Every finding on record at St Anthony Care Center

Based on interview and record review, the facility failed to provide an accurate medication list that included both prescription and over-the-counter medications at the time of discharge to one out of three (Resident 1) reviewed residents. This failure resulted in Resident 1 not receiving prescribed wound care treatment for six days post discharge. Findings: During a review of Resident 1's admission Record, dated 5/22/25, the document indicated Resident 1 was admitted to the facility in March 2025 with multiple diagnoses, including pressure ulcer of sacral region (lower back), Stage 3 (also known as a bedsore, a wound that affects the top two layers of skin), hypertension (high blood pressure), and pain in left nnee. The document indicated Resident 1 was discharged from the facility on 5/16/25. During a phone interview on 5/22/25 at 2:00 p.m. with Family Member 1 (FM1), FM1 stated when she picked up Resident 1 from the facility on 5/16/25, she did not receive any verbal instructions about wound care. FM1 stated she received handwritten discharge instructions and there was nothing on the handwritten instruction sheet about wound care. FM1 stated she also received a printout written in medical terms. FM1 stated the printed instructions read, Instructions for sacrum, cleanse with NS apply Medihoney cover with foam dressing, secure tape as needed, TX every evening shift. FM1 stated she does not know what TX or NS means, and stated she did not receive a prescription for Medihoney (a gel to help heal wounds) and does not know if it could be purchased over the counter. FM1 stated she did not understand how to follow these instructions or have access to the necessary supplies. FM1 stated that Resident 1 did not receive the prescribed wound care between the time he was discharged from the facility on 5/16/25 until the home health nurse arrived on 5/22/25. In a concurrent interview and record review on 5/23/25 at 11:03 a.m. with the Director of Nursing (DON), Resident 1's Physician's Other Order, dated 5/14/25, was reviewed. DON stated the document indicates Resident 1 may discharge home with current medication orders and treatment. DON stated the current medication orders for Resident 1 included the application of Medihoney to his sacrum for his stage 3 pressure ulcer. In a concurrent interview and record review on 5/23/25 at 11:08 a.m. with DON, Resident 1's Discharge Medication, dated 5/14/25, Nursing Discharge Summary Instructions, dated 5/16/25, and Order Summary Report, dated 5/1/25 were reviewed. DON stated Resident 1 should have received all three of the documents at the time of discharge. DON stated there were no wound care medications or instructions on Nursing Discharge Summary Instructions or Discharge Medication documents. DON stated the only mention of wound care instructions was on the Order Summary Report . DON stated the Order Summary Report stated, Tx to sacrum PU stage 3: Cleanse with NS, apply Medihoney, cover with foam dressing, secured with tape every evening shift until further notice . DON stated these instructions were written using medical terminology and they are not written in a way that non-medical professionals could easily understand. DON stated the order for Medihoney should have been discontinued and an order for Zinc Oxide cream (a barrier cream that is put on wounds to help them heal) should have been entered. DON stated instructions for wound care should have been written on the Discharge Medication document under the section Discharge Medications (Over the Counter) . In a concurrent interview and record review on 5/23/25 at 11:08 with DON, the Electronic Medical Record (EMR) for Resident 1 was reviewed. DON stated she could not find a record in the EMR that wound education was completed with Resident 1 prior to discharge. In a review of facility's policy titled Transfer or Discharge, Preparing a Resident for, dated 12/2016, the policy indicated A post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility and Nursing Services is responsible for: . preparing the discharge summary and post-discharge plan .

Based on observation, interview and record review, the facility failed to ensure safe, sanitary storage and distribution of foods when 1. dates of opened food packages were not labeled. 2. temperatures of prepared foods were not logged that were served to residents for dinners on 10/7/24 and 10//14. These failures had the potential to place all residents getting meals from the kitchen to be at risk for foodborne illness potentially leading to hospitalization or death. Findings: 1. During an observation on 10/21/24, at 10:05 a.m., in the dry storage room, opened bottles of Liquid Seasoning, Tabasco sauce and Tapatio sauce were not labeled with dates they were opened. A bag of opened, shredded coconut was labeled with an open date of 1/9/24. During a concurrent observation and interview on 10/21/24, at 10:10 a.m., with the Registered Dietician (RD), in the dry storage room, the RD stated staff were supposed to write the dates when items were opened and were not doing so. RD stated it was unknown when the items were opened and how long they were stored after opening. RD stated there are guidelines on how long dry goods are stored for. During an interview on 10/24/24, at 10:50 a.m., with the RD, the RD stated the food quality could be compromised when guidelines of food storage were not followed. During a review of the document, Dry Goods Storage Guidelines, dated 2018, the document indicated opened bottled sauces could be stored on the shelf for one year. For the shredded coconut, the document indicated it could be opened and on the shelf for 6 months. During a review of the policy and procedure P&P, titled, Storage of Food and Supplies, dated 2017, the P&P indicated liquid foods which had been opened would be labeled and dated. 2. During a review of the food temperature checklist on 10/21/24, at 10:20 a.m., no temperatures of foods served for dinner were recorded on 10/7/24 and 10/14/24. During an interview on 10/21/24, at 10:50 a.m., with Resident 80, Resident 80 stated that meals were lukewarm and preferred main dish and vegetables to be hot. During an interview on 10/21/24, at 11:00 a.m., with Resident 11, Resident 11 stated not having a hot meal because the meals were ice cold all the time. Review of the document, Meal Service, dated 2018, the document indicated, Food and Nutrition services staff member will take the food temperatures prior to service of the meal with a thermometer .at the recommended temperatures of the food item and recorded on the daily therapeutic menu in the temperature column .

Based on observation, interview, and record review, the facility failed to ensure supplies stored in the medication storage room were appropriate for use when hypodermic needles (devices intended to inject fluids into, or withdraw fluids from, parts of the body below the surface of the skin) were expired. These failures had the potential for residents to receive expired, ineffective, and contaminated medications and treatments. Findings: During a concurrent observation and interview on [DATE], at 12:35 p.m., with the Director of Nursing (DON) in the medication storage room, fourteen 18-gauge (measurement of a needle) hypodermic needles were observed in a box. The box and the individual packaged needles had listed expiration dates of [DATE]. The DON stated the needles should have been discarded so they could no longer be used. During an interview on [DATE], at 9:45 a.m., the DON stated the use of expired medical supplies might result in a loss of effectiveness. The DON also stated expired items such as needles may become dull, brittle, or break during use, injuring the resident. During a review of the facility's policy and procedure (P & P) titled, Medication Administration General Guidelines, dated 2007, indicated, Check expiration date on package/container. According to the Center for Disease Control (CDC) website titled, Preparing Vaccines for Administration, dated [DATE], it indicated, Some syringes and needles have expiration dates, so check those, too. NEVER use expired vaccine, diluent, or equipment.

Based on observation, interview, and record review, the facility failed to: 1. follow proper handwashing/hand hygiene protocol. 2. replace a full sharps container (a puncture resistant container used to safely dispose of sharp medical objects like needles and lancets). The deficient practice had the potential for spread of infection. Findings: 1. During an observation on 10/22/24, at 9:17 a.m., Licensed Vocational Nurse 1 (LVN 1) was preparing medications for Resident 27 in the hallway. LVN 1 applied hand sanitizer to both hands, prepared the medications, touched the handles of the medication cart, locked the medication cart, and touched her eye-glasses. LVN 1 then picked up the prepared medications, went inside Resident 27's room, and handed Resident 27 his medications for administration. After touching various surfaces and a personal object, LVN 1 failed to wash or sanitize her hands prior to providing direct care to the resident. During a review of Resident 27's face sheet, printed 10/28/24, the face sheet indicated Resident 57 was admitted to the facility on [DATE], with diagnoses including Parkinsonism (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking. They may also have mental and behavioral changes, sleep problems, depression, memory difficulties, and fatigue), Atherosclerotic Heart Disease (a condition where plaque builds up in the arteries of the heart. Plaque is a sticky substance made up of cholesterol, fat, blood cells, and other substances in the blood. As plaque builds up, arteries narrow, reducing blood flow to the heart and other organs. This can lead to a heart attack, stroke, or other serious medical conditions), Type 2 Diabetes Mellitus (a long-term [chronic] disease in which the body cannot regulate the amount of sugar in the blood) , and Chronic Systolic (congestive) Heart Failure (a serious, chronic condition that occurs when the left ventricle can't pump blood efficiently). During an interview on 10/24/24, at 10:05 a.m., with the Administrator (ADM- the backup Infection Preventionist Nurse), the ADM stated failure to wash or sanitize hands prior to resident contact could result in infection via cross-contamination. During a review of facility Policy and Procedure (P & P) titled, Handwashing/Hand Hygiene, dated 2019, the P&P indicated, Use alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial [products that kill or slow the spread of microorganisms] or non-antimicrobial) and water for the following situations .b. before and after direct contact with residents; c. before preparing or handling medications; . l. after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident. 2. During a concurrent interview and observation on 10/23/24, at 1:00 p.m., with LVN 1, the contents inside the sharps container attached to the left side of the medication cart was full to the top. LVN 1 stated she thought it was full, and asked do you want me to remove it now? During an interview on 10/24/24, at 10:10 a.m., with the ADM, the ADM stated the risk of continuing to use a full sharps container could result in fingerstick injury and the spread of infection to staff, and the containers should be changed when 2/3 full. During a review of facility P&P titled, Sharps Disposal, dated 2012, the P&P indicated, Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container.

Based on observation and interview, the facility had five residents' rooms (room [ROOM NUMBER], 2, 4, 5 and 8) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 10/21/24, at 10:00 a.m., the following rooms and corresponding square footage per bed were identified: Room Activity Room size Floor area 1 Rt room [ROOM NUMBER].8 x 20.3 sq. ft 297 sq. ft (74.3 per bed) 2 Rt room [ROOM NUMBER] x 21.3 sq. ft 297.5 sq. ft (74.3 per bed) 4 Rt room [ROOM NUMBER].2 x 10.4 sq. ft 146.4 sq. ft (73.2 per bed) 5 Rt room [ROOM NUMBER].2 x 9.8 sq. ft 137 sq. ft (68.5 per bed) 8 Rt room [ROOM NUMBER].4 x 17.11 sq. ft 364.3 sq. ft (72.86 per bed) During random observations of care and services from 10/21/24 to 10/24/24, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care, and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the five rooms. Granting of room size waiver recommended.

Based on observation, interview, and record review, the facility failed to follow proper sanitation, food handling, and food storage practices when: 1. Refrigerator 1 had two bags of iceberg lettuce that were discolored, wilted, and did not have received-by or used-by dates. 2. During tray line (serving and plating of food) service: - Pureed (a procedure to change the texture of solid food so that it is smooth with no lumps and has a texture like pudding) fish and pureed rice were watery and did not stay formed when scooped on the plate. - Scooped food on four resident plates were left uncovered after these plates were placed inside the open food cart. 3. Dietary staff switched from one kitchen task to the next without performing handwashing. 4. Dietary staff's hair was not fully secured with the hairnet. These failures had the potential to result in food contamination and resident foodborne illnesses. Findings: 1. During the concurrent initial observation and interview on 11/13/23, at 9:50 a.m., in the kitchen, with the Registered Dietitian (RD) and Dietary Supervisor (DS), Refrigerator 1 had an unlabeled clear plastic bag that contained a head of wilted and discolored iceberg lettuce. DS stated the plastic bag should have been labeled and dated of when it was received. DS also stated the lettuce had signs of spoilage and should be discarded right away. During the concurrent second day observation and interview on 11/14/23, at 11:25 a.m., in the kitchen, with the Registered Dietitian (RD) and Dietary Supervisor (DS), Refrigerator 1 had another unlabeled clear plastic bag that contained six heads of wilted and discolored iceberg lettuce. DS stated this was delivered the same time as the previous bag of lettuce observed on 11/13/23. DS stated all six heads of lettuce will also be discarded. A review of the facility's dietary guideline titled, Produce Storage Guidelines, dated 2018, indicated, May use longer if no signs of spoilage are visible .lettuce, salad greens, parsley - 7 to 10 days . 2. During an observation on 11/14/23, at 11:55 a.m., in the kitchen, Cook 1 preceded with the tray line service and: -Scooped pureed fish and pureed rice which were watery and did not stay formed when served on the plates. During a follow-up concurrent interview on 11/14/23, at 12:40 p.m., with Cook 1 and RD, Cook 1 stated cooked fish was pureed with fish juice while the cooked rice was pureed with rice water. RD stated when preparing pureed foods, no specific amount of liquid was mixed with the cooked food as long as the required consistency was followed for the specific type of food pureed. RD also stated correct pureed food consistency was important for food presentation to make it look more appealing and appetizing to the residents with swallowing difficulty. A review of the facility's dietary guideline titled, Handout for Puree In-service, dated 10/2020, indicated consistency for meats and starches should be slightly softer than whipped topping. - Cook 1 did not cover four of the resident plates before these plates were placed in the tray inside the open food cart. During a follow-up interview on 11/14/23, at 12:45 p.m., with the RD, RD confirmed the observation and stated all food trays need to be covered to keep the food temperature warm and to prevent cross-contamination. A review of the facility's policy and procedure (P&P) titled, Covering Food During Transport, dated 2018, indicated, .All foods will be covered on trays .All hot food will be covered to maintain the proper temperature . 3. During an observation on 11/14/23, at 12:15 p.m., Cook 1 moved from plating foods to grind fish and did not perform handwashing before and after food preparation. During a follow-up concurrent interview on 11/14/23, at 12:40 p.m., with Cook 1 and RD, RD acknowledged Cook 1 left the tray line food service to grind the fish, without performing handwashing in between the two tasks. A review of the facility's policy and procedure (P&P) titled, Inservice: Handwashing, dated 3/2021, indicated, .Hand washing, when done correctly and often, can help us stay healthy and avoid spreading disease. When should hand washing be done .After handling soiled equipment, utensils .During food preparation as often as necessary to prevent contamination . 4. During an observation on 11/14/23, at 11:55 a.m., Cook 1's hair was not fully covered with a hairnet. During a follow-up concurrent interview on 11/14/23, at 12:40 p.m., RD confirmed Cook 1's hair to the side of her ears were exposed and not completely covered with the hairnet. A review of the facility's policy and procedure (P&P) titled, DRESS CODE for Women and Men, dated 2018, indicated, .PROPER DRESS: Women .Hair net or hat completely covers the hair .

Based on observation, interview, and record review, for one of 15 sampled residents (Resident 26) with limited range of motion (ROM, a joint or body part with limited range of motion cannot move through its normal range of motion, also known as contractures), the facility failed to apply the ankle foot orthosis [AFO, boot(s) or external supportive devices used on lower legs/feet to stabilize the joints to prevent contractures] to Resident 26's left foot as ordered by the physician. This failure resulted in Resident 26's unmet care needs and had the potential to result in worsening of left foot contracture. Findings: A review of Resident 26's Admission Record, printed 11/15/23, indicated resident was admitted on [DATE] with diagnoses of dementia (memory loss), contracture of left ankle, hemiplegia (unable to move one side of the body due to damage to the parts of the brain responsible for movement), and hemiparesis (muscle weakness on one side of the body). A review of Resident 26's Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/23/23, indicated resident had moderately impaired cognition. The MDS also indicated resident had impairment of the left lower extremity that required extensive assistance with bed mobility, toilet use, personal hygiene, and total physical assistance with one-person assist on transfers between surfaces. A review of Resident 26's Physician Order, dated 8/25/23, indicated, Restorative Nursing Assistant/Certified Nursing Assistant (RNA/CNA) Program: Standard wheelchair with leg rest while wearing left (L) AFO, up on wheelchair 1-3 hours (hrs)/day, 3x/week as tolerated. Every day shift every Monday (Mon), Thursday (Thu), Sunday (Sun). A review of Resident 26's Care Plan, date initiated 3/24/23, indicated, The resident has limited physical mobility related to (r/t) Contracture left ankle. The resident will remain free of complications related to immobility, including contractures .Monitor/document/report as needed (PRN) any signs/symptoms (s/sx) of immobility: contractures forming or worsening .RNA/CNA Program as ordered . A review of Resident 26's Physical Therapy Treatment Encounter Note(s), completed on 6/21/23, indicated, Skilled Instruction; Patient and Caregiver Training: Instructed patient and primary caregivers in positioning maneuvers .increase safety and reduce the risk of further medical complications that may result from impairments/conditions . A review of Resident 26's Physical Therapy Treatment Encounter Note(s), completed on 6/22/23, indicated, Skilled Instruction; Patient and Caregiver Training: educated and trained CNA to get patient up 3x/week (wk) into wheelchair (w/c) while wearing AFO to left lower extremity (LLE) . During a concurrent observation and interview on 11/15/23, at 11:40 a.m., in the dining room/activity room, with the Activity Director (AD), the AD stated Resident 26 attended activities daily, positioned in the w/c with footrests, and AD had not seen the resident wear a boot to his left contracted foot. During an interview on 11/15/23, at 11:43 a.m., with CNA 2, CNA 2 stated he had been assigned as Resident 26's morning shift CNA the last three days and had taken the resident to activities daily, positioned up in the w/c with bilateral footrests, with no boot applied to the resident's left contracted foot. CNA 2 stated he knew of the resident's left foot contracture but was not aware of the left AFO. CNA 2 stated he could put a pillow on the footrest. During a concurrent observation, interview, and record review on 11/15/23, between 12:06-12:20 p.m., with the Director of Rehabilitation (DOR), Resident 26's Physician Order was reviewed. The DOR had Resident 26's labeled personal boot in her hand and stated Resident 26 required use of the AFO to his left foot to prevent further worsening of the contracture. DOR stated she found the left ankle boot inside the resident's room in his nightstand. The facility was unable to provide policies and procedures (P&Ps) on either Limited Range of Motion or Use of Orthotics, Braces, or Splints upon request.

Based on observation, interview, and record review, the facility failed to ensure the prevention of complications of enteral feedings for one of one sample selected resident who has a feeding tube at the facility (Resident 12) when Licensed Vocational Nurse (LVN) 1 administered the medication and water via gastrostomy tube (GT-a tube inserted through the abdomen that brings nutrition directly to the stomach) without first checking stomach residual (amount of fluid remaining in the stomach). This failure resulted in Resident 12 vomiting after receiving the medication and water via GT, and a potential for Resident 12 to aspirate (breathe in food or liquid into the airway). Findings: A review of Resident 12's Admission Record, indicated Resident 12 was admitted to the facility with multiple diagnoses including brain injury. During a concurrent interview and observation on 11/14/23, at 9:00 a.m., with LVN 1, in Resident 12's room, LVN 1 started to administer medication and water flush via GT without checking the stomach residual, and Resident 12 started vomiting immediately after receiving the medication and water. LVN 1 stated she forgot to check the stomach residual before she administered medication and water which could have prevented complications such as vomiting. A review of the facility policy and procedure titled, Medication Administration, Enternal Tubes, dated 2007, indicated, . Aspirate stomach contents with syringe. Check residual .

Based on observation, interview and record review, the facility failed to ensure prevention of infection for one of 15 sample selected residents (Resident 12), when Licensed Vocational Nurse (LVN) 1 did not disinfect the blood pressure device between resident use. This failure had the potential of transmitting infection between the residents who are residing at the facility. Findings: A review of Resident 12's Admission Record, indicated Resident 12 was admitted to the facility with multiple diagnoses including brain injury. During a concurrent observation and interview on 11/14/23, at 9:00 a.m., with LVN 1, in Resident 12's room, LVN 1 removed the blood pressure device from the medication cart and without disinfecting the device, checked Resident 12's blood pressure and put the device back inside the medication cart. LVN 1 confirmed and stated she should have disinfected the blood pressure device between residents' use for infection prevention and she forgot to do that. A review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting of Resident-Care items and Equipment, revised 2010, indicated, . Reusable items are cleaned and disinfected or sterilized between residents .

Based on observation, interview, and record review, the facility failed to provide an environment that promoted respect and dignity for four of 15 sampled residents (Resident 18, Resident 22, Resident 8, and Resident 12) when: 1. For Resident 18, Certified Nursing Assistant 1 (CNA 1) remained standing while feeding the resident her meal. 2. For Resident 22, CNA 2 remained standing while feeding the resident her meal. 3. For Resident 8, Licensed Vocational Nurse 1 (LVN 1) did not provide privacy during eye drop administration. 4. For Resident 12, LVN 1 did not provide privacy during medication administration via Gastrostomy tube (GT, a medical device used to provide nutrition and medication to the stomach for people who are unable to swallow thru the mouth). These deficient practices had the potential to result in diminished individual dignity and a loss of self-esteem. Findings: 1. A review of Resident 18's Admission Record, printed 11/15/23, indicated Resident 18 was admitted in 2021 with diagnoses of failure to thrive (decline in health and ability to live) and dysphagia (difficulty swallowing). A review of Resident 18's Minimum Data Set (MDS, an assessment tool used to guide care), dated 7/24/23, indicated resident had severely impaired cognition and was totally dependent with one-person assist in activities of daily living (ADLs), including eating. During a concurrent observation and interview on 11/13/23, at 12:20 p.m., inside the resident's room, CNA 1 was standing next to the bed while assisting Resident 18 with lunch. CNA 1 stated she does not have a chair but knew she should be seated to interact with the resident and to observe the resident with swallowing. 2. A review of Resident 22's Admission Record, printed 11/15/23, indicated Resident 22 was admitted in February 2023 with diagnoses of dementia (memory loss) and dysphagia (difficulty swallowing). A review of Resident 22's MDS assessment, dated 8/25/23, indicated resident had severely impaired cognition and was totally dependent with one-person assist in activities of daily living (ADLs), including eating. During a concurrent observation and interview on 11/13/23, at 12:31 p.m., inside the resident's room, CNA 2 was standing next to the bed while assisting Resident 22 with lunch. CNA 2 pointed to the chair inside the room but remained standing while feeding the resident. CNA 2 stated he should sit while feeding so that he was in eye level with the resident due to risk of choking. During an interview on 11/14/23, at 1:08 p.m., with the Director of Nursing (DON), DON stated CNAs should sit when feeding the residents so that they are within eye level and easier to assess and monitor residents for choking. A review of the facility's policy and procedure (P&P) titled, Feeding the Impaired Resident, undated, indicated, Be observant during the feeding process. Watch for signs of choking or anything unusual .position a chair where it will be convenient for you and the resident . A review of the facility's P&P titled, Quality of Life - Dignity, revised date August 2009, indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth .Staff shall treat cognitively impaired residents with dignity and sensitivity . 38534 3. A review of Resident 8's Admission Record, indicated Resident 8 was admitted to the facility with multiple diagnoses including dementia (dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a concurrent interview and observation on 11/14/23, at 1:25 p.m., with LVN 1, in Resident 8's room, LVN 1 started to administer medication (eye drop) to Resident 8 while the door was open wide with Resident 8 visible from the hallway, and a staff member was walking in the hallway at that time. LVN 1 stated that she forgot to close the door and she should always provide privacy for the resident during medication pass which she did not do for Resident 8. 4. A review of Resident 12's Admission Record, indicated Resident 12 was admitted to the facility with multiple diagnoses including brain injury. During a concurrent interview and observation on 11/14/23, at 9:00 a.m., with LVN 1, in Resident 12's room, LVN 1 started to administer medication via GT while the door was open wide with Resident 12 visible from the hallway, and a staff member was walking in the hallway at that time. LVN 1 stated she made a mistake and should have closed the curtain or the door for the privacy of Resident 12. A review of the facility's P&P titled, Quality of Life-Dignity, revised 2009, indicated, . Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures .

Based on observation and interview the facility had five residents (Rt)'s rooms (room [ROOM NUMBER], 2, 4, 5 and 8) with multiple beds that provided less than 80 square feet (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During an observation on 11/13/23, at 10:00 a.m., the following rooms and corresponding square footage per bed were identified: Room Activity Room size Floor area 1 Rt room [ROOM NUMBER].8 x 20.3 sq. ft 297 sq. ft (74.3 per bed) 2 Rt room [ROOM NUMBER] x 21.3 sq. ft 297.5 sq. ft (74.3 per bed) 4 Rt room [ROOM NUMBER].2 x 10.4 sq. ft 146.4 sq. ft (73.2 per bed) 5 Rt room [ROOM NUMBER].2 x 9.8 sq. ft 137 sq. ft (68.5 per bed) 8 Rt room [ROOM NUMBER].4 x 17.11 sq. ft 364.3 sq. ft (72.86 per bed) During random observations of care and services from 11/13/23 to 11/16/23, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with residents' care, and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the five rooms. Granting of room size waiver recommended.

Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 1) was provided protection from abuse when Resident 2 was allowed to enter Resident 1's room without supervision. This failure resulted in Resident 1, a dependent resident, being hit in the face with a cane by Resident 2, causing Resident 1 painful cuts in the mouth, loss of a tooth, and psychological/emotional distress. Findings: A review of Resident 1's, Admission Record, dated 1/7/22, indicated Resident 1 was admitted to the facility in 2019 with diagnoses of dementia (a brain disorder that affects the ability to remember, think clearly, communicate), generalized weakness, and difficulty walking. The Admission Record indicated Resident 1's primary language was non-English. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 11/11/21, indicated Resident 1 preferred a non-English language and use of a translator for communication. The MDS indicated Resident 1 required physical assistance from one person for bed mobility and transfer between surfaces, extensive assistance from one person for dressing and locomotion, and used a wheelchair for locomotion. The MDS indicated Resident 1 had highly impaired vision (appears able to track objects, but questionable identification of objects). The MDs indicated Resident 1 had verbal behaviors directed toward others (threatening, screaming, cursing). A review of Resident 2's Admission Record indicated an admitted [DATE] with diagnoses of heart failure and difficulty walking. A review of Resident 2's MDS dated [DATE], indicated Resident 2 required limited assistance from one person for transfer between surfaces, and only needed supervision or set-up help for locomotion on the unit. The MDS indicated Resident 2 used a walker or wheelchair for locomotion. During an interview on 1/24/22 at 10:05 a.m. with CNA 1, CNA 1 stated she was familiar with Resident 1, who had a habit of yelling from his room, which was close to the nurse station. CNA 1 stated she was familiar with Resident 2, who used a wheelchair and had learned to use a cane. CNA 1 stated she had been working on the morning of 1/5/22, when Resident 2 asked her if he could visit Resident 1 in his room. CNA 1 stated she told Resident 2 he could visit Resident 1 and he entered Resident 1's room. CNA 1 stated she then heard yelling coming from Resident 1's room and noticed Resident 2 walking away from Resident 1's room. CNA 1 stated when she went into Resident 1's room, Resident 1 was bleeding from his mouth. During a telephone interview 1/11/22 at 11:12 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she had been at the nurse station by Resident 1's room on 1/5/22, when she heard Resident 1 yell, Somebody hit me! LVN 1 stated she looked over at Resident 1's room and saw Resident 2 walking with a cane, coming out of Resident 1's room. LVN 1 stated she asked Resident 2 what had happened as she went to Resident 1's room, and he said, I don't know. LVN 1 stated she entered Resident 1's room and found Resident 1 in bed, bleeding from his mouth. LVN 1 stated Resident 1 was sent to acute care hospital for evaluation. A review of Resident 1's acute care hospital document titled, Emergency Department Note, dated 1/5/22, indicated Resident 1 was seen by the physician 1/5/22, at 1:12 p.m. The Emergency Department Note indicated Resident 1 was seen for an injury to his lower jaw after he was hit by another patient with a metal cane earlier that morning. The Emergency Department Note indicated Resident 1 should be seen by a dentist, as he most likely had a missing tooth as a result of the injury. During an observation and interview on 1/7/22 at 9:30 a.m., with Resident 1 and a translator (Director of Rehabilitation, DOR) in Resident 1's room, Resident 1 was in bed eating breakfast. Resident 1 had a dark mark on his mouth. When Resident 1 was asked how he got the mark, he stated that someone had hit him with something made of metal a few days ago. Resident 1 stated he had painful cuts in his mouth. When Resident 1 was asked what had happened before he was hit, Resident 1 stated he had been calling for his eye drops and was suddenly hit. Resident stated it was the first time he had been hit but he lost three teeth and doesn't feel safe here anymore. During an interview on 1/24/22 at 4:20 p.m., with Resident 2, Resident 2 stated his stay at the facility was OK, except some people screamed and yelled for no reason at all. Resident 2 stated there was one guy who was irritating because he randomly yelled day and night, keeping people awake. Resident 2 denied going into any other resident's room and denied hitting anyone.

Based on observation, interview and record review, the facility failed to provide care in a manner that enhanced the dignity of two (Residents 5 and 16) of 11 sampled residents when two staff members (Certified Nursing Assistant 1 and Certified Nursing Assistant 5) stood and leaned over the residents during feeding assistance with two meals. This failure had the potential for Residents 5 and 16 to feel embarrassed and disrespected. Findings: A review of Resident 5's Admission Record, undated, indicated Resident 5 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's Minimum Data Set (MDS, an assessment tool used to guide care) dated 9/12/2021, indicated Resident 5 was rarely able to be understood, and sometimes understood others. The MDS indicated Resident 5 required total assistance from one person for eating. During a meal observation on 11/30/2021 at 12:30 p.m., in Resident 5's room, Resident 5 lay in bed with the head of the bed elevated while Certified Nursing Assistant 1 (CNA 1) stood next to the bed and leaned over Resident 5 to feed him lunch. During a meal observation on 12/1/2021 at 8:05 a.m., in Resident 5's room, Resident 5 lay in bed with the head of the bed elevated while Certified Nursing Assistant 1 (CNA 1) stood next to the bed and leaned over Resident 5 to feed him breakfast. During an interview on 12/1/2021 at 10:05 a.m., with CNA 1, CNA 1 stated he had stood while he fed Resident 5 because there was no chair in the room. A review of Resident 16's Admission Record, undated, indicated Resident 16 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 16's MDS dated [DATE], indicated Resident 16 sometimes understood others, and was sometimes understood by others. The MDS indicated Resident 16 required total assistance from one person for eating. During a meal observation on 11/30/2021 at 12:40 p.m., in Resident 16's room, Resident 16 lay in bed with the head of the bed elevated while Certified Nursing Assistant 5 (CNA 5) stood next to the bed and leaned over Resident 16 to feed her lunch. During a meal observation on 12/1/2021 at 7:35 a.m., in Resident 16's room, CNA 5 stood next to the bed and leaned over Resident 16 to feed her breakfast. During an interview on 12/1/2021 at 7:45 a.m., with CNA 5, CNA 5 stated staff were supposed to sit while feeding residents but there was no chair in the room.

Based on observation, interview, and record review the facility failed to provide a clean, safe, home-like environment for: 1. One of 11 sampled residents (Resident 17), when Resident 17's bed moved whenever Resident 17 stood up or sat down on the bed. Resident 17's room had a light fixture with a non-functioning bulb, the floor on one side of his bed was not cleaned, and there was a pile of empty garbage bags on the floor near the head of his bed. 2. Residents who used the shower room, when the shower room floor had an unlabeled hairbrush, with hair in the bristles, and a shelf in the shower room had the following items: a face mask, used gloves, four empty bottles of lotion, one bottle of conditioner, and an empty box of disposable razors. These failures resulted in: 1. Resident 17 feeling unsafe when transferring in or out of bed due to bed movement on the floor, having difficulty reading from inadequate lighting, and feeling staff did not care enough about him to adequately clean and tidy his room. 2. Residents who used the shower potentially having emotional distress from an unclean, cluttered environment. Findings: 1. A review of Resident 17's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 10/26/2021, indicated Resident 17 had a diagnosis of heart failure (heart is unable to pump adequate blood for the body's needs). The MDS indicated Resident 17 understood others and was able to be understood. The MDS indicated Resident 17 had adequate vision and was able to read fine details including regular print in newspapers/books. The MDS indicated Resident 17 required extensive assistance from at least two people for transfer between surfaces and bed mobility, was unsteady during transfer and walking with assistive devices, and used either a walker or wheelchair for locomotion. During a concurrent observation and interview on 11/30/21, at 12:44 PM, in Resident 17's room, Resident 17 sat on the side of his bed, using a tablet computer placed on the overbed table in front of him. A paperback book was lying on the overbed table. Resident 17's bed had casters (wheels mounted to an apparatus or piece of equipment to make that apparatus moveable) on the legs. The bed was located approximately 15 inches from a wall with a window, opposite from the door entry. A pile of translucent garbage bags, which appeared empty, were located on the window-side corner of the room, near the head of Resident 17's bed. The light fixture on the wall at the head of Resident 17's bed had one burned out bulb. Resident 17 stated the light bulb had been burned out for about a week which made the room darker and harder for him to read. Resident 17 stated he told Maintenance 1 (MTN) 1 that the bulb was burned out, but the bulb had not been changed yet. Resident 17 said the garbage bags were not his but had been there since he was admitted . Resident 17 adjusted his position while he sat on the bed and the bed moved back and forth. Resident 17 then stood up, and sat back down, using an assistive device (a walker); the bed moved back and forth when he stood up and sat down. Resident 17 stated his bed moved every time he got up or sat down on the bed which made him feel unsafe, especially since walking was hard for him and he used a walker. Resident 17 stated the Housekeeper (HSKP) never mopped the floor on the window-side of the bed. Resident 17 stated, the lack of mopping and the pile of garbage bags left him feeling the room was not clean and that nursing and housekeeping staff did care enough to pay attention to details. During a concurrent observation and interview on 12/1/21, at 11:07 AM, with Resident 17, in Resident 17's room, the light at the head of Resident 17's bed still had a burned out bulb and the garbage bags were in the same position on the floor in the corner. Resident 17 stated his bed still moved when he got up or sat down on it, and the window-side of the floor next to his bed not been mopped. During a concurrent observation and interview on 12/2/21, at 10:28 AM, with Resident 17, in Resident 17's room, the light at the head of Resident 17's bed still had a burned out bulb and the garbage bags were in the same position on the floor in the corner. Resident 17 stated his bed still moved when he got up or sat down on it, and the window-side of the floor next to his bed not been mopped. During an interview on 12/2/21, at 1:40 p.m., with Housekeeper (HSKP), which translation by MTN 1, HSKP stated, she mopped Resident 17's room. HSKP stated she had not mopped the floor on the window-side of Resident 17's bed. HSKP stated she never noticed the pile of garbage bags on the floor in the window-side corner of the room. During an interview on 12/3/21, at 10:15 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated she was assigned to Resident 17 yesterday and today. CNA 4 stated she was unaware Resident 17's bed moved when he stood up or sat down on the bed. CNA 4 stated she always kept the bed's casters locked to prevent the bed from moving. CNA 4 stated it was not safe for the bed to move because Resident 17 could fall. CNA 4 stated she was unaware of the pile of garbage bags in the corner of the room and that one light bulb at the head of the bed was burned out. During an interview on 12/3/21, at 11:27 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she was unaware the light was burned out in Resident 17's room and was unaware Resident 17's bed moved when Resident 17 stood up or sat down on the bed. LVN 2 stated needed repairs should be reported to licensed staff who could inform MTN 1, or to MTN 1 directly. During an interview on 12/3/21, at 11:21 a.m., with Director of Nursing (DON), DON stated Resident 17's bed casters should have been locked, as bed movement could cause Resident 17 to fall and be injured. DON stated MTN 1 had inspected Resident 17's bed after notification of the bed movement and noticed one of the casters was missing a wheel lock. DON stated Resident 17's safety and comfort would be increased by repair of the [NAME] lock, a new light bulb, removal of the garbage bags, and mopping of the entire floor. 2. During an observation on 11/30/2021 at 10:29 a.m., in the shower room, a small shelf had the following items: a face mask, used gloves, four empty bottles of lotion, one bottle of conditioner, and an empty box of disposable razors. An unlabeled hairbrush, with hair in the bristles, was lying on the shower floor. During a concurrent observation and interview on 11/30/2021 at 10:45 a.m., with Licensed Vocational Nurse 1 (LVN 1), in the shower room, LVN 1 confirmed the used hairbrush was on the shower floor and the shelf contained used gloves, a face mask, empty bottles of lotion, a bottle of conditioner, and an empty box of disposable razors. LVN 1 stated staff were not supposed to the items in the bathroom, but should discard the used gloves, face mask, empty bottles and boxes in the garbage can.

Based on observation, interview and record review, the facility failed to: 1. Ensure one of (Resident 179) of 11 sampled residents received four medications as ordered by the physician. 2. Ensure expired medications were not available for resident use when one expired intravenous antibiotic ([MEDICATION(S)]) and one expired influenza vaccine were stored in the medication room refrigerator. These failures had the potential for: 1. Resident 179 to not receive medications as needed for therapeutic effect, or adverse effects if medications were administered too closely together. 2. A residents to receive expired, less effective medications. Findings: 1. A review of Resident 179's Admission Record, undated, indicated an admitted [DATE] with diagnoses of heart failure (heart is unable to pump enough blood for the body's needs) and dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities). A review of Resident 179's Medication Administration Record (MAR) dated November 2021, indicated Resident 179 had the following medications ordered for administration at 9 a.m.: one tablet of [MEDICATION(S)] for high blood pressure, one tablet of [MEDICATION(S)] for heart failure, one tablet aspirin for stroke prevention, two tablets [MEDICATION(S)] for prophylactic treatment of infection with the bacteria Heliobacter Pylori (a stomach infection). During an observation and concurrent interview on 11/30/2021 at 10:08 a.m., in Resident 179's room, was an overbed table at Resident 179's bedside. On top of the overbed table was a medication cup containing three white tablets and 4 pink tablet halves. Resident 179 stated the cups contained his medications and he did not want to take them. During an interview on 11/30/2021 at 10:20 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 179 had not wanted to take his 9 a.m. medications when she had offered them earlier, so she had left them on the overbed table for Resident 179 to take later. LVN 1 stated Resident 179 had not been evaluated for his ability to safely self-administer medications as he had just been admitted the previous day. A review of the facility policy and procedure (PNP) titled, Medication Administration General Guidelines, dated 2007, indicated, Medications are to be administered at the time they are prepared. The person who prepares the dose for administration is the person who administers the dose Medications are administered within 60 minutes of scheduled time .Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations . 2. During an observation and concurrent interview on 11/30/2021 at 11:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), of the medication room refrigerator contents, LVN 1 confirmed the medication room refrigerator had one vial of influenza vaccine, opened date of 9/29/2021; and one [MEDICATION(S)] (antibiotic) intravenous infusion bag (medication delivered by infusion through a tube inserted directly into a vein), expiration date of 11/14/2021 at 5 p.m. LVN 1 stated the influenza vaccine expired 28 days after the vial was opened on 9/29/21, and all expired medication should be discarded. During an interview on 12/1/2021 at 1:05 p.m., with the Director of Nurses (DON), the DON stated she was responsible for discarding expired medications but had been too busy to do so. A review of the facility policy and procedure (PNP) titled, Discarding and Destroying Medications, revised April 2019, indicated, Medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. A review of California Code of Regulations Title 22 § (l) indicated, Drugs shall not be kept in stock after the expiration date on the label and no contaminated or deteriorated drugs shall be available for use.

Based on observation, interview, and record review, the facility failed to maintain and implement infection control measures for six of 11 residents (3, 5, 10, 19, 21, and 23) when: 1. Certified Nursing Assistant 1 (CNA 1) did not perform hand hygiene (wash hands with soap and water or use an alcohol-based hand rub) between consecutive meal tray deliveries and set-up of meals for Residents 19, 21, and 5. 2. The blood pressure cuff was not sanitized between the consecutive use of Residents 10, 3, and 23. These failures had the potential to transmit infectious organisms and increase the risk of infection for residents. Findings: 1. During an observation on 12/01/21, at 12:20 p.m , CNA 1 carried a lunch tray into Resident 19's room. Resident 19 sat in a chair with an adjacent table. CNA 1 placed the lunch tray on the table, a cloth napkin on Resident 19's chest, took the covers off the food and drinks, and arranged the silverware on the tray. Without performing hand hygiene, CNA 1 exited Resident 19's room and walked to the tray cart, took a tray off the cart, and carried the tray into Resident 21's room. Resident 21 lay in bed, on his side, with the overbed table next to the head of the bed. CNA 1 placed the lunch tray on the overbed table, placed a cloth napkin on Resident 21's chest, took the covers off the food and drinks, and arranged the silverware on the tray. Without performing hand hygiene, CNA 1 exited Resident 21's room, walked to the tray cart, took a tray off the cart and carried it into Resident 5's room. Resident 5 lay in bed, with the head of the bed elevated and the overbed tray across his upper torso/lap. CNA 1 took the covers off the food and drinks, arranged silverware on the tray, and began assisting Resident 5 to eat. During an interview on 12/1/21, at 2:05 p.m., with CNA 1, CNA 1 stated she washed her hands before she started passing the lunch trays to residents and was sorry she had not performed hand hygiene between serving residents. During an interview on 12/2/21, at 11:03 a.m., with Director of Nursing (DON), DON stated staff were required to perform hand hygiene between residents when passing meal trays to residents, to prevent cross contamination and the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised August 2019, the P&P indicated staff were to perform hand hygiene before and after direct contact with residents and before and after assisting a resident with meals to prevent the spread of infections. 2. During a continuous observation of medication administration on 12/1/2021 from 8:00 a.m. to 8:25 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 placed a reusable blood pressure cuff on Resident 10's arm and checked Resident 10's blood pressure. After checking Resident 10's blood pressure, LVN 2 removed the blood pressure cuff and without cleaning, placed the cuff on top of the medication cart. At 8:18 a.m., LVN 2 placed the same blood pressure cuff on Resident 3's arm and checked Resident 3's blood pressure. After checking Resident 3's blood pressure, LVN 2 removed the blood pressure cuff and without cleaning, placed the cuff on top of the medication cart. At 8:25 a.m., LVN 2 placed the same blood pressure cuff on Resident 23's arm and checked Resident 23's blood pressure. After checking Resident 23's blood pressure, LVN 2 removed the blood pressure cuff and without cleaning, placed the cuff on top of the medication cart. During an interview on 12/1/2021 at 8:50 a.m., with LVN 2, LVN 2 stated she only sanitized the blood pressure cuff between residents when a resident was on isolation precautions (measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment). During an interview on 12/2/2021 at 1:08 p.m., with the Director of Staff Development (DSD), the DSD stated nursing staff were expected to sanitize blood pressure cuffs used for multiple residents, with alcohol swabs or wipes between each resident's use. A review of policy and procedure (P & P) titled, Cleaning and Disinfection of Resident Care Items and Equipment, revised October 2018, indicated, Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment).

Based on observation, interview, and record review, the facility failed to sanitize the ice machine's ice bin at the time of installation. This failure had the potential to result in resident food borne illness from contaminated ice. Findings: During a concurrent observation and interview on 11/30/21, at 12:35 p.m., with Maintenance 1 (MTN 1), an ice machine was located on a patio against the exterior wall of the facility, near the sliding glass door of the activity room. The inside of the ice machine cabinet had a reddish-brown substance on the back and side walls above the ice bin. The reddish-brown substance was removed from the walls by a paper towel. MTN 1 stated the ice from the ice machine was used in the residents' drinking water. MTN 1 stated the ice machine was three weeks old; the facility had not previously had an ice machine. MTN 1 stated the ice machine needed to be cleaned regularly to prevent contamination of the drinking water, but he had not cleaned the machine yet. MTN 1 stated he would check for the manufacturer's recommendations on how to correctly clean the ice machine. During an interview on 11/30/21, at 1:40 p.m., with Dietary Services Supervisor (DSS), DSS stated MTN 1 was responsible for cleaning of the ice machine. During an interview on 11/30/21, at 1:42 p.m., with Registered Dietician (RD), RD stated the ice machine needed to be kept clean to prevent contamination of the ice. A review of the ice machine manufacturer's manual, [Brand name] Undercounter Ice Machines, UG series, Installation, Operation and Maintenance Manual, dated 03/19, indicated, The chart below is an overview of the maintenance that the end user and service technician should perform, and the frequency. These figures are the minimum required. A review of the chart indicated the end user was responsible for sanitizing the ice bin at the time of installation.

Based on observation, interview and record review, the facility failed to provide fingernail trimming and/or facial hair removal for three of 11 sampled residents (Residents 9, 19 and 5) who were unable to perform personal grooming. These failures resulted in Residents 9, 19, and 5 appearing ungroomed, and had the potential for a reasonable person to feel a diminished sense of self-esteem; the ragged nails also had the potential to cause injury from scratches or skin tears. Findings: 1. A review of Resident 19's Admission Record, undated, indicated Resident 19 was admitted in June 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 19's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 10/29/2021, indicated Resident 19 was sometimes able to be understood, and sometimes understood others. The MDS indicated Resident 19 required total physical assistance from at least one person for personal hygiene (activities such as shaving, hair brushing, hand washing, etc.). During an observation on 11/30/2021 at 10:45 a.m., Resident 19 lay in bed with her arms on top of the bed linens. Resident 19's fingernails extended beyond the length of her fingertips and had dark brown substances beneath the fingernail tips. Resident 19 had visible white hairs on her chin. 2. A review of Resident 9's Admission Record, undated, indicated Resident 9 was admitted in 2015 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident 9's MDS dated [DATE], indicated Resident 9 was sometimes able to be understood, and sometimes understood others. The MDS indicated Resident 19 required extensive physical assistance from at least one person for personal hygiene. During an observation on 11/30/21 at 11:25 a.m., Resident 9 sat on the edge of her bed. Resident 9's fingernails extended beyond the length of her fingertips had jagged edges with dark substances beneath the fingernail tips. Resident 9 had visible white facial hairs above her upper lip and chin. During a concurrent observation and interview on 12/1/21 at 10:30 a.m., in Resident 9's room, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated Resident 9's fingernails should be trimmed and cleaned because they were long and dirty. CNA 2 stated Resident 9's upper lip and chin hairs needed to be shaved. During a concurrent observation and interview on 12/1/21 at 11:45 a.m., in Resident 19's room, the Activity Director (AD) assisted Resident 19 with eating her lunch. The AD stated Resident 19 needed her fingernails trimmed and cleaned and her chin hairs shaved. During an interview on 12/1/21 at 1:00 p.m., with the Director of Nursing (DON), the DON stated she expected the nursing staff to provide fingernail care to the residents with daily cleaning and trimming as needed. 3. A review of Resident 5's Admission Record, undated, indicated Resident 5 was admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 5's MDS dated [DATE], indicated Resident 5 was rarely able to be understood, and sometimes understood others. The MDS indicated Resident 5 required total assistance from at least one person for personal grooming. During an observation on 11/30/2021 at 12:35 p.m., in Resident 5's room, Resident 5 lay in bed with his hands crossed on his stomach. Resident 5's fingernails extended beyond his fingertips and were raggedly chipped with a black substance underneath the fingernail tips. During an observation on 12/2/2021 at 1:35 p.m., Resident 5's fingernails remained untrimmed with a black substance underneath the fingernail tips. During an observation and concurrent interview on 12/3/2021 at 8:35 a.m., in Resident 5's room, with Certified Nursing Assistant 4 (CNA 4), CNA 4 stated Resident 5's nails needed cleaning and trimming, which was a task for the assigned certified nursing assistant. During an interview on 12/3/2021 at 12:05 p.m., with the Director of Nursing (DON), the DON stated staff are supposed to check and provide needed services for the resident's fingernails during daily personal care.

Based on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) was promptly acted upon for one (Residents 5) of 11 sampled residents. This failure had the potential for delayed treatment and increased risk of adverse side effects for Residents 5. Findings: A review of Resident 5's Admission Record undated, indicated Resident 5 was admitted to the facility with a diagnosis of dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities). A review of the facility's Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 10/29/2021, indicated This resident has been taking [MEDICATION(S)] 0.5 mg since 5/18/2021. The recommendation indicated please evaluate the current dose and consider a dose reduction. During an interview and concurrent record review on 12/2/2021 at 11:05 a.m., with the Director of Nursing (DON), Resident 5's MRR dated 10/26/2021, was reviewed. The DON stated she had been so busy she had totally missed sending the pharmacist's MRR recommendations to the physician until 12/1/21, at which time the physician discontinued the medication. A review of the policy and procedure titled, Medication Regimen Review, dated May 2019, indicated, Within 24 hours of the MRR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life threatening medication irregularity If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (if the Medical Director is the physician of record) the Administrator. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it.

Based on observation, interview and record review, the facility failed to ensure one (Resident 23) of 11 sampled residents was free of significant medication errors when Licensed Vocational Nurse 2 (LVN 2) did not follow the medication instructions to shake the [MEDICATION(S)] suspension (a liquid preparation of medication used to prevent seizures) before administration. This failure had the potential to result in uneven distribution of medication in the liquid and prevent administration of the ordered dose necessary to maintain Resident 23's therapeutic drug level (the concentration of medication in the blood stream necessary to prevent seizures). Findings: A review of Resident 23's Admission Record, undated, indicated Resident 23 was admitted to the facility in May 2021 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 23's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 11/10/2021, indicated Resident 23 had a feeding tube (a plastic or rubber tube that is used to bypass chewing and swallowing in a patient who is not able to eat or drink safely). A review of Resident 23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 12/1/2021 at 8:40 a.m., in Resident 23's room, with Licensed Vocational Nurse 2 (LVN 2), Resident 23 lay in bed while LVN 2 prepared medications for administration. LVN 2 picked up the [MEDICATION(S)] suspension container and without shaking the bottle, poured 5 ml of [MEDICATION(S)] Suspension into a medication cup, used a syringe to withdraw 3 ml of [MEDICATION(S)] suspension from the med cup, and administered the medication to Resident 23's GT. During a concurrent interview and record review on 12/1/2021 at 8:50 a.m., with LVN 2, Resident 23's [MEDICATION(S)] Suspension bottle label instructions were reviewed. The [MEDICATION(S)] Suspension bottle instructions indicated, Shake well before each use. LVN 2 stated because the [MEDICATION(S)] was a suspension it needed to be shaken before administration.

Based on observation, interview, and record review, the facility failed to follow proper sanitation, food handling, and food storage practices when: 1. Proper hand hygiene (hand washing) procedures were not followed; 2. Turkey was served without ensuring it was cooked to the proper temperature and staff could not demonstrate how to calibrate a thermometer; 3. Proper procedures for cleaning dishes were not followed; 4. Shakes, frozen meat, frozen waffles, frozen doughnuts, and frozen hamburger buns were not dated to show when they were to be used or discarded; 5. Ice, frozen meat, and sherbet was stored uncovered or partially covered; 6. Food carts were not properly cleaned; 7. A food container was not cleaned following proper cleaning procedures (reference F-371, 1); 8. Food in the dry storage area was stored above manufacturer's temperature guidelines; 9. A can opener was dirty; 10. Food items were stored on the floor; and 11. There was no cool down log for left-over rice. These failed practices had the potential to result in the outbreak of foodborne illness that affected the 28 residents who resided in the facility. On 3/15/17, at 9 a.m., Immediate Jeopardy (IJ) was called. The Administrator (ADM) and was verbally notified of the IJ regarding the improper hand hygiene techniques, staffs' inability to calibrate a thermometer, improper food storage conditions, and improper kitchen equipment and dish washing sanitation procedures. The IJ was lifted on 3/15/17 at 2:20 p.m. when the facility submitted an acceptable plan of action and the Director of Staff Development (DSD) immediately began in-servicing kitchen staff on hand hygiene.) Findings: 1. During an observation on 3/13/17, at 11 a.m., Cook 1 placed her hand into a container of dried parsley and added the parsley to potatoes she was cooking. Cook 1 then placed the dried parsley container back into the cabinet. Cook 1 then got down on her hands and knees, touched the floor with her hands, and picked up the lid of cooking oil spray she dropped on the floor near the stove. Cook 1 then rinsed the lid that she dropped on the floor with water in the food preparation sink, wiped the lid with a rag that was sitting on the food preparation sink, and placed the lid back on the cooking oil spray. Cook 1 then rinsed pots, pans, and cooking utensils in the sink on the dirty side of the dish machine. Cook 1 used a scouring pad that sat by the sink to rinse the dishes. Cook 1 then placed the dishes in the dish machine and started the machine. Cook 1 did not perform hand hygiene (wash her hands) between dirty and clean tasks after washing dishes and then proceeding to prepare food and set up for the trayline (a system of food preparation in which trays move along an assembly line). One item she prepared was gravy. While Cook 1 prepared the gravy, she placed her finger in the gravy then put her finger in her mouth to taste the gravy. Cook 1 continued with food preparation and setting up the trayline which included handling utensils to serve food on trayline. During the entire observation described above, Cook 1 did not wash her hands. An observation on 3/13/17, at 1:20 p.m., showed Cook 1 rinsed dishes, returned from resident lunches, in the sink on the dirty side of the dish machine. Cook 1 then removed her gloves and wiped her hands with a white rag that was on the table near the handwashing sink. Cook 1 placed clean gloves on and did not wash her hands first. Next, Cook 1 handled clean dishes that were removed from the dish machine. Then, with the same white rag Cook 1 used to wipe her hands on after taking off her gloves, Cook 1 wiped down the food cart used for delivering resident food trays. In an interview with Cook 1 on 3/13/17, at 1:30 p.m., Cook 1 confirmed she did not wash her hands after she touched the floor with her hands to pick up the cooking spray can and continued with food preparation. Cook 1 did not indicate that it was necessary to wash her hands at this point. Cook 1 also confirmed she did not wash her hands after rinsing dishes in the sink on the dirty side of the dish machine before she continued with food preparation. Cook 1 stated she only needed to wash her hands when she washed dishes that were returned from resident meals, not when she rinsed dishes she used for food preparation. Cook 1 then confirmed she put her finger in the gravy then in her mouth and did not wash her hands before she continued with food preparation and handling clean utensils to serve food on tray line. In an interview with Cook 2 on 3/13/17, at 11:30 a.m., Cook 2 stated the scour pads were used to rinse dirty dishes in the sink on the dirty side of the dish machine were replaced every one to two days. A review of the undated document provided by the facility titled Handwashing read FREQUENCY 2. After handling soiled dishes and utensils .4. Before and after handling foods with the hands (cutting, peeling, mixing, etc) A review of the undated document provided by the facility titled Sanitation read .15. All dietary staff shall know proper handwashing According to the 2013 Federal Food Code (food safety rules) states The hands may become contaminated when the food employee engages in specific activities. The increased risk of contamination requires handwashing immediately before, during, or after the activities listed. The specific examples listed in this Code section are not intended to be all inclusive. Employees must wash their hands after any activity which may result in contamination of the hands .Food employees shall clean their hands and exposed portions of their arms .immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles . Examples listed for when hand washing is required include: After touching bare human body parts other than clean hands and clean, exposed portions of arms; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. 2. An observation on 3/14/17, at 12:00 p.m. and consecutive interviews with Cook 3 and the Dietary Supervisor (DS), indicated Cook 3 took temperatures of the food on trayline before service was started. The temperature of the lasagna, according to the cook's thermometer was 180 degrees Fahrenheit (F) and Cook 3 stated this was the only temperature she took for the lasagna. Cook 3 was about to start the tray line when the temperature of the lasagna was measured using the surveyor's thermometer. The regular lasagna measured 162 degrees F. Cook 3 then replaced her thermometer in the lasagna and the temperature read 163.5 degrees F. The DS instructed Cook 3 to place the lasagna back in the oven to heat it more. At first, the DS stated the facility only had cubed ice, not crushed ice (to make an ice slush) in order to get a more accurate thermometer calibration. The DS then used a cup filled with ice cubes and water to calibrate a different thermometer than the one used by Cook 3. The temperature of the facility's thermometer read 43.2 degrees F. and the surveyor's thermometer read 40.8 degrees F. Then, when crushed ice was made available (to make an ice slush), the facility thermometer read 32.6 degrees F (10.6 degrees lower than when measured with the cubed ice) and the surveyor's thermometer read 32.9 degrees F. Cook 3 removed the lasagna from the oven and the temperature was measured using the facility's calibrated thermometer. The temperature of the lasagna measured 160 degrees F. The DS stated the temperature for the lasagna was appropriate to serve since the lasagna contained ground turkey which only had to be cooked to 155 degrees F. At this point tray line was started and the lasagna was served. In an observation on 3/14/17, at 12:46 p.m. and concurrent interviews with Cook 3 and the DS, Cook 3 demonstrated how to calibrate a thermometer. Cook 3 filled a cup full of cubed ice and water and attempted to calibrate the thermometer for over 15 minutes. Cook 3 turned the dial to calibrate the thermometer to 32 degrees F outside of the ice water then placed it in the ice water to show the surveyor it was calibrated and the temperature on the thermometer dropped to 8 degrees F. Cook 3 then took the thermometer out of the ice water and again turned the dial so the thermometer read 32 degrees F and said it was calibrated. According to the United States Department and Agriculture Food Safety and Inspection Service, use the following directions to calibrate a food service thermometer: To use the ice water method, fill a large glass with finely crushed ice. Add clean tap water to the top of the ice and stir well. Immerse the food thermometer stem a minimum of 2 inches into the mixture, touching neither the sides nor the bottom of the glass. Wait a minimum of 30 seconds before adjusting. (Reference: www.fsis.usda.gov). A review of the undated document provided by the facility titled Food Preparation read Cook potentially hazardous foods to AT LEAST the following time and temperature standards: Poultry and stuffed food products including stuffed pasta, stuffed meats, stuffed poultry or fish and stuffing containing fish, meat or poultry (cook to) 165 degrees F for 15 seconds. The facility was not able to provide a policy and procedure for the calibration of thermometers or documentation staff was trained on calibrating thermometers. 3. An observation on 3/14/17 at 1:50 p.m. and concurrent interviews with Cook 2 and the DS, showed Cook 2 washed dishes returned from resident meals in the low temperature dish machine. Cook 2 then demonstrated how she tested the level of the chlorine sanitizer to ensure it was at the appropriate strength to sanitize the dishes. Cook 2 dipped the chlorine test strip into water/sanitizer solution immediately after the dish machine's sanitize cycle. Cook 2 stated the strip read between 50 ppm (parts per million) and 10 ppm but it was closer to 10 ppm. Cook 2 stated 10 ppm was appropriate for sanitizing the dishes. The level of the dish machine sanitizer was tested by the DS for two more consecutive sanitation cycles using test strips from two different containers. The DS stated the level of the chlorine sanitizer was 10 ppm and it was too low and it should not be below 50 ppm for adequate sanitation. A review of the undated policy and procedures provided by the facility titled Dishwashing, read Low temperature machine .The chlorine should read 50-100 ppm - the proper chlorine is crucial in sanitizing dishes. Otherwise resort to the Manual Method of Utensil Washing. A review of the undated policy and procedures provided by the facility titled Sanitation, read 2 . Each employee shall know how to operate and clean all equipment in their specific work area. 3. No dietary employee shall operate any major piece of equipment without knowing how to operate it correctly. 4. During an observation on 3/13/17, at 7:20 a.m., there were 4 cases of shakes in the reach-in refrigerator without dates to show when the shakes were to be used by or discarded. Case 1 contained over 30, thawed, strawberry shakes; case 2 contained 22, thawed, no sugar added chocolate shakes; case 3 contained 30, thawed, no sugar added vanilla shakes; and case 4 was full and contained partially thawed, no sugar added, chocolate shakes. The label on the shakes read Store frozen. Thaw under refrigeration (40 (degrees) F or below). After thawing, keep refrigerated. Use within 14 days after thawing. In a consecutive interview on 3/13/17, Cook 1 confirmed the shakes were not dated. Cook 1 stated the shakes were stored in the freezer when they were delivered and thawed in the refrigerator when needed. Continuing the initial tour of the kitchen on 3/13/17 the following items were observed in the reach-in freezer without a date to show when they were received, to be used by, or discarded: a. 1 turkey breast and thigh roast; b. 30 beef patties; c. 1 pork roast; d. 4 bags of cubed pork (3 bags were not dated and one bag had a partially rubbed off date that was undecipherable); e. 3 packages of turkey patties; f. 1 package of ground beef; g. 1 plastic bag filled with breaded fish; h. 2 bags of fish filets (these two bags were labeled with date codes but the surveyor could not identify the date; i. 2 packages of cooked ham; j. 12 packages of bologna; k. 1 package of chicken breasts; l. Bag of chicken enchiladas; m. 7 packages of waffles; and n. 1 bag of doughnuts. In a consecutive interview on 3/13/17, Cook 1 confirmed the food items listed above did not have a date to show when they were received, to be used by, or discarded. Cook 1 also stated she could not identify the date on the 2 bags of fish filets by looking at the date codes on the packages. In an interview on 3/13/17 at 10:40 a.m., Cook 1 stated she was one person who took frozen foods out of the freezer to thaw. Cook 1 did not provide a response when the surveyor asked her how she knew if the frozen food that was not dated was safe to use. A review of the undated document provided by the facility titled Procedures for Refrigerated Storage (refrigerator and freezer) read 9. Food items should be arranged so that the older items will be used first. Dating the packages or containers will facilitate this practice .15. Individual packages of refrigerated or frozen food taken from original packing box needs to be labeled and dated. Unopened foods are to be used within 1 year .16. Supplement shakes which are taken from the frozen state and thawed in the refrigerator will be dated as soon as they are placed in the refrigerator. Follow the manufacture's recommendations (specifications) for shelf life. 5. On 3/13/17, during the initial tour of the kitchen that started at 7:20 a.m., an observation of the reach-in freezer showed the following items were not covered or completely covered: a. Two ice-cube trays filled with ice and were not covered. The trays were stacked on top of each other. The bottom of the ice-cube tray on top touched the ice in the lower tray; b. 3 cooked hams wrapped in plastic bags that were ripped and the meat was exposed to the open air. Frost crystals were on the surface of all three hams; and c. 2 bowls that contained one scoop of orange sherbet each. Both bowls had a piece of plastic on top but the plastic did not completely cover the sherbet. Both scoops of sherbet had ice crystals on the surface. In a concurrent interview on 3/13/17, Cook 1 confirmed all of the items listed above were not covered or not completely covered and she stated the sherbet was used when the nurses needed it for a resident. In an interview on 3/15/17, at 8:23 a.m., the DS stated all food items in the freezer should be completely covered. The DS stated she was not aware that all the meat was not completely covered. The DS stated the facility did not keep the ice in the ice trays covered but it should be wrapped, labeled, and dated. She confirmed the ice was used for residents. In an interview on 3/15/17, at 10:45 a.m., the DS stated that all food in the freezer with frost on the surface should be thrown away. A review of the undated document provided by the facility titled Procedures for Refrigerated Storage (refrigerator and freezer), read 5. Food should be covered and stored loosely to permit circulation of air . A review of the undated document provided by the facility titled Sanitation read Ice which is used in connection with food or drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner. 6. An observation on 3/13/17, at 1:20 p.m. (reference F-371; 1) showed Cook 1 wiped a resident food cart (a cart for transporting multiple food trays from the kitchen to the residents' dining area) with a rag that she previously wiped her hands on after she took off her gloves from washing dishes. The rag Cook 1 used to wipe off the resident cart was placed on the clean side the of dish machine. In a consecutive interview on 3/13/17, Cook 1 confirmed the cart she wiped with the rag was just used to carry resident dishes back to the kitchen. In an interview on 3/15/17, 11:35 a.m., the DS stated the procedure for cleaning the food cart was to wipe down the cart with the detergent that was located above the sink on the dirty side of the dish machine with a clean rag and let it air dry. A review of the undated document provided by the facility titled Food Carts, read Cleaning Procedure: .2. Prepare a hot solution of detergent .With a clean cloth clean cart .Then rinse with clean warm water. 3. Prepare sanitizing solution in a spray bottle and repeat step 2 (do not rinse). 4. Wipe with a clean cloth. 7. An observation on 3/13/17, at 11:25 a.m. (reference F-371;1), showed Cook 1 dropped a lid from a can of cooking oil spray on the floor while she prepared food. Cook 1 got down on her hands and knees, touched the floor with her hands, and picked up the lid. Cook 1 then rinsed the lid in the food preparation sink using only tap water, wiped the lid off with a rag that was on the food preparation sink, placed the lid back on the can of cooking oil spray, and placed it back inside the cabinet. In an interview with Cook 1 on 3/13/17, at 1:30 p.m., Cook 1 confirmed she touched the floor with her hands to pick up the cooking oil spray lid on the floor, rinsed the lid with water in the food preparation sink, wiped it with a rag, and placed it back on the cooking oil spray can. Cook 1 stated this procedure was okay. In an interview with the Dietary Supervisor (DS) on 3/15/17 at 10:15 a.m., the DS stated that if a lid to cooking oil fell on the floor it should have been cleaned in the dish machine before it was placed back on the can of cooking oil spray. A review of the undated policy and procedure provided by the facility titled Dishwashing, read Policy: All dishes will be properly sanitized throught (through) the dishwasher . A review of the undated document provided by the facility titled Manual Method of Utensil Washing described when utensils were manually washed they would be washed, rinsed, sanitized, then air-dried. Wash in hot water (110-120 * (degrees) F. (Fahrenheit)with an effective detergent in proper concentration .Rinse in clean clear hot water .Sanitize by submerging in hot water (180 * F.) for 30 seconds or use a chemical as directed and approved by the State Department of Public Health .Air-Dry on a drain board. Dishtowels should not be used. 8. An observation on 3/13/17, at 10:40 a.m., showed a thermometer on the inside wall at the entrance of the storeroom. The thermometer read 85 degrees Fahrenheit (F.) The surveyor also measured the temperature inside the storeroom with her calibrated thermometer. The surveyor's thermometer read 86.5 degrees F. An observation on 3/14/17, at 11:30 a.m., showed the temperature of the dry storeroom in the kitchen was 86.4 degrees Fahrenheit (F) when measured with the surveyor's calibrated thermometer. Food items that included muffin mix, olive oil, and grill and griddle cooking spray were located inside the storeroom. The manufacture's instruction on the package of muffin mix and on the can of olive oil read store in a cool, dry place. The manufacturer's label on the cooking spray read Store in a cool, dry place 68 degrees F - 75 degrees F. An observation and consecutive interview with DS on 3/14/17, at 11:50 a.m., showed the thermometer on the inside wall to the entrance of the storeroom read 90 degrees F. The DS confirmed this temperature. In an interview on 3/15/17, at 10:45 a.m., the DS stated the she was responsible for logging storage room temperatures but she did not get around to it since she began working at the facility 1 year and 2 months ago. The DS stated she was not aware that there were items in the storeroom that had to be stored in a cool place or below a certain temperature. In an interview on 3/15/17, at 11:30 a.m., the Maintenance Manager (MM) stated last week one of the cooks told him it was hot in the kitchen and in the storeroom, but he didn't have it documented. The MM stated he had a log book that nursing documented in to notify him of maintenance issues but the kitchen staff were not expected to log in the log book. The MM also stated he didn't recall the dietitian reported the kitchen storeroom was hot. In an interview on 3/15/17, at 12:15 p.m., the RD stated the kitchen and the kitchen storeroom got hot in the summertime. The RD stated that she reported issues about the kitchen to the DS, MM, or the Administrator. The RD said sometimes she documented kitchen issues in a report to the administrator but she didn't remember if she documented the kitchen and storeroom was hot. A review of the document provided by the facility titled Registered Dietitian Resident Review Summary dated 1/14/16 indicated the RD recommended a temperature log in the storeroom. No other documentation was presented by the facility that showed the dry food storeroom inside the kitchen was hot. A review of the undated policy and procedure provided by the facility titled Storage of Food and Supplies read Policy: Food and supplies will be stored properly and in a safe manner. Procedures For Dry Storage: 1. The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. Thermometers should be placed in all storage areas and checked frequently. Recommended temperature is 50-70 degrees F. (Maximum temperature of 80 degrees or re-evaluate cooling system). 9. An observation on 3/13/17, during the initial tour of the kitchen that started at 7:20 a.m., showed a can opener that had brown, sticky drip marks down the shaft. When the surveyor wiped the blade of the can opener with a paper towel, a brownish residue came off onto the paper towel. In a consecutive interview on 3/13/17 with Cook 1, she stated the can opener was not used that day but was used the prior day by her supervisor. Cook 1 stated the can opener was supposed to be cleaned after it was used. A review of the undated document provided by the facility titled Can Opener and Base, read Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation .Cleaning procedure: 1. The can opener must be thoroughly cleaned each work shift and when necessary, more frequently. 10. An observation on 3/13/17, during the initial tour of the kitchen that started at 7:20 a.m., showed the walkway in the dry food store room piled with boxes of food and items such as lids for cups. The boxes on the floor were piled between 2 to 5 feet high and made a barrier to access items in the storeroom. One box that contained 6 number 10 cans (three quarts equals one number 10 can) of fruit cocktail was stored directly on the floor. On top of the box of fruit cocktail there was another box of fruit cocktail that contained 5 number 10 cans, and a large box of oranges. Behind the fruit cocktail, a large box of lids for cups was stored directly on the floor. On top of the box of lids there was a box of dried lasagna noodles and a box of saltine crackers. In a consecutive interview on 3/13/17, Cook 1 stated the boxes of food and cup lids stored in the dry storeroom were on the floor since they were delivered Thursday the week prior. In an interview on 3/15/17, at 10:30 a.m., the DS stated the boxes of food and cup lids should not have been stored on the floor. The DS confirmed the boxes were on the floor since the delivery on Thursday 3/9/17. The DS stated food deliveries were every Thursday and there was a staff assigned to put all the delivered food away that day. The DS stated when she was at work on Saturday, 3/11/17, she observed the boxes of food were still on the floor in the dry food storeroom. A review of the undated policy and procedures provided by the facility titled (Storage of Food and Supplies, read Policy: Food and supplies will be stored properly and in a safe manner. Procedures for Dry Storage: 4. All shelves and storage racks or platforms should be in accordance with state and federal regulations to facilitate air circulation and promote easy and regular cleaning. All food and food containers are stored off the floor and on clean surfaces in a manner that protects it from contamination .7. Remove foods from packaging boxes upon delivery (this is to minimize pests) According to the 2013 Federal Food Code, stored food shall be protected from contamination by storing the food at least 6 inches above the floor. 11. An observation on 3/13/17, at 11:25 a.m. and concurrent interview with Cook 1 showed a container of cooked rice in the walk-in refrigerator dated 3/12/17 was heated up to use for lunch. Cook 1 stated there were three residents that always requested rice. In an interview with the DS on 3/15/17, the DS stated cool down logs were not currently kept because cooked foods were not cooled instead they discarded any cooked foods after trayline. The DS also stated, when the rice was cooked and used on 3/12/17, the left-over rice should have been discarded and not cooled. A review of the undated policy and procedure provided by the facility titled Cooling and Reheating Potentially Hazardous Foods read Policy: Cooked potentially hazardous foods shall be cooled and reheated in a method to ensure safety .This list includes .cooked rice, and Utilize the cool down log when cooling down food to document proper procedure.