hose showed it was a Quaternary Sanitizer. She stated items had to be in the sanitizer for 10 seconds. The directions posted above the sink titled 2-Compartment Sink Procedure showed to fully submerge service ware in sanitizer solution for 1 Minute. Review of the manufacturer's instructions located on the quat sanitizer container, showed for food contact surfaces, to immerse items in a sanitizer solution for 60 seconds. 4. In an observation, interview, and review of manufacturer's instructions on 10/3/23 at 11 a.m., Diet Aide 1 (DA1) demonstrated how she prepared and tested the food contact surface sanitizer. She filled a red bucket with a quaternary ammonia sanitizer solution that was dispensed from a hose above the two-compartment sink. She removed a test strip from a container and dipped it in the solution for three seconds. DA1 stated the solution was 200 ppm (parts per million). She was asked to test the sanitizer again this time dipping the test strip in the sanitizer solution for 10 seconds. After 10 seconds, she removed the strip and it was darker than the strip she held in the solution for three seconds. She stated the strip she held in the solution for 10 seconds was between 200-300 ppm. The manufacturer's instructions for the test strips located inside the container of the sanitation test strips showed to dip the paper in the quat solution for 10 seconds.

Based on observation, interview and record review, the facility failed to follow the planned menu when: 1) The incorrect serving size of the main entree was served according to the menu for a lunch meal; 2) Pureed melon was not served according to the menu for a lunch meal. 3) Pureed salad was not served according to the menu for a lunch meal. 4 ) Fresh strawberry and ice cream were not served according to the menu for a lunch meal. This failure to follow the planned menu had the potential to result in residents not receiving the nutrients the menu was intended to provide leading to decreased nutrient intake and further compromising residents' medical status for 51 residents who received food from the kitchen. Findings: Review of the policy and procedure titled Menus revised October 2017, showed menus are developed and prepared following established national guidelines for nutritional adequacy. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board. The dietitian reviews and approves all menus. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. Review of the policy and procedure titled Purchasing Food and Supplies dated 2018, showed the Food and Nutrition Services Director is responsible for specifying quantity of food desired when ordering food from an appropriate vendor. Proper procedures are to be followed in purchasing food and seeing that food is delivered. Food purchasing begins with a planned menu. Supplies shall be appropriate to meet the requirements of the menu and therapeutic diets ordered. 1. Review of the document titled Daily Cook's Menu dated Fall 2023, 10/2, showed the serving size for the regular textured Beef and Broccoli entree was 3/4 of a cup. The menu showed all regular textured diets received 3/4 of a cup except for small portions. On 10/2/23 at 12 p.m., an observation and concurrent interview with Dietary Supervisor 2 (DS2) and Registered Dietitian 1 (RD1), showed Cook 1 plated food for residents' lunch meal. For the main entree, Beef and Broccoli, Cook 1 used a spoodle (a cross between a ladle and a spoon) that had a label marked on the handle showing the spoodle was 4 ounces (1/2 cup). DS2 and RD1 referred to the cook's spreadsheet and confirmed the portion for the beef and broccoli was 3/4 of a cup and Cook 1 was using the incorrect size spoodle and was serving a portion that was less than indicated on the menu. 2. Review of the document titled Daily Cook's Menu dated Fall 2023, 10/2, showed regular textured diets received cubed fresh melon and pureed diets received pureed fresh melon. During tray line observation and interview with DS2 on 10/2/23 around 12:15 PM in the kitchen, food for resident lunch was placed on trays. The trays with a tray ticket that specified the resident was on a pureed diet received a small bowl of a light colored pureed substance. DS2 stated the pureed substance was pureed pears and there was no pureed melon for the pureed diets., DS2 stated she only received one box of melons. She stated she ordered five melons but she just received three. On 10/2/23 at 3 p.m., the food invoice dated 10/2/23 was reviewed with DS2. The invoice showed 1 case of cantaloupe was ordered and 1 case of cantaloupe was shipped. When DS2 was asked how many melons came in a case, she stated 3. DS2 confirmed she did not order enough melon to meet the needs of the menu for lunch today (10/2/23). 3. Review of the document titled Daily Cook's Menu dated Fall 2023, 10/2, regular textured diets received Asian Cucumber Salad, and pureed diets received pureed Asian Cucumber Salad. The menus also showed the entree for pureed diets was pureed Beef and Broccoli. An observation and interview with Cook 1 on 10/2/23 at 12:10 p.m., showed food was placed on to trays for resident lunches. Trays with tray tickets that indicated residents were on a pureed diet, did not have pureed salad on their trays. Cook 1 stated there was no pureed salad for pureed diets today. Cook 1 stated he gave pureed diets broccoli instead of salad. 4. Review of the document titled Daily Cook's Menu dated Fall 2023, 10/42, showed all diets received fresh strawberries and ice cream except for residents on a renal diet (a diet typically prescribed to a person with kidney disease). During dining observation on 10/4/23 at 12:15 PM, residents had small containers of strawberry ice cream on their lunch tray. There were no fresh strawberries on resident trays. In an interview and document review on 10/4/23 at 12:11 p.m., DS2 stated confirmed strawberry ice cream was served for lunch today (12/4/23) not fresh strawberries and ice cream. DS2 retrieved the recipe titled Standard A Fall 2023 Strawberries & Ice Cream and stated the recipe showed the ingredients were vanilla ice cream and fresh strawberries. DS2 stated the residents should have received vanilla ice cream and fresh strawberries but she did not order strawberries.

Based on observation, interview and record review, the facility failed to ensure food safety requirements in accordance with professional standards for food service safety when: 1. Staff did not ensure food was cooled safely. 2. Pans and bowls were not dried appropriately. 3. Frying pans were in poor condition. 4. A large mixer was not clean and in poor condition. 5. An industrial can opener was not clean and in poor condition. 6. Refrigerator and Freezer door rubber gaskets (a rubber strip surrounding the perimeter of the inside of the cooler door to seal the door when it is closed so air cannot go in or out) were not clean. 7. Staff did not handle clean dishes appropriately to prevent contamination of the dishes. 8. There was no airgap (a gap between the sink drains and the drain that leads to sewage drain. This gap prevents a back-up of non-potable water and/or bacteria into the sink) for the food preparation sink drain. 9. Nursing staff who monitored food refrigerator temperatures did not know appropriate refrigerator temperatures to store food safely. 10. Refrigerated food belonging to residents were not labeled to show who the food belonged to. 11. Expired tube feedings (liquid nutrition provided through a tube when a person is not able to eat on their own by mouth) were stored expired and available for use; and 12. Perishable food at resident's bedside (Resident 19) was beyond the amount of time that was considered safe for consumption. The failure to store, prepare, serve, and distribute food in a safe and sanitary manner had the potential to put residents at risk for foodborne illness leading to severe illness and even death for 51 residents who consumed food by mouth and through tube feeding. Findings: 1. A concurrent observation and interview with Dietary Supervisor 1 (DS1), and Dietary Supervisor 2 (DS2) on [DATE] at 10:05 AM in the kitchen, showed cooked rice dated [DATE]-[DATE] in a closed container in the refrigerator. DS1 stated rice was cooked almost every day. DS2 stated rice should be documented on the cool down log. The cool down logs for the months of September and October were checked and were both blank. DS1 and DS2 confirmed there was no cooldown documented for any foods for September and [DATE]. DS1 stated the rice had to be discarded because she did not know if it was cooled appropriately. On [DATE] at 11:28 a.m., an observation showed tuna salad in the refrigerator in a plastic container dated [DATE]-[DATE]. In an interview on [DATE] at 12:36 p.m., Cook 2 stated she made the tuna salad yesterday that was stored in the refrigerator dated [DATE]. She stated she used packaged tuna that was stored in the dry storeroom at room temperature to prepare the tuna salad. She stated she did not document cooldown for the tuna salad. Review of the policy and procedure titled Food Preparation, Cooking and Holding Time/Temperatures revised 2019, showed potentially hazardous foods (also known as time temperature control for safety (TCS) foods, foods more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) are to be cooled rapidly from 135 degrees Fahrenheit (F) to 70 degrees F within two hours and then to a temperature of 41 degrees F or below within the next four hours. The total cooling time between 135 degrees F and 41 degrees F is not to exceed 6 hours. Review of the Cool Down Temperature Log dated [DATE], showed directions which read potentially hazardous foods prepared from room temperature ingredients such as salads and sandwich fillings, including tuna salad, are to be cooled to 41 degrees F within 4 hours. 2. During a concurrent observation and interview with the DS1 on [DATE] at 9:30 a.m. in the kitchen, showed a storage rack that held metal pans and mixing bowls of various sizes. The mixing bowls and pans were stacked within one another and were wet. The DS1 acknowledged the observation and stated, they should have been air dried completely. During a review of the facility's policy and procedure titled 3 compartment procedure for manual dishwashing dated 2018 indicated all items are air-dried, which means no water droplets are present. According to the 2022 Federal Food Code, after cleaning and sanitizing, equipment and utensils are to be air-dried before storing. According to the annex, wet nesting occurs when dishes or pots and pans are stacked, preventing them from drying, and creating conditions that are ripe for microorganisms to grow. 3. A concurrent observation and interview with the DS1 on [DATE] at 9:30 a.m., in the kitchen, showed frying pans hanging above the two-compartment sink. During observation three pans were examined. Three frying pans (two large and one small) had thick black, hard, and solidified residue. The flat cooking surface of the frying pans were scratched and had a rough surface. DS 1 stated the pans were used to cook eggs and confirmed the pans had a coating that was scratched, and the pans had to be replaced. Review of the policy and procedure titled Sanitization dated 2001, showed all equipment and utensils shall be kept clean, and maintained in good repair. According to the 2022 Federal Food Code, food-contact surfaces are to be smooth and free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. In addition, the food-contact surfaces of cooking equipment and pans are to be kept free of encrusted grease deposits and other soil accumulations. 4. A concurrent observation and interview with DS1 and DS2 on [DATE] at 9:32 a.m. in the kitchen, showed a large mixer covered with a plastic. DS1 stated, the mixer was used to prepare cakes and when it was covered with plastic, it was supposed to be clean. The flat beater attached to the mixer had a silver coating on the surface that had partially come off. Also, there was white, greasy to the touch residue where the flat beater attached to the mixer, and also white residue on the safety shield. DS1 confirmed the coating was coming off the flat mixer and there was residue on the mixer, and it had to be cleaned. During a review of the facility policy and procedure titled: Electrical Food Machine, 2018, indicated, keep, and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slicers, and toasters. According to the 2022 Federal Food Code, food-contact surfaces are to be smooth and free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Equipment food contact surfaces and utensils are to be clean to sight and tough. In addition, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 5. An observation and concurrent interview on [DATE] at 9:44 a.m., showed an industrial can opener on a food preparation table. [NAME] sticky residue was embedded on the blade around the seem where the blade was screwed on to the can opener. A white paper was used to wipe the can opener blade and dark brown dirt came off onto the paper towel. In addition, the silver coating on the can opener blade was rubbed off. The facility's document titled: can opener and base, 2018 indicated, proper sanitation and maintenance of the can opener is important to sanitary food preparation. The can opener must be cleaned thoroughly each work shift, and more frequently when necessary. According to the 2022 Federal Food Code, food-contact surfaces are to be smooth and free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. Equipment food contact surfaces and utensils are to be clean to sight and tough. In addition, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 6. During a concurrent observation and interview with DS1 and DS2 on [DATE] at 10:06 a.m. in the kitchen, showed the rubber gaskets (a rubber strip surrounding the perimeter of the inside of the cooler door to seal the door when it is closed so air cannot go in or out) for the doors of one reach-in refrigerator and one reach-in freezer had black residue embedded in the surface of the gaskets. DS1 confirmed the gaskets were dirty and had to be cleaned. During a review of the facility policy and procedure titled, Refrigerator and Freezer (2018), it indicated, maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. The procedures showed refrigerator and freezers should be on a weekly cleaning schedule and to wipe down gaskets with soapy water. According to the 2022 Federal Food Code, nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 7. During a concurrent observation and interview with DS1 on [DATE] at 10 a.m. in the kitchen, showed DA1 handled washed dishes on the clean side of the dish machine with her bare hands and placed the dishes in the plate warmer next to the tray line. When she handled the plates, she touched the food contact surface of the plate. DS1 confirmed DA1 touched the food contact of the plates with her bare hands and stated only the underside or the side of the plates should be handled with bare hands, not the food contact surface. According to the 2022 Federal Food Code, sanitized utensils are to be handled so that contamination of food and lip-contact surfaces is prevented. 8. During a concurrent observation and interview with DS1 and DS2 on [DATE] at 10 a.m., showed a food preparation sink in the kitchen with a drain that was plumbed directly into the wall. The Maintenance Supervisor (MS) stated there was no air gap (a gap between the sink drains and the drain that leads to sewage drain. This gap prevents a back-up flow of non-potable water and/or bacteria into the sink). He also confirmed drain was attached to the wall, and it went straight to the ground and was connected to the sewer. According to the 2022 Federal Food Code, a direct connection may not exist between the sewage system and the drain originating from equipment in which food, portable equipment, or utensils are placed. 9. In an interview on [DATE] at 2:40 p.m., Registered Nurse 1 (RN1) stated he monitored and documented the temperature of the resident food refrigerator located in the medication room. He stated the proper temperature for the food refrigerator was on the log. The log was reviewed with RN1, and he confirmed the log showed ,d+[DATE] degrees as the appropriate temperature. At the top of the log it showed If the temperature is not between 36 and 46 degrees, notify Maintenance. RN1 stated it was okay for the food refrigerator to go up to 46 degrees Fahrenheit (F). In an interview on [DATE] at 10:22 a.m., RN1 stated he thought he had training regarding food refrigerator temperatures from the DSD, but he could not remember when. He stated during the training the DSD reviewed the refrigerator temperature log sheet. In an interview on [DATE] at 10:24 a.m., the DSD stated she trained nurses on the food refrigerator temperature according to the log sheet that showed ,d+[DATE] degrees F. She stated she did not receive training from Food and Nutrition staff regarding proper food/refrigerator temperatures. During a review of the facility policy and procedure titled, Procedure for Refrigerated Storage dated 2019, showed the refrigerator was to be 41 F or lower. 10. During a concurrent observation and interview on [DATE] at 2:15 p.m., a resident food storage refrigerator located in the medication room contained foods that were not dated and that was not labeled with resident names. This food included two packages of shredded cheese, a package of deli meat ham, a container of mustard, a container of strawberry preserves, and two tubs of butter. The Director of Staff Development (DSD) confirmed the food belonged to residents and stated the food should be dated and labeled with the resident names to show who it belonged to. Review of the policy and procedure titled Foods Brought by Family/Visitors revised [DATE], showed food brought by family/visitors and left for the resident to consume later are to be labeled with the resident's name. 11. During a concurrent observation and interview with DS1 and DS2 on [DATE] at 10:28 a.m. in the dry food storage room, 27 expired plastic bottles of tube feedings (TF) were found. The 27 expired bottles included: 15 bottles of Nepro [Therapeutic nutrition to help meet the nutritional needs of dialysis patients] with expiration date of [DATE], and 3 bottles with expiration date of [DATE]; and 2 plastic bottles of Jevity [a complete balanced nutrition with fiber] with expiration date of [DATE] and 7 bottles with expiration date of [DATE]. The DS1 confirmed the tube feedings were expired and they had to be discarded. During an interview with the Medical Records Director (MRD) and the [NAME] Clerk (WC) on [DATE] at 1:52 p.m., WC stated the [NAME] Clerks monitored the inventory of the tube feedings every Tuesday. The MRD stated expired tube feedings should not be in the storeroom. 38066 12. During a concurrent observation and interview on [DATE] at 9:32 AM with Resident 19 in the resident's room, a sandwich was on the over bed table. The sandwich was covered with a plastic wrap and dated, [DATE]. Resident 19 stated, That's from last night. During an interview on [DATE] at 9:51 AM with the Director of Staff Development (DSD), the DSD acknowledged that the sandwich was dated [DATE]. DSD stated, It's not supposed to be here. It's not refrigerated, not good anymore. It's from yesterday. During an interview on [DATE] at 11:09 AM with the Registered Dietitian (RD) 1, when queried regarding the sandwich, RD1 stated, That should be consumed within two to four hours or as soon as possible after it has left the kitchen. It should be thrown away. Review of facility policy titled, Food and Nutrition Services revised [DATE], indicated, .Food and nutrition services staff will inspect food trays to ensure .it is served at a safe and appetizing temperature .b. Foods that are left without a source of heat (for hot foods) or refrigeration (for cold foods) longer than 2 hours will be discarded .

Based on observation, interview, and facility document review, the facility failed to maintain the outside compost bin in a clean manner. This failure had the potential to attract pests resulting in pest related illness for 51 residents out of a census of 51. Findings: An observation and interview with Dietary Supervisor 2 (DS2) on 10/3/23 at 12:51 p.m., showed a compost bin stored outside with other waste receptacles directly next to the facility's outside side wall. The compost bin had a significant amount of thick dark brown and black residue on the outside surface and sides of the inside surface of the bin also covered with a thick black and brown residue. DS2 stated the black and brown residue was food residue. In an interview on 10/3/23 at 2:54 p.m., the maintenance supervisor confirmed the outside compost bin was dirty. Review of the document titled Miscellaneous Areas dated 2020, showed each time the garbage is emptied, containers must be cleaned thoroughly. In addition, the trash collection area is a potential feeding ground for vermin and rodents and must be clean. According to the 2022 Federal Food Code, soiled receptacles and waste handling units for refuse shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.

Based on observation, interview, and facility document review, the facility failed to: 1. Provide food preferences to one resident (Resident 10); and 2. Provide an appealing option of similar nutritive value for milk when 39 residents chose not to drink milk. These failures had the potential for residents to not receive the amount of nutrients provided by the planned menu and/or the Registered Dietitians recommended nutrient needs leading to nutrient deficiency, weight loss, and/or malnutrition out of a census of 51. Findings: 1. A record review for Resident 10 showed he was originally admitted to the facility on [DATE] with diagnoses including but not limited to congestive heart failure ((a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease stage 3 (when kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood), severe obesity, depression, and pulmonary edema. The MDS (Minimum Data Set, an assessment tool) dated September 9, 2023, showed Resident 10 with a BIMS (Brief Interview for Mental Status) score of 12 showing moderate cognitive impairment. It was identified during the recertification conducted from 10/2/23 to 10/6/23 that Resident 10 did not like the food he was served, documentation showed he had poor intake continuously, he was losing weight, and food preferences were not updated since his original admission. (Cross-reference F692) Review of the policy and procedure titled Food and Nutrition Services revised October 2019, showed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The Interdisciplinary Team (IDT, a group of dedicated healthcare professionals who work together to provide care) will assess food likes, dislikes, and eating habits. Reasonable efforts will be made to accommodate resident choices and preferences. Review of the policy and procedure titled Food Preferences dated 2018, showed updating food preferences will be done as residents' needs change. Review of the policy and procedure titled Food Substitutions for Residents Who Refuse the Meal dated 2018, showed the FNS [Food and Nutrition Services] Director is to document on the resident's profile and tray card what menu items are disliked and, if necessary, re-interview the resident or staff for food preferences. In an interview on 10/5/23 at 1:57 p.m., Dietary Services Supervisor 2 (DS2) stated when a resident had weight loss, the RD notified her and asked her to get resident food preferences. DS2 confirmed there was no documentation for Resident 10's food preferences since his initial admission in August 2023. 2. Review of the Daily Cook's Menu dated Fall 2023 10/2, showed all diets received milk except for Renal diets (a diet typically prescribed to a person with kidney disease). An observation and concurrent interview with RD1 and DS2 on 10/02/23 at 12:15 a.m., showed trays were prepared for lunch food service. Drinks were placed on the trays. Milk was not observed on many trays. RD1 stated residents did not receive milk unless milk was printed on the tray ticket as a standing order, even when milk was on the menu. She stated it was a resident's preference if they did not want milk. She stated many residents were [of certain ethnic origin] and they did not like milk. She said resident did not get a substitute for milk to make up for the nutrients they were missing in relation to the planned menu. DS2 confirmed residents did not receive a substitute for milk. Review of the lunch meal tickets showed 39 tray tickets did not have milk printed on them as a standing order and did not indicate the resident should not receive milk due to an allergy or preference (renal diet meal tickets were not included). Review of the Policy and Procedure titled Food Preferences dated 2018, showed Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. Review of the policy and procedure titled Menus revised October 2017, showed menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established guidelines for nutritional adequacy.

Based on interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for four of 13 sampled residents (Residents 18, 19, 43, and 31) when: 1. The CP for Resident 19 did not have specific interventions for the use of Trazodone (medication used to treat depression). 2. No individualized person-centered CP was developed for the management of peripherally inserted central catheter (PICC - a long thin tube that's inserted through a vein in an arm and passed through a larger vein near the heart) line for Residents 18 and 43. 3. No individualized person-centered CP was developed for the management of the urinary catheter (a tube left in the bladder to carry urine from the bladder to outside the body) for Resident 43. 4. No individualized person-centered CP was developed for the use of oxygen for Resident 43. 5. No individualized person-centered CP was developed for Resident 31 to include her lack of teeth and dentures. This failure had the potential for not meeting the residents' nursing needs and goals to attain their highest practicable well-being. Findings: 1. Resident 19 was admitted on [DATE] with diagnoses including alcoholic cirrhosis of liver with ascites (chronic liver damage from a variety of causes leading to scarring and liver failure with buildup of fluid in the abdomen), traumatic brain injury (brain dysfunction caused by an outside force usually by a violent blow to the head), and major depressive disorder. During a review of Resident 19's Order Summary Report (OSR), the OSR indicated, Resident 19 had active orders as of 10/4/23, .Trazodone HCl (Trazodone Hydrochloride - used to treat depression) Oral Tablet 100 mg (milligram) give 1 tablet by mouth at bedtime for insomnia (a sleep disorder characterized by difficulty falling asleep, staying asleep, or both) .monitor hours of sleep daily from 3-11 and 11-7 with the use of (specify drug and diagnosis) document hours of sleep every evening and night shift for Trazodone . with a start date of 9/8/23. During a concurrent interview and record review on 10/4/23 at 11:05 AM with Registered Nurse (RN) 2, Resident 19's CP for the use of Trazodone was reviewed. RN2 acknowledged that the CP did not include monitor hours of sleep. RN2 stated, It's not individualized. It doesn't reflect the intervention for monitoring of sleep to see if medication is effective. 2a. Resident 18 was readmitted to the facility on [DATE] with Pneumonia (Lung infection). During a concurrent observation and interview on 10/4/23 at 9:10 AM, Resident 18 had two separate tubing and two cap PICC line, with dressing clean, dry, intact, and dated. Resident 18 stated Today is the last day of my antibiotics. During review of Resident 18's OSR. Resident 18's OSR had active orders as of 10/5/23, .Ceftriaxone Sodium (medication that kills bacteria and prevents its growth) Injection Solution Reconstituted 2 gm (grams) IV every 24 hours for Right Lower Extremity (RLE) hardware infection .Flush the PICC line 10 ml (milliliters) NS (Normal Saline) before and after medication administration in the morning . Flush the PICC line 10 ml NS for patency every dayshift . Assess length of external catheter and upper arm circumference in cm (centimeters) every shift . PICC line dressing change every 7 days. During a concurrent interview and record review on 10/5/23 at 3:41 PM with the DON, the DON verified that there was no CP developed for the management of Resident 18's PICC line and stated, There should be a CP. I didn't see a CP for PICC line. I thought I was sure of it that this resident has PICC line CP, but there's none. The DON said that a CP is important to monitor the condition of the PICC line site. 2b. Resident 43 was admitted on [DATE] with diagnoses including malignant neoplasm of lung (lung cancer), and secondary malignant neoplasm of brain (caused by cancer cells spreading to the brain from a different part of the body). During a concurrent observation and interview on 10/2/23 at 11:00 AM with Resident 43 in the resident's room, Resident 43 had a PICC line on his left upper extremity, which was capped, with dressing dry and intact. Resident 43 stated, It's used for my chemotherapy. During a concurrent interview and record review on 10/5/23 at 3:13 PM with the Director of Nursing (DON), Resident 43's CP was reviewed. The DON said that Resident 43 has a PICC line used for chemotherapy (type of cancer treatment) and for intravenous antibiotics (medications delivered into a vein). The DON acknowledged that there was no CP developed for the management of Resident 43's PICC line and stated, There should be a CP, I didn't see a CP for PICC line. The DON said that a CP is important to monitor the condition of the PICC line site, for any changes, and address it with the primary care physician. The DON further stated, For patient safety. 3. During an observation on 10/2/23 at 11:00 AM, Resident 43 had a urinary catheter hanging below the right side of the bed, no kinks, bag covered, and was off the floor. During a concurrent interview and record review on 10/4/23 at 3:00 PM with RN2, Resident 43's CP was reviewed. RN2 said that Resident 43 had a foley catheter for urinary incontinence (the loss of bladder control). RN2 acknowledged there was no CP developed for the management of Resident 43's foley catheter. RN2 stated, There's no care plan for the foley catheter. Care plan is important to see what goals and interventions they have. Review of an undated facility policy titled, Care Plans, Comprehensive Person-Centered indicated, .Interpretation and Implementation .1. A Comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative .6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible . 4. During a concurrent observation and interview on 10/2/23 at 11:00 AM with Resident 43 in the resident's room, Resident 43 was on oxygen at 2L/min (liters/minute) via nasal cannula (device that delivers extra oxygen through a tube and into the nose that help people who are having difficulty breathing). Resident 43 stated, My nose is stuffed. During a concurrent interview and record review on 10/4/23 at 3:32 PM with RN2, Resident 43's CP was reviewed. RN2 verified that Resident 43 uses oxygen and stated, He's on oxygen 24/7 via nasal cannula at 2L/min for shortness of breath. RN2 acknowledged there was no CP developed for Resident 43's use of oxygen and stated, None for administering oxygen. Review of facility policy, Oxygen Administration revised October 2010, indicated, .Preparation .2. Review the resident's care plan to assess for any special needs of the resident . 34975 5. A record review showed Resident 31 was admitted on [DATE]. The MDS 3.0 Nursing Home Quarterly dated July 28, 2023, showed Resident 31 with a BIMS (Brief Interview for Mental Status) score of 8 showing moderate cognitive impairment. On 10/4/23 at 12:09 p.m., Resident 31 was observed in the dining room eating her lunch. The tray ticket on her tray indicated Resident 31 was on a Mechanical Soft textured diet (a diet designed for people who have trouble chewing and/or swallowing). Resident 31 ate pieces of chicken that were too large for a mechanical soft diet. In addition, her plate of food contained vegetables that were too hard for a mechanical soft diet (cross-reference F805). In an interview on 10/6/23 at 9:25 a.m., Speech Language Pathologist (SLP) stated he recommended mechanical soft textured food for Resident 31 because she was missing teeth and did not have dentures. Review of the Speech Therapy SLP Evaluation and Plan of Treatment signed and dated by SLP on 10/26/22, showed under Clinical Impressions that Resident 31 was missing dentition resulting in prolonged mastication (chewing) and reported difficulty of masticating regular texture. Patient demonstrates adequate oral motor structures appropriate for accepting and manipulating textures of mechanical soft and thin liquids, which is patient's baseline as reported by [family member]. Review of the document titled Oral Health Care dated 7/31/23, showed Resident 31 did not want dentures. In an interview on 10/6/23 at 12:27 p.m., the Director of Nursing and Dietary Supervisor 1 (DS1) verified there was no care plan initiated for Resident 31 regarding dental issues prior to 10/6/23. The DON stated there should be a care plan for a resident with dental issues such as missing teeth and/or no dentures. Review of the undated document titled Care Plans, Comprehensive Person-Centered showed a comprehensive, person-centered care plan should include measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs. The care plan should be developed by the interdisciplinary team, with input from the resident, and his/her family or legal representative. The care plan should be developed within 21 days of admission and the care plan should be reviewed and updated by the interdisciplinary team when there is a significant change in the resident's condition, and at least quarterly.

Based on observation, interview, and record review, the facility failed to ensure one resident's (Resident 10) nutritional status was maintained when poor intake, significant weight loss, and insidious weight loss were not monitored and assessed. This failure had the potential to result in avoidable weight loss from inadequate nutrient intake for one resident out of a facility census of 51. Findings: A professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014 showed, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1. A professional reference review of BSN (Balance Senior Nutrition) Solutions, titled, Weight Loss in the Elderly: When Should You Be Concerned? dated March 19, 2018, showed, According to the Centers for Medicaid and Medicare services (CMS), weight can be a useful indicator of nutritional status when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. Insidious weight loss refers to a gradual, unintended, progressive weight loss over time. (https://www.bsnsolutions.net/weight-loss-in-the-elderly-when-should-you-be-concerned-clone#:~:text=%E2%80%9CInsidious%20weight%20loss%E2%80%9D%20refers%20to,progressive%20weight%20loss%20over%20time). The standard of practice in medical nutrition therapy is the implementation of The Nutrition Care Process (NCP) which is a framework for systematic problem-solving. It is used by nutrition and dietetics professionals to critically think and make decisions when providing safe and effective quality nutrition care. The NCP consists of four distinct, interrelated steps: Nutrition Assessment and Reassessment; Nutrition Diagnosis; Nutrition Intervention; Nutrition Monitoring and Evaluation (Academy of Nutrition and Dietetics) Review of the policy and procedure titled Weight Assessment and Intervention revised March 2022, showed the threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant and greater than 5% is severe; 3 months - 7.5% weight loss is significant and greater than 7.5 percent is severe. In addition, undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: the resident's target weight range, the resident's calorie, protein, and other nutrient needs compared with the resident's current intake, and whether and to what extent weight stabilization or improvement can be anticipated. Interventions for undesirable weight loss are based on careful consideration of the following including but not limited to: resident choice and preferences, nutritional needs of the resident, medications that may interfere with appetite, etc. Review of the policy and procedure titled Calorie Counts revised April 2007, showed resident food intake will be monitored and recorded by direct care staff on a daily basis. Direct care staff will notify nursing staff of any poor intake, defined as consumption of 25 percent or less of a meal or snack. Nursing staff will document poor intake in progress notes. Three or more episodes of poor intake in a two-day period will be reported in writing to the dietitian. Verbal communication will be confirmed in writing. A record review for Resident 10 showed he was originally admitted to the facility on [DATE] with diagnoses including but not limited to congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should), chronic kidney disease stage 3 (when kidneys have mild to moderate damage, and are less able to filter waste and fluid out of the blood), severe obesity, depression, and pulmonary edema (a condition caused by excess fluids in the lungs). The MDS (Minimum Data Set, an assessment tool) dated September 9, 2023, showed Resident 10 with a BIMS (Brief Interview for Mental Status) score of 12 showing moderate cognitive impairment. Section K of the MDS showed Resident 10 was not on a physician-prescribed weight-loss regimen. On 10/4/23 at 12:21 p.m., an observation and interview with Resident 10 showed Resident 10 was in his room sitting up in bed with his lunch tray in front of him. The food on the plate, which consisted of beef, noodles, and vegetables, appeared untouched. The juice was partially consumed, and the ice cream cup was opened and partially consumed. Resident 10 stated he did not like the food and that it tasted flat. He said he did like ice cream and juice and these items had a lot of flavor. Resident 10 also had an unopened Glucerna supplement shake (Glucerna is a low sugar nutritional supplement typically meant for diabetic patients) on his bedside table. He stated facility staff provided the Glucerna, but he was afraid to drink it because it was different from what was provided to him in the hospital. He stated the supplement he received in the hospital said for people with kidney disease on the container, but the Glucerna did not say that on the container, so he did not know if it was safe for him to drink given his diagnoses. He also stated sometimes when he did not eat his meals, staff provided him a sandwich as a substitute, but he did not like the sandwiches. A record review, for Resident 10 showed weights were recorded on the document titled Weights and Vitals Summary. Weights from 8/15/23 to 10/3/23 and were as follows: 8/15/23 286 lbs 8/22/23 282 lbs: 8/29/23 273 lbs: a loss of 13 pounds (4.5%) in 2 weeks, which is considered significant. 9/6/23 269.4 lbs: 9/12/23 269.8 lbs: 9/18/23 266.8 lbs: a loss of 19 pounds (6.7) in 6 weeks, which is considered severe. 9/21/23 263.2 lbs: 9/28/23 265 lbs: a loss of 21 pounds in 2 months (7.3%), which is considered severe. 10/3/23 260.4 lbs: a cumulative loss in 26 pounds in 9 weeks, or 9% which is considered severe. According to the parameters provided in the policy and procedure titled Weight Assessment and Intervention revised March 2022, Resident 10 consistently exhibited either significant or severe weight loss from 8/15/23 through 10/3/23. Record review for Resident 10 showed various care plans created related to nutrition status: A care plan initiated on 8/14/23 showed Resident 10 was at risk for malnutrition. The goal for this plan was to maintain adequate nutritional status as evidenced by stable weight. The interventions included but were not limited to cater to food preferences initiated on 8/14/23. A Nutritional Risk Assessment completed by RD2 on 8/15/23. In this assessment RD2 documented interventions including but not limited to, monitor po (by mouth) intake, weight . The next RD documentation for Resident 10 was a Nutritional Risk assessment dated [DATE] after Resident 10 was readmitted from the hospital (Resident 10 was away from the facility from 9/1/23-9/6/23). RD2 documented interventions including but not limited to monitor po intake, weights . There was no evaluation of Resident 10's nutrient needs in comparison to his reported intake. There was no target weight range documented. There was no documentation to show to what extent weight stabilization or improvement could be anticipated. An IDT (Interdisciplinary Team) Weight Variance note written by RD2 on 9/7/23 showed Resident 10 had a 14.2 pound (4.9%) weight loss in one month and po intake was 25-75% of diet. Interventions included but were not limited to . monitor weekly weights. There was no evaluation whether Resident 10's nutrient needs were met in comparison to his reported intake. There was no target weight range documented. There was no documentation to show to what extent weight stabilization or improvement could be anticipated. A revised care plan on 9/7/23 confirmed Resident 10 was at nutritional risk. The goal created was for Resident 10 to receive adequate calories and nutrition for stable weight. The interventions included but were not limited to for the RD to reassess as indicated. An additional care plan for unplanned/unexpected weight loss . was initiated on 9/7/23 and revised on 9/16/23. The goals created included the resident will regain lost, and the resident's weight will return to baseline range. Interventions for this care plan included but were not limited to, Alert dietitian if consumption is poor for more than 48 hours (initiated 9/16/23), If weight decline persists, contact physician and dietitian immediately (initiated 9/16/23), and Offer substitutes as requested or indicated. The resident prefers: (Resident 10's preferences were not indicated on the care plan, initiated 9/16/23). An IDT Conference Note was created on 9/29/23. The Nutrition and Eating section was documented by Dietary Supervisor 2 (DS2). The note indicated intake by mouth was variable. The IDT conference note did not reflect an RD assessment to address Resident 10's poor intake, insidious weight loss and no new interventions were recommended. This IDT note did not show an RD evaluation of nutrient needs in comparison with intake, a target weight range or documentation to show to what extent weight stabilization or improvement could be anticipated. The next documented RD note was three and a half weeks later which was a progress note written by RD2 on 10/2/23. This note read weekly weights were stable and intake by mouth had declined to 25 to 75% of diet. Interventions included but were not limited to update food preferences. There was no evaluation of Resident 10's nutrient needs in comparison to his reported intake. There was no target weight range documented. There was no documentation to show to what extent weight stabilization or improvement could be anticipated. There was no target weight range documented. There was no documentation to show to what extent weight stabilization or improvement could be anticipated. During a record review for Resident 10, the document for amount eaten showed from 8/14/23-8/23/23, 11 of 53 meals 0-25% intake, and for 18 of 53 meals 26-50% intake. From 9/6/23-9/30/23, 40 of 73 meals 0-25 % intake, and 23 of 73 meals 26-50% intake. From 10/1/23 - 10/3/23, three of eight meals showed 0-25% intake and 3 of eight meals showed 26-50% intake. The documentation also showed 2 meals were refused during this time frame in October. In addition, documentation showed Resident 10 ate 25% or less for the following dates: 4 meals from 8/29/23-8/30/23; 4 meals from 9/7/23-9/8/23; 4 meals 9/11-9/12; 4 meals 9/13-9/14; 5 meals 9/18-9/19/23; 4 meals 9/21-/9/22/23; 4 meals 9/26-9/27; from 10/2-10/3/23 Resident 10 ate 25 percent of 2 meals and refused 2 meals. Record review for Resident 10 showed on the document titled 50% or less meal consumption and/or refusal (Alternate meal/nourishment), showed in a look back of 30 days from 10/6/23, an alternate meal was provided on 9/23/23 at 2:30 p.m. There was no other documentation of an alternate provided in the 30 day look back. In an interview on 10/5/23 at 11:24 a.m., Registered Dietitian 1 (RD1) stated Resident 10's weight loss was triggered to assess when he was readmitted from the hospital on 9/6 and an IDT meeting was held and documented on 9/7/23. RD1 stated an RD assessment would be completed for residents with significant weight loss, for example weight loss of 5% in one month and/or 2% in a week. Resident 10's weight documentation was reviewed with RD1. RD1 stated his weight was not stable and he had gradual weight loss since admission. RD1 further stated Resident 10's weight loss was not significant therefore an RD assessment was not completed. RD1 stated insidious weight loss was defined as gradual continuous weight loss. RD1 stated weight loss would be considered insidious if there was a continuous downward trend of weights two weights in a row. When RD1 was asked if Resident 10 had insidious weight loss, RD1 would not confirm if Resident 10 had insidious weight loss. The interview continued with RD1 on 10/5/23 at 11:40 a.m., and Resident 10's electronic medical record was reviewed. RD1 confirmed Resident 10's food preferences were documented on August 14, 2023. RD1 was unable to confirm resident 10's food preferences were updated after August 14, 2023. RD1 added if a resident experienced weight loss, staff from the kitchen should update resident food preferences. RD1 also stated the documentation in the electronic medical record showed Resident 10 refused his bedtime snack. RD1 stated a resident had the right to refuse the snack. In an interview on 10/5/23 at 1:57 p.m., Dietary Services Supervisor 2 (DS2) stated when a resident experienced weight loss, the RD would notify her and ask her to obtain resident food preferences. DS2 confirmed there was no documentation Resident 10's food preferences were updated since his initial admission in August 2023. In an interview on 10/5/23 at 3:50 p.m., RD1 stated if a resident had insidious weight loss, an RD would assess the resident and discuss the resident in the weekly weight variance meeting. During an interview on 10/6/23 at 10:45 a.m., with the Director of Nursing (DON), she reviewed Resident 10's electronic medical record (EMR). The DON confirmed cater to food preferences documented as an intervention in Resident 10's care plan, meant the facility would provide the resident's food preferences. The DON also confirmed Alert dietitian if consumption is poor more than 48 hours which was also documented in Resident 10's care plan, meant if CNA documented poor consumption of food for more than 48 hours, the CNA reported this to the nurse and the nurse reported the poor intake to the RD. In an interview on 10/6/23 at 11:51 a.m., the DON confirmed there was no documentation by nursing of Resident 10's poor intake nor notification of poor intake by nursing to the RD. The DON also confirmed there was no documentation Resident 10's weight loss was beneficial or planned.

Based on observation, interview, and record review, the facility failed to ensure care and services provided meet professional standards for one of 13 sampled residents (Resident 43) when there was no order for the use of oxygen for Resident 43. This failure could potentially prevent staff from providing Resident 43 with appropriate treatment and care which could jeopardize the resident's health and safety. Findings: Resident 43 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - lung disease that cause airflow blockage and breathing related problems), and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred, as it worsens, become progressively more short of breath). During a concurrent observation and interview on 10/2/23 at 11:00 AM with Resident 43 in the resident's room, Resident 43 was on oxygen at 2L/min (liters/minute) via nasal cannula (device that delivers extra oxygen through a tube and into the nose that help people who are having difficulty breathing). Resident 43 stated, My nose is stuffed. During a concurrent interview and record review on 10/4/23 at 3:32 PM with Registered Nurse (RN) 2, Resident 43's Order Summary Report (OSR) with active orders as of 10/4/23 was reviewed. RN2 verified that Resident 43 uses oxygen and stated, He's on oxygen 24/7 via nasal cannula at 2L/min for shortness of breath. RN2 acknowledged that the OSR did not reflect an order for the use of oxygen for Resident 43. RN2 stated, I don't believe there's an order for oxygen. I don't see it. RN2 further said, Yes, there should be an order, so we know how much to give/administer per MD (doctor of medicine). Review of facility policy titled, Oxygen Administration revised October 2010, indicated, .Preparation .1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration .

Based on observations, interview, facility document and record review, the facility failed to ensure resident food was stored, prepared, distributed and served under sanitary conditions when: 1. Unpasteurized shelled eggs were available upon request for 45 residents (residents who ate food from the kitchen and an egg allergy or dislike for eggs was not indicated) and served to Resident 46 when they were not cooked to ensure all parts of the eggs were completely firm to eliminate the risk of salmonella infection (salmonella is a bacteria and a common cause of food borne illness, sometimes called food poisoning); 2. Dietary staff did not follow proper hand hygiene and handling of utensils; 3. Storage areas, equipment, and utensils were dirty; 4. Equipment was in disrepair and had rough surfaces; 5. A proper procedure for thawing meat was not followed; 6. Proper storage guidelines were not followed to help prevent cross contamination of food in the refrigerator; and 7. Steam table and ice machine did not have an air gap. These failures had the potential to result in food borne illness, with the possibility of death, in a highly susceptible population of 47 residents who received food from the kitchen out of a census of 47 residents. An Immediate Jeopardy situation was declared on (MONTH) 20, 2019 at 2:04 p.m., in the presence of the Administrator due to the facility's failure to ensure unpasteurized shelled eggs were cooked until all parts of the eggs were completely firm to eliminate the risk of salmonella infection before serving to Resident 46. Findings: 1. During the initial tour of the kitchen on 3/18/19 at 8:51 a.m., an observation showed flats of shell eggs were stacked on top of one another in the reach-in refrigerator. The stacked eggs were stored directly next to a ready-to-eat baked pie. The eggs were not stored in a box or stamped with a letter P to indicate if the eggs were pasteurized (eggs are often delivered in a box that has a label to indicate if the eggs are pasteurized and pasteurized eggs are distinguishable from unpasteurized eggs by a P stamped on the shell; A pasteurized egg is an egg that has been gently heated to eliminate bacteria. The process makes the pasteurized egg safe to use in recipes that call for a raw or undercooked egg.) During a concurrent interview and observation with the Certified Dietary Manager (CDM) on 3/18/19, at 8:51 a.m., when the surveyor asked the CDM if the shell eggs were pasteurized, he stated it showed on the invoice from the vendor that the eggs were pasteurized and they were USDA (United Stated Department of Agriculture) eggs so he assumed they were pasteurized. Review of the invoice from the vendor with a delivery date of 3/13/2019, showed 15 dozen extra-large AA USDA shell eggs. The invoice did not indicate pasteurized. The CDM then stated he would call the vendor for documentation that the eggs were pasteurized. According to the USDA Specifications for Shell Eggs, dated 11/10/17, eggs are eligible to carry the USDA trademark such as USDA AA when they are packed under a program to help ensure they meet quality and size standards, and the plant processing equipment, facilities, sanitation and operating procedures meet established requirements. Based on this information from USDA, the USDA AA trademark does not indicate eggs are pasteurized. Review of the facility document titled, Organization of Refrigerated Food Storage dated 1/15/19, showed pictures of food and how they should be organized on the refrigerator racks from top to bottom. The document showed that ready-to-eat foods (foods that will not be cooked before eaten and the standard of practice requires special precaution to protect food ready-to-eat food from contamination before it is eaten) are stored on the top rack and pasteurized shell eggs on the rack below ready to eat foods. During an interview on 3/20/19 at 9:29 a.m., the CDM stated he spoke with the vendor and they stated the shell eggs sent to the facility were not pasteurized. He also stated the vendor website did not indicate the eggs ordered were pasteurized. During an interview on 3/20/19 at 9:33 a.m., with Cook 1 and the CDM, Cook 1 stated sometimes residents requested soft eggs and that one resident, resident 46, ate sunny side up eggs (eggs fried on one side and never flipped. The yolk is runny and the whites are just set) every day. The CDM confirmed resident 46 did request and ate soft cooked eggs and he spoke with the resident to ask him not order them soft cooked but the resident said to him, that is how he always ate them and wanted them served soft. According to the U.S, Food and Drug Administration (FDA), Egg Safety Final Rule, dated 1/26/18, fresh eggs, may contain a bacteria called Salmonella that can cause foodborne illness. The FDA estimates 79,000 cases of foodborne illness and 30 deaths each year are caused by eating eggs contaminated with Salmonella. Also, egg-associated illness caused by Salmonella is a serious public health problem and that individuals may suffer mild to severe gastrointestinal illness such as diarrhea, fever, abdominal cramps, and vomiting, short term or chronic arthritis, or even death. The FDA requires that all cartons of shell eggs that have not been treated to destroy Salmonella to carry the safe handling statement: Safe Handling Instructions To Prevent illness from bacteria: keep eggs refrigerated, cook yolks until yolks are firm, and cook foods containing eggs thoroughly. According to the Centers for Disease Control (CDC), under Salmonella and Food and Five Facts that (MONTH) Surprise you, to avoid Salmonella, you should never eat raw or lightly cooked (runny whites or yolks) eggs. Cooking reduces the number of Salmonella bacteria present in an egg. However, a lightly cooked egg with a runny egg white or yolk still poses a greater risk than a thoroughly cooked egg. Lightly cooked egg whites and yolks have both caused outbreaks of Salmonella infections. Although anyone can get a Salmonella infection, older adults, infants, and people with impaired immune systems are at increased risk for serious illness. In these people, a relatively small number of Salmonella bacteria can cause severe illness. According to the Federal Food Code (YEAR), although foodborne illnesses can be severe or even fatal, milder cases are often not detected through routine surveillance. According to the Food Code, eggs are still a major source of Salmonella infections, causing large outbreaks when they are combined and undercooked so special added precautions need to be in place with those most susceptible to foodborne illness. The Food Code defines a highly susceptible population as persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such as custodial care, health care, or assisted living, such as a child or adult day care center, kidney [MEDICAL TREATMENT] center, hospital or nursing home, or nutritional or socialization services such as a senior center. Review of Resident 46's clinical record indicated he was [AGE] years old admitted on [DATE] with [DIAGNOSES REDACTED]. The Comprehensive Minimum Data Set ((MDS) dated [DATE] showed on a scale of 0-15 with 15 the best score for cognitive status, Resident 46 scored a 12 for his mental status which indicated the resident was interviewable with moderate cognitive impairment. During an interview on 3/20/19 at 11:27 a.m., Resident 46 stated he liked his eggs served sunny side up, over easy, and straight up. He explained he liked them runny with his hotcakes. During an interview on 3/20/19 at 11:52 a.m., the CDM stated he served runny or undercooked eggs to any resident that requested them. He stated he was aware that serving unpasteurized, undercooked eggs was not safe. Then he stated but it was only for one resident. During an interview on 3/20/19 at 3:42 p.m., Resident 46 stated he asked for and received runny eggs starting a week after he was admitted to the facility. He stated that all the cooks prepared his eggs runny, but he liked the way the CDM prepared them the best. During an interview on 3/20/19 at 4:12 p.m., the CDM confirmed he cooked eggs for resident 46 and that the resident liked them runny so he cooked them so the yolk was hard on the surface and runny in the middle. During an interview and concurrent observation on 3/20/19 at 5:24 p.m., the CDM showed there were 15 dozen pasteurized eggs in the kitchen. The CDM said the eggs were just brought into the facility. The eggs were in a box that was labeled Pasteurized Shell Eggs and the eggs had a letter P stamped on the outside of the shell. On (MONTH) 20, 2019, at 7:28 p.m., the Immediate Jeopardy situation was lifted in the presence of the Administrator when the survey team approved the facility's Corrective Action Plan and after observations, interviews and record reviews confirmed that the dietary staff was knowledgeable on safe handling of unpasteurized shelled eggs. The Corrective Action Plan included the following components: a. No apparent negative outcome was noted from Resident 46 upon nursing assessment for signs and symptoms of Gastrointestinal illness (GI). The resident will be monitored by nursing staff every shift for one week for any signs and symptoms of GI illness and the Physician will be notified as needed. b. Upon Administrator's interview with the CDM, it was confirmed that there were no other residents that were served undercooked eggs and the nursing communication report was reviewed by the Director of Nursing and no residents exhibited signs and symptoms of GI illness for the last 2 weeks. c. Dietary Manager will only purchase pasteurized eggs from approved sources for all residents beginning on 3/20/19 at 1500 (3:00) p.m. All unpasteurized eggs will be discarded on 3/20/19 at 1600 (4:00) p.m. In the event that the facility runs out of pasteurized eggs, the Dietary Manager or designee will have pasteurized eggs ordered immediately. Residents will be informed of the possibility of wait times and alternative meal options will be offered. If pasteurized eggs cannot be obtained it will be explained that they are not available. d. The Dietary Manager or Designee will track weekly on an audit log that pasteurized eggs are delivered at the facility and will discuss any findings during stand up meetings. The Dietary Manager or Designee will provide compliance written report to the Quality Assurance Performance Improvement (QAPI) Committee during monthly meetings for 3 months with the goal to be in 100 percent compliance of serving pasteurized eggs to residents at the facility. After 3 months of written reports, the Administrator will perform quarterly audits on the ordering of pasteurized eggs with the goal to be in 100 percent compliance in ordering pasteurized eggs. During an observation and concurrent interview with Resident 46 on 3/21/19 at 7:39 a.m., Resident 46 was in the dining room eating his breakfast. The resident had 2 eggs and pancakes on his plate. There was orange liquid spread over the plate. Resident 46 stated this was how he liked his eggs cooked and he pointed to the thick, orange liquid on his plate. When he cut into another yolk with his knife, the yolk was not firm, and ran out onto the plate. He also stated that this was how the facility usually served his eggs for breakfast every morning. During an interview on 3/21/19 at 9:28 a.m., the CDM stated he ordered the eggs. He said all the eggs came from one vendor and he ordered what was already locked into the formulary. He explained the formulary was a locked-in order so the same thing was ordered each time. He said he assumed the eggs were pasteurized but now he did not think they ordered and received pasteurized eggs for the past year. Review of the food vendor invoice submitted on 3/20/2019 to order pasteurized eggs, and had a Delivery Date of 3/21/19, showed the description of the shell eggs included the word pasteurized. During an interview on 3/22/19 at 12:50 p.m., the surveyor asked the facility to provide written documentation from the egg vendor to show if pasteurized eggs were delivered to the facility in the past year. The Regional Director of Clinical Services (RDCS) stated they would not get a written confirmation and the facility would only provide invoices from the company. Review of purchase orders for eggs from 3/18/18 to 3/20/19 did not indicate the word pasteurized to show that pasteurized eggs were ordered between these dates. Review of the Resident tray-line tickets (a ticket used by the kitchen staff to identify what food to place or not to place on a resident meal tray) dated 3/22/19 showed one resident did not like eggs and one resident had an allergy to eggs. There were a total of 47 tray line tickets. Each for a different resident. During an interview and concurrent record review with the Administrator on 3/22/19 at 10:50 a.m., the Administrator stated the egg policy provided to the surveyor was in place prior to the beginning of the survey. A review of the undated policy titled, Eggs, read, The Food and Nutrition Services Department should ensure that eggs are prepared in a manner to . be free of salmonella and acceptable to the resident. Procedure . 4. Do not use raw eggs as an ingredient in the preparation of uncooked, ready-to-eat menu items unless using pasteurized eggs. 2. Dietary staff did not follow proper hand hygiene and handling of utensils as evidenced by: a. During an observation on 3/19/19 at 11 a.m., Cook 1 touched the sprayer (dirty side of dish machine) to rinse off the food processor, then went back to prepare food for tray line without washing his hands. During an observation on 3/19/19 at 11:10 a.m., Cook 1 wore gloves while preparing sandwiches. Changed gloves and did not wash hands and continued to prepare the sandwiches. Cook 1 removed his gloves and did not wash hands, then handled clean plates to put the sandwiches on. Then Cook 1 continued to prepare for the start of tray line. During an interview on 3/19/19 at 11:43 a.m., the Certified Dietary Manager (CDM) stated hands must be washed every time gloves are removed. He also stated staff must wash their hands before putting on gloves and when gloves are removed before beginning another task. During an interview on 3/20/19 at 10:18 a.m., Cook 1 stated he needed to wash his hands every time there was a change in an activity and when he changed gloves. During an interview on 3/21/19 at 11:13 a.m., the Registered Dietitian (RD) stated hands had to be washed between changing gloves, before putting on gloves, and after touching the sprayer on the dirty side of the machine and starting a new task. During a review of facility document titled, Proper Handwashing dated 11/17/19, indicated employees will understand the importance of proper handwashing and the proper handwashing technique .hands must be washed: after contact with unsanitary surfaces (i.e. soiled dishes, pots and pans, garbage, cleaning .before putting on gloves. b. During an observation on 3/19/19 at 11:05 a.m., Cook 2 handled utensils by the part that goes into the resident's mouth when placing the utensils on resident's trays. Cook 2 also handled the eating end of the utensils that were in the plastic tray used to store utensils. During an interview on 3/19/19 at 11:07 a.m., Cook 2 confirmed she touched the eating end of the utensils with her bare hands and stated, I washed my hands so it's okay to touch them (forks, spoons, knives). During an interview with the CDM on 3/19/19 at 11:10 a.m., the CDM stated Cook 2 should not touch the eating end of utensils with bare hands; she should touch only the utensil handles and it was okay to touch the eating end of utensils only if she wore gloves. During an observation on 3/19/19 at 11:39 a.m., Cook 2 touched the spout of a water pitcher with her bare hands. The water pitcher was used for pouring water into a blender to liquefy resident food. During an interview on 3/19/19 at 11:41 a.m., Cook 2 stated it was okay to touch the spout without gloves because, I washed my hands. During a review of facility document titled, Temperatures and Safe Food Handling, it indicated, .g. do not handle food or utensils with bare hands . c. During an observation on 3/19/19 at 11:31 a.m. Diet Aide 1 (DA 1) filled plastic cups with milk, juice, and water and handled the cups at the top, where residents place their mouth, with bare hands. During an interview with the DA 1 on 3/19/19 at 11:36 a.m., the DA 1 stated the proper place to hold a glass was in the middle. During review of facility document titled, Temperatures and Safe Food Handling indicated .g. do not handle food or utensils with bare hands . 3. Storage areas, equipment, and utensils were dirty as evidence by: During the initial tour of the kitchen, an observation and concurrent interview on 3/18/19 at 8:51 a.m., showed the inside of the microwave had a significant amount of dry, orange residue that covered the inside, top surface. The inside surface also had a significant amount of black residue in the corners. The residue wiped off with a paper towel. The CDM stated it (the microwave) could use a wipe down. He also said that the microwave was supposed to be cleaned after each use as well as 3 times a day. As the initial tour continued, an observation and concurrent interview with the CDM, showed the lowerater (a piece of equipment that holds plates) had a significant amount of greasy, black residue around the area where the plug cord was connected. The residue wiped off with a paper towel. The CDM confirmed there was black residue. Continuing the initial tour, a cabinet located under the steam table was lined with cardboard. The cardboard was discolored and had black residue on the surface. Pans were stored on top of the cardboard that the CDM identified as pans that were used on the tray line. Under the cardboard were a significant amount of crumbs and brown and black residue. There was a container of instant coffee stored on in the cabinet on top of the cardboard. The CDM stated the coffee was for a resident. He also stated food was not supposed to be stored in the cabinet but people just to it. The CDM stated the cardboard surface was not cleanable. Also under the steamtable were large drawers that held large muffin pans, lids to pots, and a clear plastic container. The inside surface of the drawers had a black, greasy residue and a muffin pan rested against and came in contact with the black, greasy surface. The drawers, when closed were exposed to the underside of the steam table where there were pipes. The pipes had a residue that wiped off. The contents in the drawers (muffin pans and lids) had brown and black crumbs on the surface. The CDM stated the pans and lids were not clean. The clear plastic container in the drawer, which the CDM identified as a container to fill the steam table with water, had white, green, and brown residue on the inside surface. The residue wiped off with a paper towel. The CDM confirmed the storage areas under the steam table were not clean and he stated that the areas under the steam table were not on a cleaning schedule. Review of the document titled, Food Storage dated 2011, showed for dry food storage, walls, ceiling, and floor should be . regularly cleaned. Review of the document titled, lowerator dated (YEAR), stated daily cleaning included 2. Wipe down stainless steel on entire unit. Review of the document that the CDM identified as the cleaning schedule for the kitchen titled House Cleaning Daily/Weekly Schedule revised 7/20/03, listed areas and equipment in the kitchen. The steam table, all carts in the cooks' area, and microwave were on the list and showed they were cleaned twice a day, 7 days a week. It was noted that the cleaning schedule did not specifically identify the cabinets and drawers under the steam table and the lowerator. The cleaning schedule did not identify if the equipment and areas were cleaned, for instance there was not a to check or initials. During an interview on 3/21/19 at 09:12 a.m., the CDM confirmed there was no documentation to show that cleaning was done by staff or checked off by a supervisor. Review of the Policy and Procedure titled, Cleaning Schedules dated (YEAR), showed 7. Under the days of the week or the weeks, the Director of Food and Nutrition Services or other clinically qualified nutrition professional can check off assignments completed or the employee initial. According to the (YEAR) Federal Food Code all food-contact surfaces of cooking equipment and pans shall be kept free of soil accumulations and nonfood-contact surfaces of equipment shall be kept free of and accumulation of dust, dirt, food residue, and other debris. 4. Equipment was in disrepair and had rough surfaces as evidence by: During the initial tour of the kitchen on 3/18/19 at 8:51 a.m., an observation and concurrent interviews with the CDM, showed the plastic edge all along the lower edge of the cooking cavity of the microwave was worn away and exposed a black material. When the black material was wiped with a paper towel, a brownish red residue wiped off. The CDM identified the residue as rust and stated the microwave was old and worn and needed to be replaced. As the initial tour continued, the lowerator weldment heads (a part of the equipment that holds stacked plates in place) had a coating that was worn off and exposed metal. The exposed metal appeared brownish orange in color. When wiped with a paper towel, a brownish orange residue wiped off. The CDM said the residue was rust. He also stated he was responsible for reporting to the Administrator when equipment needed repair or needed to be replaced and he did not report either the microwave or the lowerator. Continuing the initial tour, caulking (a waterproof substance to seals openings) around the steam table wells had jagged edges, was loose, and was discolored with a brown residue. Also, a wooden preparation table located next to the oven range, had a significant deep gap between the raised wood edge of the table and a metal wall. Between the gap was a hard, rough, chunky black and brown material. During an interview on 3/22/19 at 11:03 a.m., the RD stated the caulking around the steam table wells was disintegrating and the gap in the wood table would be difficult to clean. Review of the undated Policy and Procedure titled, Operation and Sanitation read 5. When equipment is not functioning correctly or there are cracks and chips in the walls or floors, write a work order to request repair/maintenance of the equipment and follow up to ensure repair work is completed. According to the (YEAR) Federal Food Code, nonfood-contact surfaces of equipment and food-contact surfaces are to have smooth surfaces for cleanability and equipment and physical facilities shall be maintained in good repair. 5. A proper procedure for thawing meat was not followed as evidence by: During an observation on 3/18/19 at 1:58 p.m., it showed meat thawing in a sink. A large piece of wrapped meat was in a metal pan and on top the wrapped meat was a 5-pound package of ground beef. The meat in the pan was submerged in water and 80 percent of the ground beef package outside of the water, not submerged. Water from the faucet ran to the side of the ground beef into the pan but the running water from the faucet did not come into contact with the beef. During an interview on 3/21/19 at 11:25 a.m., the RD stated one way of thawing meat was under cool running water. He also stated running water over the meat was fine but did not necessarily have to be submerged. Review of the document titled, Thawing Food dated 2019, showed when thawing food under running water, the food is submerged under running water. A pictorial showed a turkey in a pot fully submerged in water with water running over the top. 6. Proper storage guidelines were not followed to help prevent cross contamination of food in the refrigerator as evidence by: During the initial tour of the kitchen on 3/18/19 at 8:51 a.m., an observation and concurrent interview with the CDM showed two large, shallow baking sheets holding raw chicken. One baking sheet with the chicken were stacked on top of a box bacon and the other was stacked on top of a box of raw ground beef. Directly next to the baking sheet of chicken was a baked ready to eat pie. Also stored directly next to the ready to eat pie were flats of unpasteurized shell eggs not enclosed in a box. The CDM confirmed the order of how the items were stored in the refrigerator. During an interview on 3/19/19 at 2:36 p.m., the CDM stated the ready to eat pie, such as the peach pie observed in the refrigerator and was served to residents for lunch yesterday, should have been stored on the top rack of the reach in refrigerator not down below by the raw chicken and shelled eggs. He also stated because the raw chicken was not dripping that it was okay to store on top of the bacon and raw ground beef. During an interview on 3/21/19 at 11:25 a.m., the RD stated ready to eat pie should be stored above thawing meats and it was not appropriate for raw chicken to be stored over ground beef and bacon. Review of the document titled, Organization of Refrigerated Food Storage dated 2019, showed a pictorial of the order of food storage in a refrigerator. From the top rack to the bottom rack the order showed ready to eat foods at the top, then below the ready to eat food pasteurized eggs, then raw whole muscle meats, then raw ground meats such as ground beef, then on the bottom rack raw poultry. 7. Steam table and ice machine did not have an air gap as evidence by: During an observation on 3/18/19 at 9:43 a.m., showed a drain pipe under the steam table. The pipe led into a raised metal opening. There was no air gap. Further observations showed a drain pipe that lead from the ice machine and went through the wall to the outside. Outside the pipe from the ice machine connected directly to another raised pipe that went into the ground. There was no air gap. During an interview on 3/20/19 at 2:43 p.m. the Maintenance Supervisor (MS) confirmed the pipe leading from the ice machine into the ground was the drain pipe. He stated the pipe that went into the ground that the ice machine drain pipe was connected to the sewer. He confirmed that there was no air gap. During an interview on 3/21/19 at 9:54 a.m. with the MS, he confirmed that the pipe under the steam table drained the water from the steam table and went directly into the raised drain without an air gap. According to the (YEAR) Federal Food Code, an air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or NONFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch)

Based on interview and record review, the facility failed to provide adequate supervision and intervention for two of 37 sampled resident (Resident 44 and Resident 214) when: 1a. For Resident 44, there was no resident assessment to identify and evaluate hazard and risk to prevent fall incident on 2/28/18, 3/27/18, and 4/1/18, b. The Interdisciplinary Team (IDT) recommended intervention did not address fall risk factor such as confusion, weakness, and unsteady gait to prevent fall incidents on 2/28/18, 3/27/18, and 4/1/18' c. There was no evidence of monitoring for the effectiveness and necessary modification of recommended intervention, d. There was no plan of care developed to address fall risk and intervention to prevent fall incidents on 2/28/18, 3/27/18, and 4/1/18; 2. The lighter used for smoking was kept in the possession of Resident 214. Inability to maintain safe smoking practices could result in accidents. These deficient practices resulted in Resident 44's multiple fall incidents (on 2/28/18, 3/27/18 and twice on 4/1/18). The fall incident on 4/1/18 resulted in right head hematoma (a solid swelling of clotted blood within the tissues) and bruising on the right side of the face, neck, and thigh. Findings: 1. Resident 44 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During an observation, on 4/12/18, at 09:18 AM, Resident 44 was standing in the doorway of her room. There was a huge bump on the right side of her forehead (approximately 1 inch in diameter and 1 centimeter (cm) in height) and a bruise on the right side of her face from the right eye brow to the neck area. The bruise on her face appeared greenish and yellowish and the bruise on her chin was purplish in color. Review of Resident 44's Admission Minimum Data Set (MDS, an assessment tool) with Assessment Reference Date (ARD) of 1/23/18, indicated a severe cognitive impairment. Under functional status, indicated, Resident 44 required limited assistance on bed mobility, transfer, walk, and locomotion in room and corridor. Limited assistance means resident highly involved in activity, staff provide guided meneuvering of limbs . According to the Centers for Disease Control and Prevention (CDC) Cognitive Impairment . article, Published on (MONTH) 2011, retrieved from https://www.cdc.gov/aging/pdf/cognitive_impairment/cogimp_policy_final.pdf, .Severe cognitive impairment is when a person has trouble remembering, learning new things, concentrating or making decisions that affect their everyday life .Severe level of impairment can lead to loosing the ability to understand the meaning and importance of something and the ability to talk or write, resulting in the inability to live independently . Review of Resident 44's Fall Risk Observation/ Assessment, dated 1/13/18, under balance and mobility, indicated, Non-ambulatory/ wheelchair for locomotion. Under the cognitive status and behavior indicated, .easily distracted; periods of altered perception or awareness of surroundings; episodes of disorganized speech; periods of restlessness . Review of Resident 44's Nurse's Progress Notes, dated 2/28/18, indicated, Witnessed (resident) rolling out of bed at 5:30 AM with redness on her left face c/o (complain of) hit (her) face on floor .rolling off from the low bed .Noted with redness and mild swelling on left side of face .(Resident) informed that she has pain on her left shoulder when raise left hand . Review of Resident 44's IDT Progress Notes, dated 3/1/18, indicated, the fall incident on 2/28/17 was discussed during the meeting with a recommendation to Reeducate use of call light. Continue to keep bed in low position. Review of Resident 44's Nurse's Progress Notes, dated 3/24/18, indicated, .noted ambulating in the hallway . resident noted right side flaccid (limply) with right facial droop (sagging of the face). Unable to talk and stare on one direction .(At) 8:04 (AM) transferred out to (name of the hospital). Review of Resident 44's Fall Risk Observation/ assessment dated [DATE], indicated Resident 44's vision status was impaired, had changes in cognitive status and behavior, and ambulates with problems and with devices (gait is unsteady, slow, lurching). Review of Resident 44's Nurse's Progress Notes, dated 3/27/18, indicated, .right sided weakness . appears with unsteady gait and high risk for falls . Review of Resident 44's Nurse's Progress Notes, dated 3/28/18, indicated, (Resident) alert and verbally responsive with confusion. S/P (status [REDACTED].Noted Res with unsteady gait . Review of Resident 44's IDT notes, dated 4/3/18, indicated, IDT met on 3/28 to discuss fall on 3/27. IDT recommendation included, place visual reminder for resident to use the call light for assistance. There was no recommendation to address the cognitive status, behavior, and unsteady gait of Resident 44. Review of Resident 44's Nurse's Progress Notes, dated 4/1/18, at 2:31 AM, indicated, .resident ambulating in the hallway from the nursing station towards her room and suddenly tip over and landed her buttocks on the floor . Further review of Nurse's Progress Notes at 7:01 AM, indicated, .(at) 6 (AM) heard a blog sound went to resident room resident noted sitting next to the door of the bathroom .noted a big lump on her right parietal area (relating to or denoting the wall of the body) .hematoma measured 7 cm (centimeter) x 6 cm length and 1 cm height . Noted mild blood from the bump .Around 10:15 AM (resident) complains of pain on her right leg .Noted unstable while walking .Unwitnessed fall . There was no indication that resident received supervision or assistance while walking in the hallway and when he tried to ambulate and was found sitting next to the door of the bathroom. Review of Resident 44's record indicated that there were only two post fall review completed, dated 3/1/18 and 4/1/18. The post fall review dated on 3/1/18 did not indicate the date of fall incident under review and the document was signed on 3/31/18. There was no evaluation and analysis of fall risk and cause of fall incidents (2/28/18, 3/27/18, and 4/1/18) documented. During an interview, on 4/12/18, at 11:30 AM, the Director of Nursing (DON) acknowledged there was no care plan initiated to address the risk for fall and/or intervention to prevent fall incident and stated, I don't see it here (care plan). Review of Resident 44's care plan indicated that the care plan addressing Recurrent falls related to weakness, confusion, poor safety awareness, unsteady gait . was initiated on 4/1/18 (after four fall incidents). The care plan addressing .potential for impaired functional mobility and gait . was initiated on 4/6/18 (5 days after the last fall incident). During an interview, on 4/18/18, at 1:21 PM, the DON acknowledged there was no post fall review for 2/28/18 and 3/27/18 fall incidents. The DON stated, Each incident should have a post assessment. Review of the facility policy titled, Assessing Falls and Their Causes, dated (MONTH) 2010, indicated, .The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .General Guidelines .5. Residents must be assessed in a timely manner for potential causes of falls .Performing a Post-Fall Evaluation: 1. After a first fall, a nurse and/or physical therapist will watch the resident attempt to rise from a chair .and will document the result of this effort .3. If the individual has difficulty or is unsteady in performing this test, additional evaluation may be initiated as warranted .Documentation .5. Completion of a fall risk assessment. 6. Appropriate interventions taken to prevent future falls . Review of the facility policy titled, Fall Risk Assessment, dated (MONTH) 2007, indicated, .4. The Attending Physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions or sensory impairments (such as decreased vision .) that may predispose to falls. 5. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls .8. The staff and Attending Physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. The Agency for Healthcare Research and Quality (AHRQ) article titled, The Falls Management Program: A Quality Improvement Initiative for Nursing Facilities, published on (MONTH) 2005, obtained from https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/injuries/fallspx/fallspxmanual.pdf, indicated, .Past history of a fall is the single best predictor of future falls. In fact, 30% - 40% of those residents who fall will do so again. Thus, it is crucial for staff to respond quickly and effectively after a fall. The Fall Response is a comprehensive approach that forms the backbone of the Falls Management Program (FMP). It includes the following eight steps: 1. Evaluate and monitor resident for 72 hours after the fall. Immediate evaluation by the nurse after a resident falls should include a review of the resident systems and description of injuries . 2. Investigate fall circumstances. If fall circumstances are not investigated at the time of the incident, it is very difficult later to piece together the event and to determine what risk factors were present. Even when a resident is found on the floor after an unwitnessed fall, direct care staff can use their experience and knowledge of the resident to make educated guesses based on the evidence . 3. Record circumstances, resident outcome and staff response. A written full description of all external fall circumstances at the time of the incident is critical. This includes factors related to the environment, equipment and staff activity . 4. FAX Alert to primary care provider . 5. Implement immediate intervention within first 24 hours. An immediate response should help to reduce fall risk until more comprehensive care planning occurs . Some examples of immediate interventions are: Increased toileting with specified frequency of assistance from staff. Increased assistance targeted for specific high-risk times. Increased monitoring using sensor devices or alarms. Increased staff supervision targeted for specific high-risk times. Pain management .Protective clothing (helmets, wrist guards, hip protec-tors). Safe footwear. Low bed/mat. Specific behavior management strategies . 6. Complete falls assessment . 7. Develop plan of care .Results of the Falls Assessment, along with any orders and recommendations, should be used by the interdisciplinary team to develop a comprehensive falls care plan within 1-7 days after the fall . 8. Monitor staff compliance and resident response. While the falls care plan may include potentially effective interventions, it is staff compliance that will reduce fall risk. A programs success or failure can only be determined if staff actually implement the recommended interventions .Resident response must also be monitored to determine if an intervention is successful. Changes in care and alternate interventions should be decided based on continued assessment of the resident and family input . 2. Resident 214 was admitted on [DATE] with [DIAGNOSES REDACTED]. During an interview on 4/10/18, at 1:11 PM, Resident 214 confirmed he is a smoker and stated, I only smoke once or twice a day. During an observation on 4/10/18, at 1:12 PM, the Registered Nurse (RN) 1 showed the container for the safekeeping of the cigarette that was kept in the nurse's station. There were two cigarette boxes inside the container. There was no lighter observed. During an interview, on 4/10/18, at 1:38 PM, the DON stated, He (Resident 214) goes to the corner store to buy cigarette. The DON did not offer an answer when asked how the facility ensures the safety of Resident 214 when he goes out and smoke or buys a cigarette from the store. The DON confirmed that safekeeping of the cigarette in the nurse's station was initiated today (4/10/18). During an interview, on 4/11/18, at 9:24 AM, Resident 214 stated,They (facility) change the policy recently, like two days ago. Before I'm keeping my cigarette in my property now I have to give it to them. I'm keeping my lighter, it's in my pocket. Review of Smoking Policy, dated (MONTH) (YEAR), indicated, .This facility shall establish and maintain safe resident smoking practices .10. Residents who have independent smoking privileges are not permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. All other forms of lighters, including matches, are prohibited .