Every finding on record at The Bradley Gardens

Based on observation, interview and record review, the facility failed to implement effective interventions for one of two residents reviewed for abuse (Resident 1) with known wandering (the act of moving about without a fixed plan, destination, or clear purpose) behavior.This failure resulted in a resident-to-resident altercation after Resident 1 entered Resident 2's room.Findings:On June 19, 2026, a review of Resident 1's face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses which included psychosis (a condition in which a person has difficulty distinguishing what is real from what is not).A review of Resident 1's Minimum Data Set (an assessment tool) dated May 20, 2026, indicated the resident was rarely or never understood. A review of Resident 1's Care Plan Report dated November 24, 2025, indicated the resident demonstrated intrusive behaviors as evidenced by lack of awareness of others' personal space and boundaries due to neurocognitive impairment. Interventions included reality orientation and redirection as needed. The care plan did not include additional interventions after staff observed the resident repeatedly entering other residents' rooms.A review of Resident 1's eINTERACT SBAR (Situation, Background, Assessment, and Recommendation- standardized healthcare communication framework) Summary for Providers dated June 19, 2026, indicated:- Resident 1 was found lying on the floor outside Resident 2's room.- Resident 2 reported Resident 1 hit him with a closed fist.- Resident 2 pushed Resident 1 pushed Resident 1 with open hands to remove him from the room. - Resident 1's physician was notified and ordered transfer to the emergency room for further evaluation.On June 19, 2026, at 1:00 p.m., during a concurrent observation and interview, Resident 2 was in his room, lying in bed, alert and awake. Resident 2 stated Resident 1 came to his room earlier that morning. Resident 2 stated he asked Resident 1 to leave, but Resident 1 did not respond. Resident 2 stated he stood up and attempted to guide Resident 1 out of the room by placing his arms around him. Resident 2 stated Resident 1 then punched him in the chest and head. Resident 2 stated he pushed Resident 1, causing Resident 1 to fall to the floor. Resident 2 stated this was not the first time Resident 1 had entered his room and stated Resident 1 comes into my room all the time. On June 19, 2026, at 1:12 p.m., during an interview, Certified Nurse Assistant (CNA) 1 stated Resident 1 is known to wander and has entered other residents' rooms. CNA 1 stated all staff members are responsible for keeping an eye on Resident 1 but he is so quick that in the blink of an eye he will be somewhere else.On June 19, 2026, at 1:36 p.m., during an interview, Licensed Vocational Nurse (LVN) 1 stated Resident 2 informed her that Resident 1 entered his room. LVN 1 stated Resident 2 attempted to escort Resident 1 out of room, Resident 1 punched Resident 2, and Resident 2 pushed Resident 1. LVN 1 stated Resident 1 wanders the hallways and has entered other residents' rooms before. LVN 1 stated staff conduct hourly rounds and continuously monitor Resident 1 to prevent him from entering other residents' rooms.On June 19, 2026, at 3:43 p.m., during an interview, LVN 2 stated Resident 2 has wandered since admission. LVN 2 stated she had observed Resident 1 enter other residents' room before and staff redirected him and provided activities. LVN 2 stated other residents called for assistance when Resident 1 entered their rooms. On June 19, 2026, at 4:03 p.m., during an interview, the Director of Nursing (DON) stated this was the first time she had been informed that Resident 1 entered another resident's room. The DON stated she was not aware staff had previously observed Resident 1 entering other residents' room. The DON stated staff should have reported the behavior so it could be monitored and appropriate interventions implemented, including consultation with the psychiatrist to determine whether medication adjustments or other interventions were needed. A review of the facility's facility and procedure titled Wandering and Elopements dated March 2019 indicated .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents .If identified as at risk for wandering .the resident's care plan will include strategies and interventions to maintain the resident's safety .

Based on observation, interview, and record review, the facility failed to ensure food was stored, labeled, and maintained under sanitary conditions when multiple food items were not labeled or dated once opened, containers had food residue, and shelving inside the walk-in refrigerator showed signs of rust. These failures had the potential to result in cross-contamination, bacterial growth, and attraction of pests, placing resident at risk for food borne illness.Findings:On August 18, 2025, at 9 a.m., during a kitchen tour with the Dietary Supervisor (DS), the following were observed: a. One undated sandwich inside the refrigerator. b. One bag of breadcrumbs undated and unlabeled. c. One gallon container of balsamic vinegar open with no open date or use by date.d. One gallon container of soy sauce open with no open date or use by date, with residue on the outside of the bottle.e. Two bottles of honey without open or use by date, with sticky residue on the outside.f. A bag of pasta, opened and taped shut, without a label or open date.g. A flour container with excess flour spilled on the outside. h. A sugar container with excess sugar residue on the lid. i. The walk-in refrigerator contained a green shelf with brown discoloration resembling rust. During a concurrent interview with the DS, the DS stated, the following:a. The sandwich and breadcrumbs should have been labeled and dated. b. Once opened, vinegar and soy sauce containers should be dated, and bottles should be kept clean to prevent attracting pests. c. Honey bottles should be cleaned and free from residue. d. Pasta should be stored in a container once opened.e. Flour and sugar containers should be clean and free from residue to prevent pests.f. The walk-in refrigerator shelf appeared rusted and should be replaced.On August 21, 2025, at 3:07 p.m., during an interview with the Registered Dietitian (RD), the RD stated the storage shelves in the walk-in refrigerator should be rust free otherwise it is difficult to clean. The RD further stated that all food needs to have label and date, and shelves to be clean in order to prevent cross contamination, and bacterial growth.A review of the facility policy's titled Sanitization, dated November 2022, indicated .all kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.all utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning . A record review of the Food Code, 2022, the Food Code indicated, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and the Equipment is cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted.

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when one dumpster was overflowing with trash, and the lid was not closed.This failure had the potential to attract pests and rodents, which could cause food borne illness.Findings:On August 18, 2025, at 9:30 a.m., during an observation of the dumpster storage area outside the facility, one out of two dumpster lids was not closed, and trash was observed overflowing.On August 18, 2025, at 9:30a.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DS) at the dumpster site. The DS stated the dumpster lids were open and should have been closed, and the trash should not have been overflowing in order to prevent pest infestations. On August 21, 2025, at 2:15 p.m., a concurrent observation and interview were conducted with the Maintenance Supervisor (MS) at the dumpsters. The MS stated, the staff throwing away trash were responsible for keeping the dumpster lids closed and the surrounding area clean. The MS further stated the dumpster lids should always be closed and the area free from trash to prevent attracting flied and rodents. A review of the facility policy and procedure titled Sanitization, dated November 2022, indicated, .kitchen wastes that are not disposed of by mechanical means are kept clean, leakproof, nonabsorbent, tightly closed containers and disposed daily.garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/ compactors with lids (or otherwise covered).

Based on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for five of five sampled residents (Residents 5, 6, 10, 11 and 30) when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning medications. Resident 5 and Resident 6 were receiving rivaroxaban (an anticoagulant, or blood thinning medication). Residents 10, 11, and 30 were receiving apixaban (an anticoagulant, or blood thinning medication). This failure had the potential for the medication not being optimized for best possible health outcome, and unnecessary or prolonged use of the medication which could lead to adverse effects such as bleeding or excessive bruising.During an interview on August 20, 2025 at 2:47 p.m., Licensed Vocational Nurse (LVN) 3 described the process for when a resident was admitted to the facility on a blood thinning medication as follows:Nursing staff should have monitored daily for adverse effects such as bleeding;Nursing staff should have documented monitoring in the medication administration record (MAR); andA care plan should have been developed. During an interview on August 20, 2025 at 2:50 p.m., LVN 1 stated when a resident was receiving anticoagulation therapy, nursing staff should have monitored for signs and symptoms of bleeding/bruising and should have documented monitoring in the MAR every day. LVN 1 further stated that any resident on anticoagulation therapy needed a provider's order to monitor for bleeding. LVN 1 stated nursing staff would have known what adverse reactions to monitor from reviewing the physician's orders and the care plan.1a. During a review of Resident 6's admission Record, dated August 20, 2025, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of chronic embolism (a blockage in a blood vessel) and thrombosis (blood clot) of unspecified deep veins of left lower extremity.A review of Resident 6's medical record indicated the following physician's orders:On December 13, 2024, Rivaroxaban Oral Tablet 20 milligram (mg, unit of measurement) Give 20 mg by mouth in the evening for DVT (deep vein thrombosis) prevention; [NAME] March 31, 2025, Monitor/document/report adverse reactions of anticoagulant therapy: bleeding such as: Nosebleeds that happen often, unusual bleeding from gums, menstrual bleeding that is heavier than normal, or vaginal bleeding, bleeding that is severe or you cannot control, red, pink, or brown urine, bright red or black stools, coughing up blood or blood clots, vomit blood or vomit looks like coffee grounds, headaches, feeling dizzy or weak, pain, swelling, or new drainage at wound sites, every shift write progress note and notify physician of identified drug side effect(s).A review of Resident 6's medical record, including the MARs dated December 14, 2024 to March 30, 2025, indicated Resident 6 was administered rivaroxaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. 1b. During a review of Resident 30's admission Record, dated August 20, 2025, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. A review of Resident 30's Acute Hospital Records, dated November 23, 2024, indicated Resident 30 had a DVT.A review of Resident 30's medical record indicated the following physician's orders:On November 23, 2024, Apixaban Oral Tablet 5 mg Give two tablets by mouth two times a day for DVT for 7 days;On November 30, 2024, Apixaban Oral Tablet 5 mg Give one tablet by mouth two times a day for DVT prevention; [NAME] February 28, 2025, Monitor/document/report adverse reactions of anticoagulant therapy: bleeding such as: Nosebleeds that happen often, unusual bleeding from gums, menstrual bleeding that is heavier than normal, or vaginal bleeding, bleeding that is severe or you cannot control, red, pink, or brown urine, bright red or black stools, coughing up blood or blood clots, vomit blood or vomit looks like coffee grounds, headaches, feeling dizzy or weak, pain, swelling, or new drainage at wound sites, every shift write progress note and notify physician of identified drug side effect(s).A review of Resident 30's medical record, including the MARs dated November 23, 2024 to February 27, 2025, indicated Resident 30 was administered apixaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. 1c. During a review of Resident 10's admission Record, dated August 21, 2025, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of acute embolism and thrombosis of unspecified deep veins of left lower extremity. A review of Resident 10's medical record indicated a physician's order on July 16, 2025, for Apixaban Oral Tablet 5 mg Give 5 mg by mouth two times a day for acute embolism and thrombosis of unspecified deep veins of left lower extremity. A review of Resident 10's medical record indicated there was no documented evidence of a physician's order for Monitor/document/report adverse reactions of anticoagulant therapy between July 16, 2025 to August 20, 2025. A review of Resident 10's medical record, including the MARs dated July 16, 2025 to August 20, 2025, indicated Resident 10 was administered apixaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. During a concurrent interview and record review on August 20, 2025 at 2:53 p.m., with LVN 1, Resident 10's medical record, including physician's orders and MARs dated July 16, 2025 to August 20, 2025, were reviewed. LVN 1 confirmed Resident 10 started taking apixaban on July 16, 2025, there were no physician orders for monitoring adverse reactions of anticoagulation therapy, and there was no documentation of monitoring for bleeding during apixaban use. LVN 1 stated there should have been physician orders for monitoring adverse reactions of anticoagulation therapy and nursing staff should have documented the monitoring daily. 1d. During a review of Resident 5's admission Record, dated August 21, 2025, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of acute embolism and thrombosis of unspecified deep veins of left lower extremity. A review of Resident 5's medical record indicated a physician's order on May 20, 2025, for Rivaroxaban Oral Tablet 20 mg Give 20 mg by mouth one time a day for acute embolism and thrombosis of unspecified deep veins of left lower extremity. Further review of Resident 5's medical record indicated he had been administered rivaroxaban since January 8, 2025. A review of Resident 5's medical record indicated there was no documented evidence of a physician's order for Monitor/document/report adverse reactions of anticoagulant therapy between January 8, 2025 to August 20, 2025. A review of Resident 5's medical record, including the MARs dated January 8, 2025 to August 20, 2025, indicated Resident 5 was administered rivaroxaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. During a concurrent interview and record review on August 20, 2025 at 2:56 p.m., with LVN 1, Resident 5's medical record, including physician's orders and MARs dated January 8, 2025 to August 20, 2025, were reviewed. LVN 1 confirmed Resident 5 started taking rivaroxaban on January 8, 2025, there were no physician orders for monitoring adverse reactions of anticoagulation therapy, and there was no documentation of monitoring for bleeding during rivaroxaban use. LVN 1 stated there should have been physician orders for monitoring adverse reactions of anticoagulation therapy and nursing staff should have documented the monitoring daily. 1e. During a review of Resident 11's admission Record, dated August 20, 2025, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnosis of acute embolism and thrombosis of unspecified deep veins of right lower extremity. A review of Resident 11's medical record indicated a physician's order on May 11, 2025, for Apixaban Oral Tablet 5 mg Give one tablet by mouth two times a day related to acute embolism and thrombosis of unspecified deep veins of right lower extremity. Further review of Resident 11's medical record indicated he had been administered apixaban since May 2, 2025. A review of Resident 11's medical record indicated there was no documented evidence of a physician's order for Monitor/document/report adverse reactions of anticoagulant therapy between May 2, 2025 to August 20, 2025. A review of Resident 11's medical record, including the MARs dated May 2, 2025 to August 20, 2025, indicated Resident 11 was administered apixaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. During a concurrent interview and record review on August 20, 2025 at 3:04 p.m., with LVN 1, Resident 11's medical record, including physician's orders and MARs dated May 2, 2025 to August 20, 2025, were reviewed. LVN 1 confirmed Resident 11 started taking apixaban on May 2, 2025, there were no physician orders for monitoring adverse reactions of anticoagulation therapy, and there was no documentation of monitoring for bleeding during apixaban use. LVN 1 stated when the anticoagulant medication was ordered for Resident 11, the adverse effect monitoring should have been entered but it was not done. During an interview on August 20, 2025 at 3:09 p.m., the Registered Nurse (RN) 1 stated residents on anticoagulation therapy required daily monitoring for side effects such as bleeding/bruising symptoms. RN 1 stated nursing staff were expected to document daily monitoring of side effects in the MAR and if there was an issue with bleeding, nursing staff should have documented in the health status notes. Additionally, RN 1 stated a care plan should have been initiated anytime a new medication such as anticoagulation therapy was started. During an interview on August 20, 2025 at 3:33 p.m., the Director of Nursing (DON) stated the process for anticoagulation therapy was as follows: The physician would have written an order for anticoagulation therapy; The nurse that received the order should have written a corresponding order for side effect monitoring such as bleeding/bruising; andThe nurse should have initiated a care plan for anticoagulation therapy. During the same interview on August 20, 2025 at 3:33 p.m., the DON stated nursing staff were expected to document monitoring for bleeding under the Monitoring MAR during every shift. A review of the consultant pharmacist's (CP) monthly MRRs from November 2024 to July 2025 for Resident 5, 6, 10, 11, and 30 indicated there were no recommendations from the CP related to the need for potential adverse effect monitoring during anticoagulant therapy. During a follow-up interview on August 21, 2025 at 3 p.m., the DON stated it was important to monitor side effects during blood thinner use because bleeding could cause complications for the residents if not identified in a timely manner. Additionally, the DON stated the irregularity should have been identified and reported by the CP in the monthly MRR between November 2024 - July 2025 for Residents 5, 6, 10, 11, and 30 who were receiving anticoagulant therapy. A review of the manufacturer's instructions for apixaban tablets, dated May 2024, retrieved from DailyMed (The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration.), indicated, Warnings and precautions .Apixaban can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. A review of the manufacturer's instructions for rivaroxaban tablets, dated July 2025, retrieved from DailyMed, indicated, Warnings and precautions.Risk of bleeding: Rivaroxaban can cause serious and fatal bleeding. A review of the facility's policy and procedures (P&P), titled Medication Regimen Reviews, dated May 2019, indicated, The consultant pharmacist reviews the medication regimen of each resident at least monthly.The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example.inadequate monitoring for adverse consequences.An irregularity refers to the use of medication that is inconsistent with accepted pharmaceutical services standards of practice.It may also include the use of medication without adequate monitoring. A review of the facility's P&P, titled Anticoagulation - Clinical Protocol, dated November 2018, indicated, Assess for any signs or symptoms related to adverse drug reactions due to the medication .The staff and physician will monitor for possible complications in individuals who are being anticoagulated .if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (coughing or spitting up blood from the respiratory tract), or other evidence of bleeding, the nurse will discuss the situation when the physician before giving the next scheduled dose of anticoagulant.

Based on interview and record review, the facility failed to ensure five of five sampled residents (Residents 5, 6, 10, 11 and 30) were free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning mediations. Resident 5 and Resident 6 were receiving rivaroxaban (an anticoagulant, or blood thinning medication). Residents 10, 11, and 30 were receiving apixaban (an anticoagulant, or blood thinning medication).This failure had the potential to result in unnecessary use of medications for Residents 5, 6, 10, 11 and 30; and for side effects of these medications (such as bleeding or excessive bruising) to go undetected or recognized for timely intervention.Findings:During an interview on August 20, 2025 at 2:47 p.m., Licensed Vocational Nurse (LVN) 3 described the process for when a resident was admitted to the facility on a blood thinning medication as follows: Nursing staff should have monitored daily for adverse effects such as bleeding; Nursing staff should have documented monitoring in the medication administration record (MAR); andA care plan should have been developed. During an interview on August 20, 2025 at 2:50 p.m., LVN 1 stated when a resident was receiving anticoagulation therapy, nursing staff should have monitored for signs and symptoms of bleeding/bruising and should have documented monitoring in the MAR every day. LVN 1 further stated that any resident on anticoagulation therapy needed a provider's order to monitor for bleeding. LVN 1 stated nursing staff would have known what adverse reactions to monitor from reviewing the physician's orders and the care plan.1a. During a review of Resident 6's admission Record, dated August 20, 2025, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of chronic embolism (a blockage in a blood vessel) and thrombosis (blood clot) of unspecified deep veins of left lower extremity. A review of Resident 6's medical record indicated the following physician's orders:On December 13, 2024, Rivaroxaban Oral Tablet 20 milligram (mg, unit of measurement) Give 20 mg by mouth in the evening for DVT (deep vein thrombosis) prevention; [NAME] March 31, 2025, Monitor/document/report adverse reactions of anticoagulant therapy: bleeding such as: Nosebleeds that happen often, unusual bleeding from gums, menstrual bleeding that is heavier than normal, or vaginal bleeding, bleeding that is severe or you cannot control, red, pink, or brown urine, bright red or black stools, coughing up blood or blood clots, vomit blood or vomit looks like coffee grounds, headaches, feeling dizzy or weak, pain, swelling, or new drainage at wound sites, every shift write progress note and notify physician of identified drug side effect(s).A review of Resident 6's medical record, including the MARs dated December 14, 2024 to March 30, 2025, indicated Resident 6 was administered rivaroxaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy.1b. During a review of Resident 30's admission Record, dated August 20, 2025, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. A review of Resident 30's Acute Hospital Records, dated November 23, 2024, indicated Resident 30 had a DVT.A review of Resident 30's medical record indicated the following physician's orders:On November 23, 2024, Apixaban Oral Tablet 5 mg Give two tablets by mouth two times a day for DVT for 7 days;On November 30, 2024, Apixaban Oral Tablet 5 mg Give one tablet by mouth two times a day for DVT prevention; [NAME] February 28, 2025, Monitor/document/report adverse reactions of anticoagulant therapy: bleeding such as: Nosebleeds that happen often, unusual bleeding from gums, menstrual bleeding that is heavier than normal, or vaginal bleeding, bleeding that is severe or you cannot control, red, pink, or brown urine, bright red or black stools, coughing up blood or blood clots, vomit blood or vomit looks like coffee grounds, headaches, feeling dizzy or weak, pain, swelling, or new drainage at wound sites, every shift write progress note and notify physician of identified drug side effect(s).A review of Resident 30's medical record, including the MARs dated November 23, 2024 to February 27, 2025, indicated Resident 30 was administered apixaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. 1c. During a review of Resident 10's admission Record, dated August 21, 2025, the admission Record indicated Resident 10 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of acute embolism and thrombosis of unspecified deep veins of left lower extremity. A review of Resident 10's medical record indicated a physician's order on July 16, 2025, for Apixaban Oral Tablet 5 mg Give 5 mg by mouth two times a day for acute embolism and thrombosis of unspecified deep veins of left lower extremity. A review of Resident 10's medical record indicated there was no documented evidence of a physician's order for Monitor/document/report adverse reactions of anticoagulant therapy between July 16, 2025 to August 20, 2025. A review of Resident 10's medical record, including the MARs dated July 16, 2025 to August 20, 2025, indicated Resident 10 was administered apixaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. During a concurrent interview and record review on August 20, 2025 at 2:53 p.m., with LVN 1, Resident 10's medical record, including physician's orders and MARs dated July 16, 2025 to August 20, 2025, were reviewed. LVN 1 confirmed Resident 10 started taking apixaban on July 16, 2025, there were no physician orders for monitoring adverse reactions of anticoagulation therapy, and there was no documentation of monitoring for bleeding during apixaban use. LVN 1 stated there should have been physician orders for monitoring adverse reactions of anticoagulation therapy and nursing staff should have documented the monitoring daily. 1d. During a review of Resident 5's admission Record, dated August 21, 2025, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of acute embolism and thrombosis of unspecified deep veins of left lower extremity. A review of Resident 5's medical record indicated a physician's order on May 20, 2025, for Rivaroxaban Oral Tablet 20 mg Give 20 mg by mouth one time a day for acute embolism and thrombosis of unspecified deep veins of left lower extremity. Further review of Resident 5's medical record indicated he had been administered rivaroxaban since January 8, 2025. A review of Resident 5's medical record indicated there was no documented evidence of a physician's order for Monitor/document/report adverse reactions of anticoagulant therapy between January 8, 2025 to August 20, 2025. A review of Resident 5's medical record, including the MARs dated January 8, 2025 to August 20, 2025, indicated Resident 5 was administered rivaroxaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. During a concurrent interview and record review on August 20, 2025 at 2:56 p.m., with LVN 1, Resident 5's medical record, including physician's orders and MARs dated January 8, 2025 to August 20, 2025, were reviewed. LVN 1 confirmed Resident 5 started taking rivaroxaban on January 8, 2025, there were no physician orders for monitoring adverse reactions of anticoagulation therapy, and there was no documentation of monitoring for bleeding during rivaroxaban use. LVN 1 stated there should have been physician orders for monitoring adverse reactions of anticoagulation therapy and nursing staff should have documented the monitoring daily. 1e. During a review of Resident 11's admission Record, dated August 20, 2025, the admission Record indicated Resident 11 was admitted to the facility on [DATE] with diagnosis of acute embolism and thrombosis of unspecified deep veins of right lower extremity. A review of Resident 11's medical record indicated a physician's order on May 11, 2025, for Apixaban Oral Tablet 5 mg Give one tablet by mouth two times a day related to acute embolism and thrombosis of unspecified deep veins of right lower extremity. Further review of Resident 11's medical record indicated he had been administered apixaban since May 2, 2025. A review of Resident 11's medical record indicated there was no documented evidence of a physician's order for Monitor/document/report adverse reactions of anticoagulant therapy between May 2, 2025 to August 20, 2025. A review of Resident 11's medical record, including the MARs dated May 2, 2025 to August 20, 2025, indicated Resident 11 was administered apixaban and there was no documented evidence of monitoring for adverse reactions of anticoagulant therapy. During a concurrent interview and record review on August 20, 2025 at 3:04 p.m., with LVN 1, Resident 11's medical record, including physician's orders and MARs dated May 2, 2025 to August 20, 2025, were reviewed. LVN 1 confirmed Resident 11 started taking apixaban on May 2, 2025, there were no physician orders for monitoring adverse reactions of anticoagulation therapy, and there was no documentation of monitoring for bleeding during apixaban use. LVN 1 stated when the anticoagulant medication was ordered for Resident 11, the adverse effect monitoring should have been entered but it was not done. During an interview on August 20, 2025 at 3:09 p.m., the Registered Nurse (RN) 1 stated residents on anticoagulation therapy required daily monitoring for side effects such as bleeding/bruising symptoms. RN 1 stated nursing staff were expected to document daily monitoring of side effects in the MAR and if there was an issue with bleeding, nursing staff should have documented in the health status notes. Additionally, RN 1 stated a care plan should have been initiated anytime a new medication such as anticoagulation therapy was started. During an interview on August 20, 2025 at 3:33 p.m., the Director of Nursing (DON) stated the process for anticoagulation therapy was as follows: The physician would have written an order for anticoagulation therapy; The nurse that received the order should have written a corresponding order for side effect monitoring such as bleeding/bruising; andThe nurse should have initiated a care plan for anticoagulation therapy. During the same interview on August 20, 2025 at 3:33 p.m., the DON stated nursing staff were expected to document monitoring for bleeding under the Monitoring MAR during every shift. During a follow-up interview on August 21, 2025 at 3 p.m., the DON stated it was important to monitor side effects during blood thinner use because bleeding could cause complications for the residents if not identified in a timely manner. A review of the manufacturer's instructions for apixaban tablets, dated May 2024, retrieved from DailyMed (The contents of DailyMed is provided and updated daily by the U.S. Food and Drug Administration.), indicated, Warnings and precautions .Apixaban can cause serious, potentially fatal, bleeding. Promptly evaluate signs and symptoms of blood loss. A review of the manufacturer's instructions for rivaroxaban tablets, dated July 2025, retrieved from DailyMed, indicated, Warnings and precautions.Risk of bleeding: Rivaroxaban can cause serious and fatal bleeding. A review of the facility's policy and procedures (P&P), titled Anticoagulation - Clinical Protocol, dated November 2018, indicated, Assess for any signs or symptoms related to adverse drug reactions due to the medication .The staff and physician will monitor for possible complications in individuals who are being anticoagulated .if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (coughing or spitting up blood from the respiratory tract), or other evidence of bleeding, the nurse will discuss the situation when the physician before giving the next scheduled dose of anticoagulant.

Based on observation, interview, and record review, the facility failed to ensure dignity was provided for two of two residents reviewed for dignity (Residents 5 and 38) when Resident 5 and 38's lunch tray was not provided at the same time at their tables.This failure had the potential to negatively affect Residents 5 and 38's self-worth and self-esteem. Findings:1a. On August 18, 2025, at 12:18 p.m., an observation was conducted in the dining room with Resident 5. Resident 5 was seated at a table with another resident, who was served his meal and began eating. Resident 5 did not receive his lunch for approximately five minutes and was observed looking over his right shoulder until his meal arrived. On August 18, 2025, at 12:30 p.m., an interview was conducted with Resident 5. Resident 5 stated that it has happened before that he had to wait for his meal while other residents at his table were already eating.1b. On August 18, 2025, at 12:50 p.m., an observation was conducted in the dining room with Resident 38. Resident 38 was seated at a table with two other residents, who were served their meals and began eating. Resident 38 did not receive his lunch for approximately eight minutes and was observed watching the other two residents eat. The other two residents were nearly finished with their meal trays before Resident 38 received his.On August 18, 2025, at 12:56 p.m., a concurrent observation and interview was conducted with the Director of Staff Development (DSD). The DSD stated Resident 38's meal was delayed due to room change. On August 18, 2025, at 1:02 p.m., an interview was conducted with Resident 38. Resident 38 stated that he will just watch the other residents eat their food while he waits for his food. On August 21, 2025, at 4:23 p.m., an interview was conducted with the DSD. The DSD stated that the meal trays should be served one table at a time, so the residents are not waiting and watching others eat, in order to respect residents' rights.On August 21, 2025, at 2:40 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated residents seated together were expected to receive their meals at the same time as a group. The RD stated serving meals separately could make residents feel left out and affect their sense of dignity.A review of the facility Policy and Procedure titled, Dignity, dated February 2021, indicated, .Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level or satisfaction with life, feeling of self-worth and self-esteem .Residents are treated with dignity and respect at all times .

Based on observation, interview and record review, the facility failed to ensure one of one resident reviewed (Resident 38) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when Resident 38 was administered risperidone (an anti-psychotic medication used for schizophrenia) without adequate monitoring. This failure resulted in unnecessary medications for Residents 38, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of psychotropic medications that included but not limited to sedation, respiratory depression, constipation, anxiety, agitation, and memory loss.Findings:A review of Resident 38's admission Record dated August 21, 2025, indicated he was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (mental illness).A review of Resident 38's Order Listing Report dated August 21, 2025, indicated the following physician's orders were ordered on June 19, 2025: Risperdal Oral tablet 3 mg (milligrams - a unit of measurement) Give 3 mg by mouth two times a day for PARANOID SCHIZOPHRENIA . Anti-Psychotic Monitor of episodes of PARANOID SCHIZOPHRENIA AEB (as evidenced by): paranoid ideations. Drug: RisperDaL .every shift . A review of Resident 38's Care Plan Report indicated Focus .admitted with antipsychotic medication r/t (related to) Medical Diagnosis: PARANOID SCHIZOPHRENIA AEB: paranoid ideations. Medication: Risperdal. At risk for adverse drug reaction .Approaches .Monitor/record occurrence of target behavior symptoms(s) AEB paranoid ideations . were initiated on June 20, 2025.A review of Resident 38's Medication Administration Record (MAR) for the period of June 19 to August 21, 2025, indicated the resident received risperidone as ordered by the physician.A review of Resident 38's Monitoring Record indicated the resident was monitored for episodes of paranoid schizophrenia aeb paranoid ideations as follows:1. For the period of June 19 to 30, 2025, the resident did not have any episode for morning, evening and night shifts.2. For the period of July 1 to 32, 2025, the resident had six episodes in the morning shift on July 19, 22, 25-28, 2025, four episodes in the evening shift on July 26, 27, 29 and 30, 2025, and none in the night shift.3. For the period of August 1 to 21, 2025, the resident had 17 episodes in the morning shift on August 1, 3-13, 15-19, 2025, and none in the evening and night shifts. A review of resident 38's e-Mar (electronic MAR) - Medication Administration Note and Health Status Note for the period of June 19, 2025, to August 21, 2025, did not indicate any documented evidence that Resident 38's episodes of paranoid ideations were described when it was observed on July 19, 25, 28, August 1, 3-13, 15-19, 2025.On August 18, 2025, at 11:30 a.m., Resident 38 was observed in the hallway asking for his medication.On August 18, 2025, at 4:00 p.m., Resident 38 was observed in the hallway asking for his medication.On August 21, 2025, at 9:47 a.m., during a concurrent interview with Licensed Vocational Nurse (LVN) 1 and record review of Resident 38's physician's orders, LVN 1 stated Resident 38 was being monitored for his paranoid ideations. LVN 1 stated Resident 38's paranoid ideations are asking for his medications and missing smoke break. LVN 1 stated there was no specific monitoring of Resident 38's paranoid ideations and it should be indicated on the monitoring so that it will be clear what behavior is exactly being monitored. On August 21, 2025, at 10:19 a.m., during an interview, the Behavioral Health Nurse Director (BHND) stated he ensures there is behavior monitoring for every psychotropic medication that a resident is on. The BHND stated he does not tailor behavior monitoring because residents' behavior can change. The BHND stated Resident 38's paranoid ideation is asking for Tylenol (a pain medication). The BHND stated it was tricky and behavior monitoring does not have to be tailored to the resident because the nurses will only focus on one behavior and leave other behaviors out, so the behavior monitoring is left broad and general. The BHND stated the expectation was if a resident was observed with frequent behavior changes through out the day, the nurses should describe it in their progress notes by creating a Health Status Note.On August 21, 2025, at 11:21 a.m., during an interview, the Director of Nursing (DON) stated the practice was every resident behavior is monitored. The DON stated her expectation was for the nurses to document Resident 38's behavior in the Health Status Note to be able to identify if his behaviors are frequent. On August 21, 2025, at 12:55 p.m., during a follow up interview, the BHND stated Resident 38's behavior of paranoid ideation is specific to the resident. The BHND stated they are not going to have monitoring for all behaviors and that is hard. On August 21, 2025, at 1:30 p.m., during an interview, LVN 2 stated paranoid ideation is when a resident says someone's out to get me or is afraid of something. LVN 2 stated paranoid ideation can be different for every resident. On August 21, 2025, at 3:03 p.m., during a follow up interview, the DON stated behavior monitoring should be resident specific. The DON stated it is important to monitor target behaviors specific to each resident to adjust doses if needed or appropriate, to evaluate for the effectiveness or ineffectiveness of the medication, and to identify changes of conditions or new behaviors. A review of the facility's policy and procedure (P&P) titled Behavioral Assessment, Intervention, and Monitoring dated February 2025 indicated .Behavioral symptoms are identified using facility-approved behavioral screening tools and the comprehensive assessment .The nursing staff identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including .onset, duration, intensity, and frequency of behavioral symptoms .The IDT [Interdisciplinary team, a group of healthcare professionals from different disciplines] thoroughly evaluates new or changing behavioral symptoms to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition .If psychotropic medications are prescribed for behavioral symptoms, documentation includes .specific target behaviors and expected outcomes .monitoring for efficacy.The IDT monitors for and documents any new, worsening, or improved symptoms in the resident's behavior.A review of the facility's P&P titled Psychotropic Medication Use, dated February 2025 indicated, Residents receiving psychotropic medication are monitored and the response to treatment is documented.Monitoring may include.behavior flow sheets, medication administration records.

Based on interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was initiated according to the facility's policy when two of five sampled residents (Resident 5 and 6) received anticoagulant therapy with rivaroxaban (an anticoagulant, or blood thinning medication). This failure had the potential to result in delays in treatment and care for Residents 5 and 6. During an interview on August 20, 2025 at 2:47 p.m., Licensed Vocational Nurse (LVN) 3 described the process for when a resident was admitted to the facility on a blood thinning medication as follows: Nursing staff should have monitored daily for adverse effects such as bleeding; Nursing staff should have documented monitoring in the medication administration record (MAR); andA care plan should have been developed. During an interview on August 20, 2025 at 2:50 p.m., LVN 1 stated when a resident was receiving anticoagulation therapy, nursing staff should have monitored for signs and symptoms of bleeding/bruising and should have documented monitoring in the MAR every day. LVN 1 further stated that any resident on anticoagulation therapy needed a provider's order to monitor for bleeding. LVN 1 stated nursing staff would have known what adverse reactions to monitor from reviewing the physician's orders and the care plan.1a. During a review of Resident 6's admission Record, dated August 20, 2025, the admission Record indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of chronic embolism (a blockage in a blood vessel) and thrombosis (blood clot) of unspecified deep veins of left lower extremity. A review of Resident 6's medical record indicated a physician's order on December 13, 2024, for Rivaroxaban Oral Tablet 20 milligram (mg, unit of measurement) Give 20 mg by mouth in the evening for DVT (deep vein thrombosis) prevention.A review of Resident 6's MARs dated December 14, 2024 to April 7, 2025, indicated Resident 6 was administered rivaroxaban as prescribed by the physician.A review of Resident 6's Care Plan Reports dated December 14, 2024 to April 7, 2025, indicated there was no documented evidence of a care plan developed for anticoagulation therapy use and management after rivaroxaban was ordered and administered. A review of Resident 6's Care Plan Report dated April 8, 2025, approximately 3.5 months after anticoagulant therapy was initiated, indicated Focus - Anticoagulant therapy r/t (related to) chronic embolism and thrombosis of unspecified deep veins of left lower extremity. At risk for abnormal bleeding or hemorrhage. Medication: Rivaroxaban. 1b. During a review of Resident 5's admission Record, dated August 21, 2025, the admission Record indicated Resident 5 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnosis of acute embolism and thrombosis of unspecified deep veins of left lower extremity. A review of Resident 5's medical record indicated a physician's order on May 20, 2025, for Rivaroxaban Oral Tablet 20 mg Give 20 mg by mouth one time a day for acute embolism and thrombosis of unspecified deep veins of left lower extremity. Further review of Resident 5's medical record indicated he had been administered rivaroxaban since January 8, 2025. A review of Resident 5's MARs dated January 8, 2025 to May 29, 2025, indicated Resident 5 was administered rivaroxaban as prescribed by the physician. A review of Resident 5's Care Plan Reports dated January 8, 2025 to May 29, 2025, indicated there was no documented evidence of a care plan developed for anticoagulation therapy use and management after rivaroxaban was ordered and administered. A review of Resident 5's Care Plan Report dated May 30, 2025, approximately 5 months after anticoagulant therapy was initiated, indicated Focus - Anticoagulant therapy r/t (related to) acute embolism and thrombosis of unspecified deep veins of L (left) . At risk for abnormal bleeding or hemorrhage. Medication: Rivaroxaban. During an interview on August 20, 2025 at 3:09 p.m., the Registered Nurse (RN) 1 stated a care plan should have been initiated anytime a new medication such as anticoagulation therapy was started. During an interview on August 20, 2025 at 3:33 p.m., the Director of Nursing (DON) stated the process for anticoagulation therapy was as follows: The physician would have written an order for anticoagulation therapy; The nurse that received the order should have written a corresponding order for side effect monitoring such as bleeding/bruising; andThe nurse should have initiated a care plan for anticoagulation therapy. During the same interview on August 20, 2025 at 3:33 p.m., the DON stated a care plan should have been initiated for new medication orders and the care plan gets revised if medications are discontinued. A review of the facility's policy and procedures (P&P), titled Care Plans, Comprehensive Person-Centered, dated March 2022, indicated, The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS [Minimum Data Set, an assessment tool] assessment (Admission, Annual, or Significant Change In Status), and no more than 21 days after admission.

Based on interview and record review, the facility failed to ensure timely communication and implementation of a hospice physician's medication order (Prednisone - to reduce inflammation) for one of one resident reviewed for hospice (medical care provided to individuals with terminal illnesses) (Resident 3).This failure resulted in Resident 3 receiving Prednisone four days after it was ordered by the hospice physician, which had the potential to cause unnecessary delay in treatment and comfort.Findings: A review of Resident 3's admission Record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD- a chronic respiratory problem) and Alzheimer's disease (progressive loss of memory). Resident 3 was admitted to hospice services on April 28, 2025.A review of Resident 3's History and Physical Examination dated May 9., 2025, indicated .Mentally Capable of Understanding - No.A review of Resident 3's hospice physician's order dated August 8, 2025, indicated .Prednisone 20 mg (milligram- unit of measurement) 2 tablets daily for five days.A review of Resident 3's e-MAR (electronic MAR - medication administration record) indicated Prednisone was first administered on August 12, 2025 - four days after the order was written.On August 21, 2025, at 9:55 a.m., during a concurrent interview and record review of Resident 3's hospice physician order, LVN 2 stated she was not aware of the Prednisone order. LVN 2 stated the standard practice was for a medication ordered on August 8, 2025, to be available within the same day or by the following day, and to be administered as soon as it became available.On August 21, 2025, at 4:15 p.m., during an interview with the Director of Nursing (DON), the DON stated it was the expectation that any change in condition or new medication order must be communicated with her by the hospice physician or hospice nurse. The DON further stated she was not aware of the Prednisone order.On August 21, 2025, at 2:22 p.m., during a concurrent interview and record review with Hospice Registered Nurse (HRN), she stated on August 8, 2025, the Nurse Practitioner evaluated Resident 3 and issued the Prednisone order. The HRN stated she sent the order to the facility via e-fax and also called the facility pharmacy. The HRN stated she should have verified with the facility staff that the order was received. The HRN further stated that not communicating and implementing the order could cause delay in treatment and comfort for Resident 3. On August 21, 2025, at 2:28 p.m., in an interview with LVN 3, LVN 3 stated she saw the delivered Prednisone tablets on her medication cart for Resident 3 on August 12, 2025. LVN 3 stated she contacted the hospice and the physician for the order, at which time the physician authorized initiation of the medication. A review of the facility undated document titled Hospice Program, indicated .Hospice services are available to residents at the end of life.Hospice Providers who contract with the facility: Are held responsible for meeting the same professional standards and timeliness of service.

Based on observation, interview and record review, the facility had a medication error rate of 6.9% when two medication errors occurred out of 29 opportunities during medication administration for one of nine residents (Resident 29). The facility did not administer Resident 29's stool softener (used for constipation) and laxative (used for constipation) medications according to the physician's orders.This failure had the potential to result in Resident 29 not receiving the full therapeutic benefit of their medication or experiencing side effects (such as diarrhea) from receiving the wrong dosage of a laxative.Findings:On August 19, 2025, at 8:40 a.m., during a medication administration observation with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing six medications for Resident 29, including one docusate (a stool softener) 100 mg soft gel capsule and 30 ml (milliliters, unit of measurement) lactulose (a laxative) oral solution. A review of Resident 29's medical record indicated the following physician's orders: On April 11, 2025, Lactulose Oral Solution 20GM/30ML give 15 mL by mouth one time a day for constipation; [NAME] June 11, 2025, DSS oral capsule 100 mg, give 200 mg by mouth two times a day for supplement (hold for loose stool).On August 19, 2025, at 10:01 a.m., during a concurrent interview and record review of Resident 29's electronic medication administration record (e-MAR) with LVN 1, LVN 1 stated Resident 29 had an order for docusate 200 mg by mouth, she only gave one docusate soft gel which is 100mg instead of two soft gels (200mg). LVN 1 stated Resident 29 had an order for lactulose 15 ml, she administered 30 ml. LVN 1 stated, she should have administered 15 ml.On August 19, 2025, at 1:24 p.m., during an interview, the Director of Nursing (DON) stated LVN 1 should have done the triple check process for medication administration which is comparing the physician's order on the computer screen with the bubble pack, checking the resident's name, and the expiration date. The DON stated they are not supposed to take short cuts because they are dealing with human life.A review of the facility's policy and procedure titled Administering Oral Medications dated October 2010 indicated .Steps in the Procedure .Check the label on the medication and confirm the medication name and dose with the MAR . Check the medication dose. Re-check to confirm the proper dose .Prepare the correct dose of the medication .For liquid medications .Place cup on a level surface and read the poured amount at eye level to check accuracy .For tablets or capsules from a bottle .pour the desired number into the bottle cap and transfer to the medication cup .

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when two opened and expired refrigerated multi-dose vials (MDV) of Tuberculin Purified Protein Derivative (PPD- test agent used in the diagnosis of tuberculosis, a serious illness that mainly affects the lung) were not discarded according to the manufacturer's specifications and the facility's policy.This failure had the potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock.Findings:On August 18, 2025, at 9:24 a.m., during a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2 in the medication room, there were two opened refrigerated MDV of PPD 5 TU (test unit) per 0.1 ml (milliliter- a unit of measurement) with an open date label that indicated the vials were opened on July 12, 2025. LVN 2 stated the vials were good for 30 days when opened and both vials expired on August 11, 2025 (7 days ago). LVN 2 stated expired medications should have been discarded.On August 19, 2025, at 1:24 p.m., during an interview, the Director of Nursing (DON) stated she expected the licensed nurses to go through all the medications in the refrigerator to check for expired medications. A review of the PPD vial manufacturer's instructions dated October 2021, indicated, .A vial of [PPD] which has been entered and in use for 30 days should be discarded .A review of the facility's policy and procedure titled Medication Labeling and Storage dated February 2023 indicated .Multi-dose vials that have been opened or accessed .are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial .

Based on observation and interview, the facility failed to ensure the two resident bedrooms (rooms [ROOM NUMBERS]) did not accommodate more than four residents per room.This failure had the potential to have an adverse effect on the residents' safety and wellbeing.Findings:During the facility survey on August 18 to August 21, 2025, rooms [ROOM NUMBERS] were observed to have five beds which can accommodate five residents in each room. room [ROOM NUMBER] was observed to have five beds occupied by five residents. room [ROOM NUMBER] was observed to have five beds and currently being occupied by five residents.During the facility survey days on August 18 to August 21, 2025, no adverse effects impacting the quality of life of the residents residing in rooms [ROOM NUMBERS] were observed. On August 21, 2025, at 4:15 p.m. the Director of Nursing (DON) was interviewed. The DON stated, there was no complain from the residents regarding having five residents in the room. The DON stated, there was no quality of life issues.

Based on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the state survey agency within two hours for two of four residents (Residents 1 and 2). This failure had the potential for the state survey agency to investigate the allegation and ensure residents were safe. Findings: A review of Resident 1's medical records indicated he was admitted on [DATE], with diagnoses of schizophrenia, (a mental illness that is characterized by disturbances in thought), chronic obstructive pulmonary disease, (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder, (a chronic condition characterized by an excessive and persistent sense of apprehension). A review of Resident 1's History and Physical dated January 3, 2025, indicated he did not have the capacity to make decisions. A review of Resident 1's Progress Notes dated March 6, 2025, at 11:15 p.m., indicated .Resident continues on behavior monitoring d/t physical/verbal aggression towards peers and staff. Resident was in TV Room with peers and staff when he began to display aggressive behavior during this shift. This staff was present and witnessed resident appear confused and angry. Assuming a female peer was talking and pointing at him, he leaned towards her in his wheelchair and swung and hit her hand/arm. Male staff attempted to stand between the two peers to deescalate the situation and resident pushed male staff at that time . A review of Resident 2's medical records indicated she was admitted [DATE], with diagnoses of cerebral edema, (swelling in the brain), secondary malignant neoplasm of brain, (cancer in the brain from the original location), schizophrenia, and chronic obstructive pulmonary disease. A review of Resident 2's History and Physical dated February 14, 2024, indicated she was alert and oriented to person, place, and time, with intellectual disability. A review of Resident 2's Progress Notes dated March 6, 2025, at 11:15 p.m., indicated .Altercation occurred towards end of shift with a male peer. Resident alert and oriented x3. Resident was hit by confused male peer on right arm/hand, while in TV Room. Both residents were immediately separated for resident safety. Head to Toe assessment done on this resident immediately following altercation, no injury noted. No c/o pain or discomfort, no sign of redness or swelling observed to right arm/hand. When asked if she felt safe, resident stated, yes, I'm fine. Continued to encouraged resident to use the call light if she needed anything. Q15min monitoring initiated. DON .Will continue with current plan of care . On March 11, 2025, at 12:32 p.m., an interview was conducted with Resident 2. Resident 2 stated, she was involved in an altercation with Resident 1 in the television room. Resident 2 stated, a staff member was within touching distance of Resident 1. Resident 2 stated, she was talking to a nurse, Resident 1 threatened her. Resident 2 stated she was pointing at the nurse she was speaking to, Resident 1 hit her on the hand. On March 11, 2025, at 2:38 p.m., an interview was conducted with the Certified Nursing Assistant, (CNA). The CNA stated she was working the 3 p.m. to 11 p.m. shift on March 6. 2025. The CNA stated that Resident 1 was in the television room when Resident 2 pointed toward the nurse she was speaking to, Resident 1 hit her on the hand. The CNA stated she removed Resident 1 from the area. On March 11, 2025, at 2:46 p.m., a telephone interview was conducted with the Licensed Vocational Nurse (LVN). The LVN stated that on March 6, 2025, at 11:15 p.m., Resident 1 hit Resident 2's hand. The LVN stated she notified the Director of Nursing (DON) and facility administrator right away. The LVN stated that they must notify the DON and administrator within two hours for an allegation of abuse. On March 11, 2025, at 3:23 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated that on March 6, 2025, at 11:15 p.m., the incident between Resident 1 and Resident 2 was reported to the Administrator right away. The DON stated that they are required to report an allegation of physical abuse within two hours to the police, Ombudsman, and state survey agency. On March 11, 2025, at 3:27 p.m., an interview was conducted with the Administrator, (Admin). The Admin stated that she notified the state survey agency on March 7, 2025, at 5 a.m. by telephone (six hours after the allegation was made). A review of the facility 's policy and procedure titled Abuse Investigation and Reporting revised July 2017, indicated .All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management .

Based on interview and record review, the facility failed to ensure the transfer or discharge requirements were met and the transfer was appropriate and necessary for two of 22 residents (Residents 1 and 2), when two cognitively impaired residents were transferred to another skilled nursing facility. This failure had the potential to cause confusion and discomfort for these residents due to unfamiliar environment. Findings: 1. A review of Resident 1's admission records indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit, unspecified dementia (loss of memory, language, problem solving and other thinking abilities), unspecified psychosis (collection of symptoms that affect the mind), and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1 ' s history and physical (a reference document that gives concise information about a patient ' s history and examination findings at the time of admission) dated July 2, 2022, indicated the resident is not mentally capable of understanding. A review of Resident 1 ' s Brief Interview for Mental Status (BIMS- a tool to assess cognitive impairment) dated 5/31/24, indicated Resident 1 has a BIMS score of 3, which indicated severe impairment of cognitive skills. A review of Resident 1 ' s Baseline Plan of Care dated 2/16/2022, indicated Resident 1 ' s discharge plan is Long Term Care (LTC). A review of Resident 1 ' s Social Service Note, dated 5/23/2024, indicated, Care plan conference was held with resident during which the change in the facility ' s operations were discussed and patient verbalized a desire and agreed to explore a transfer to another long-term care (LTC) facility . A review of the Physician and Telephone Orders dated 7/2/2024, indicated an order to transfer Resident 1 to SNF B for custodial care (The same plan of care for Resident 1 at the current SNF[SNF A]). A review of Resident 1's Physician's Discharge Summary dated, 7/12/2024, indicated, .Transfer/Discharge was necessary due to per resident request . On July 24, 2024, at 5:08 p.m. during an interview, the Social Services Director (SSD) stated Resident 1 has no living family, and he is the one deciding on his care. She stated she felt confident at the time of interview, they understood the changes, and so she went ahead and proceeded with the discharge process. On July 25, 2024, at 1:40 p.m., during an interview, the Director of Nursing (DON) stated Resident 1 ' s BIMS score was a 3; however, during the care conference, the resident understood what the facility staff were asking them, so the discharge was still resident-initiated discharge. A review of Resident 1 ' s progress notes and social services notes did not indicate what was explained to the resident regarding the changes in the facility operations that prompted the resident to agree to the transfer to another SNF. On August 2, 2024, at 11:05 a.m., during an interview while at SNF B, Resident 1 was unable to provide pertinent information to the reason why was he transferred from SNF A to SNF B. 2. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including Alzheimer ' s disease (a progressive disease that destroys memory and other mental functions), and history of transient ischemic attack (stroke). A review of Resident 2 ' s history and physical dated 8/8/23 indicated the resident is not mentally capable of understanding. A review of Resident 2 ' s Baseline Plan of Care dated 2/7/2022, indicated Resident 2 ' s discharge plan is Long Term Care. A review of Resident 2 ' s Social Service Annual assessment dated [DATE], indicated, .Resident has been in facility since 2022 .plans to remain in facility . A review of Resident 1 ' s BIMS dated 5/15/2024 indicated that Resident 2 has a score of 4, which indicated severe impairment of cognitive skills. A review of Resident 2 ' s Social Service Note, dated 5/22/2024 indicated, Care plan conference was held with resident in person on May 22, 2024, during which the change in the facility operations were discussed and patient verbalized a desire to explore a transfer to another LTC facility where smoking is prohibited. A review of the Physician and Telephone Orders dated 6/28/2024, indicated, may transfer to (Name of Long-Term Care facility- SNF B) for custodial care. (The same plan of care for Resident 2 at the current SNF [SNF A]) A review of Resident 2's Physician ' s Discharge Summary, dated 7/2/2024, indicated, .Transfer/Discharge was necessary due to per resident request . A review of Resident 2 ' s progress notes did not indicate any documentation that Resident 1 requested a transfer to another SNF or other health care facility prior to the care conference conducted on May 23, 2024. On July 24, 2024, at 5:08 p.m., The Social Services (SS) was interviewed. She stated Resident 2 has no living family, and he is the one deciding on his care. She stated she felt confident at the time of interview that the resident understood the changes, and she went ahead and proceeded with the discharge process. On July 25, 2024, at 1:40 p.m., during an interview, the DON stated Resident 2 made the decision to transfer to another SNF. On August 2, 2024, at 10:50 a.m., during an interview while at SNF B, Resident 2 was confused and did not know where he was and the reason of his transfer to the new facility (SNF B). On August 23, 2024, at 3:11 p.m., during an interview with the Social Service Director (SSD), the SSD stated, Residents 1 and 2 did not ask to be discharged prior to the care conference meeting discussing the facility changes. A review of the facility policy and procedure titled, Transfer or Discharge, Facility-Initiated, dated October 2022, indicated, .Once admitted to the facility, residents have the right to remain in the facility, and not be transferred or discharged unless .the transfer or discharge is necessary for the resident's welfare and the resident's need cannot be met in this facility .the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by this facility .Facility -initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation .'Facility- initiated transfer or discharge' means a transfer or discharge which .did not originate through a resident's verbal or written request, and/or is in alignment with the resident's stated goals for care and preferences .

Based on interview and record review, the facility failed to provide a written notice of transfer or discharge to two of 22 residents reviewed (Residents 1 and 2). Residents 1 and 2 were deemed with cognitive impairment and had no legal representative. In addition, the written notice of transfer or discharge for Residents 1 and 2, was not provided timely to the Office of the Long Term Care (LTC) Ombudsman. These failures had the potential to result in violation of the resident ' s rights, as issues related to the transfer or discharge may not be addressed promptly, leading to harm to the resident, especially if the transfer or discharge was not in the best interest of the resident or was done without proper procedure. This failure did not provide opportunity for the Ombudsman to advocate for the residents to ensure the transfer or discharge was necessary. Findings: 1. A review of Resident 1 ' s ADMISSION RECORD, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit (difficulties in communication that arise from impairment in cognitive functions) and dementia (memory loss). Further review of the admission record indicated the resident did not have any listed legal representative. A review of Resident 1 ' s Brief Interview for Mental Status, dated May 23, 2024, indicated Resident 1 had severe cognitive impairment. A review of Resident 1 ' s Social Service Note, dated May 23, 2024, indicated .Care plan conference was held with resident during which the change in the facility operations were discussed and patient verbalized a desire and agreed to explore a transfer to another LTC facility . A review of Resident 1 ' s physician order dated July 1, 2024, indicated, .may transfer to (name of the skilled nursing facility) .for custodial care . A review of Resident 2 ' s Notice of Proposed Transfer/Discharge, dated July 8, 2024, provided by the facility, indicated the document was crossed out. A review of progress notes, did not indicate whether a notice of proposed transfer or discharge was provided to the resident and the LTC Ombudsman on the day the transfer or discharge was discussed on May 23, 2024, with Resident 1. 2. A review of Resident 2 ' s ADMISSION RECORD, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills). Further review of the admission record indicated the resident did not have any listed legal representative. A review of Resident 2 ' s document titled Brief Interview for Mental Status, dated May 15, 2024, indicated Resident 2 had severe cognitive impairment. A review of Resident 2 ' s Notice of Proposed Transfer/Discharge, dated July 8, 2024, indicated the document was crossed out. A review of Resident 2 ' s Social Service Note, indicated the following: - Dated May 22, 2024, .Care plan conference held with resident in person on May 22, 2024, during which the change in the facility operations were discussed and patient verbalized a desire to explore a transfer to another LTC facility . - Dated June 28, 2024, .Spoke to resident and informed that he was accepted @ (at) (name of the facility) . - Dated July 1, 2024, .Resident will be transported to (name of the facility) . A review of Resident 2 ' s physician order dated June 28, 2024, indicated, .Resident may transfer to (name of the facility) under custodial care . A review of progress notes, did not indicate whether a notice of proposed transfer or discharge was provided to the resident and the LTC Ombudsman on the day the transfer or discharged was discussed on May 22, 2024, with Resident 2, or at least 30 days prior to the proposed transfer to SNF B. On August 23, 2024, at 3:11 p.m., the Social Service Director (SSD) was interviewed, and she stated, the notice of the proposed transfer/discharge form would not be given to the resident unless the resident requested. The SSD stated, the Ombudsman would receive the written notice of proposed transfer/discharge on the day of the discharge or the following day of the discharge. A review of the facility policy and procedure titled, Transfer or Discharge, Facility-Initiated, dated October 2022, indicated, .Once admitted to the facility, residents have the right to remain in the facility. Facility -initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation .'Facility- initiated transfer or discharge' means a transfer or discharge which .did not originate through a resident's verbal or written request, and/or is in alignment with the resident's stated goals for care and preferences .the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility .A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .

Based on interview and record review, the facility failed to ensure two of 22 sampled residents (Residents 1 and 2), was provided orientation in the form the residents could understand, to ensure a safe and orderly transfer from a skilled nursing facility (SNF A) to another skilled nursing facility (SNF B). Residents 1 and 2 were deemed with cognitive impairment, lacked the capacity to make decisions, and had no listed legal representatives. This failure of the facility had the potential to negatively affect the psychosocial well-being of Residents 1 and 2. Findings: A review of the facility discharged and transferred list from May 2024 to July 2024, indicated there were two residents who were transferred to another SNF with no family representative's involvement, and were deemed incapable of making decisions. A review of Resident 1's admission records indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included cognitive communication deficit, unspecified dementia (loss of memory, language, problem solving and other thinking abilities), unspecified psychosis (collection of symptoms that affect the mind), and bipolar disorder (episodes of mood swings ranging from depressive lows to manic highs). A review of Resident 1's history and physical (a reference document that gives concise information about a patient's history and examination findings at the time of admission) dated July 2, 2022, indicated the resident is not mentally capable of understanding. A review of Resident 1's Brief Interview for Mental Status (BIMS- a tool to assess cognitive impairment) dated 5/31/24, indicated Resident 1 has a BIMS score of 3, which indicated severe impairment of cognitive skills. A review of Resident 1's Social Service Note, dated 5/23/2024, indicated, Care plan conference was held with resident during which the change in the facility's operations were discussed and patient verbalized a desire and agreed to explore a transfer to another long-term care (LTC) facility . A review of the progress notes did not indicate any documentation that the facility explained or oriented the resident, deemed incapable of understanding, the discharge plan to another SNF. A review of the Physician and Telephone Orders dated 7/2/2024, indicated an order to transfer Resident 1 to SNF B for custodial care (The same plan of care for Resident 1 at the current SNF [SNF A]). A review of Resident 1's Physician's Discharge Summary dated, 7/12/2024, indicated, .Transfer/Discharge was necessary due to per resident request . On July 24, 2024, at 5:08 p.m. during an interview, the Social Services Director (SSD) stated Resident 1 has no living family, and he is the one deciding on his care. She stated she felt confident at the time of interview, they understood the changes, and she went ahead and proceeded with the discharge process. On July 25, 2024, at 1:40 p.m., during an interview, the Director of Nursing (DON) stated Resident 1's BIMS score was a 3; however, during the care conferences, the resident understood what the facility was asking them. A review of Resident 1's progress notes and social services notes did not indicate what was explained and the details of the transfers. On August 2, 2024, at 11:05 a.m., during an interview while at SNF B, Resident 1 was unable to provide pertinent information to the reason why was he transferred from SNF A to SNF B. A review of Resident 2's Admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other mental functions), and history of transient ischemic attack (stroke). A review of Resident 2's history and physical dated 8/8/23, indicated the resident is not mentally capable of understanding. A review of Resident 2's Baseline Plan of Care dated 2/7/2022, indicated Resident 2's discharge plan is Long Term Care. A review of Resident 2's Social Service Annual assessment dated [DATE], indicated, .Resident has been in facility since 2022 .plans to remain in facility . A review of Resident 1's BIMS dated 5/15/2024 indicated that Resident 2 has a score of 4, which indicated severe impairment of cognitive skills. A review of Resident 2's Social Service Note, dated 5/22/2024 indicated, Care plan conference was held with resident in person on May 22, 2024, during which the change in the facility operations were discussed and patient verbalized a desire to explore a transfer to another LTC facility where smoking is prohibited. A review of the Physician and Telephone Orders dated 6/28/2024, indicated, may transfer to (Name of Long-Term Care facility- SNF B) for custodial care. (The same plan of care for Resident 2 at the current SNF [SNF A]) A review of Resident 2's Physician's Discharge Summary, dated 7/2/2024, indicated, .Transfer/Discharge was necessary due to per resident request . A review of Resident 2's progress notes did not indicate any documentation that Resident 1 requested a transfer to another SNF or other health care facility prior to the care conference conducted on May 23, 2024. On July 24, 2024, at 5:08 p.m., The Social Services (SS) was interviewed. She stated Resident 2 has no living family, and he is the one deciding on his care. She stated she felt confident at the time of interview, the resident understood the changes, and she went ahead and proceeded with the discharge process. On 7/25/2024, at 1:40 p.m., during an interview, the DON stated Resident 2 made the decision to transfer to another SNF. On 8/2/2024, at 10:50 a.m., during an interview while at SNF B, Resident 2 was confused and did not know where he was and the reason of his transfer to the new facility (SNF B). A review of the facility's policy and procedure titled Transfer or Discharge, Resident Initiated, dated April 1, 2024, indicated, .Resident- initiated transfer or discharge means the resident or if appropriate, the resident representative has provided verbal or written notice of intent to leave the facility (leaving the facility does not include the general expression of a desire to return home or the elopement of residents with cognitive impairment) .for resident-initiated discharges .the comprehensive care plan contains the residents goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident-initiated . A review of the facility policy and procedure titled, Transfer or Discharge, Facility-Initiated, dated October 2022, indicated, .Once admitted to the facility, residents have the right to remain in the facility. Facility -initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation .'Facility- initiated transfer or discharge' means a transfer or discharge which .did not originate through a resident's verbal or written request, and/or is in alignment with the resident's stated goals for care and preferences .

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. The Prep sink did not have an air gap (is vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water); 2. The Quat sanitizer used to sanitize food preparation surfaces did not meet the right concentration requirements on 3/26/2024, 3/27/2024 and 3/28/2024; ( Cross referred 802) 3. Dust was observed on several areas in the kitchen; 4. Reach in refrigerator shelves had chipped paint; 5. Several equipment in the kitchen found to have buildup; 6. Trash were found in multiple areas in the kitchen; 7. Inside the containers used to store clean scoops, utensils and lids had food residuals; 8. Broken tiles found under reach in refrigerator and utility area; 9. During thawing process, ground meat not fully submerged into running water; 10. Cook with facial hair did not wear hair restraint; 11. The dirty trash can touching several clean surfaces; 12. Rust found on several equipment in the kitchen; and 13. There were several food items that were open and exposed to the air in the reach in freezer. Having the food exposed to the air in the freezer could potentially cause freezer burn and affect the quality of the foods. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 30 out of 31 residents who received food prepared in the kitchen. 1. On March 26, 2024, at 10:31 a.m., during a concurrent observation and interview with Cook 1 (CK 1) in front of the Prep sink (sink used for washed produce), CK 1 stated he used the sink as Prep sink. CK 1 stated, there was no air gap for the Prep sink. On March 26, 2024, at 3:15 p.m., an interview was conducted with the Dietary Supervisor (DSS) in front of the Prep sink. The DSS confirmed the Prep sink did not have an air gap. The DSS stated she was not aware the Prep sink needs an air gap. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, Section 5-203.14 Backflow Prevention Device, the FDA Food Code indicated, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, .backflow prevention is required by LAW, by: (A) Providing an air gap . 2. A review of the Quat sanitizer bottle's guidelines showed appropriate sanitizing levels were 200-400 ppm. On March 26, 2024, at 10:10 a.m., a concurrent observation and interview were conducted with Dietary Aide 1 (DA 1). DA 1 was asked to test the [NAME] sanitizer solution in the sanitizer bucket. The sanitizer test strip read between 100 -200 ppm (parts per million). DA 1 stated the test strip should read 100 -200 ppm and the sanitizer was in right concentration. On March 26, 2024, at 11:06 a.m., a concurrent observation and interview were conducted with Cook 2 (CK 2). CK 2 was observed testing the Quat sanitizer solution in the sanitizer bucket. The sanitizer test strip read between 100 -200 ppm. CK 2 stated the test strip should read between 200 -400 ppm. CK 2 hesitated for few seconds and stated the sanitizer was at the right concentration even though it was under 200 ppm. CK 2 did not throw away or change the sanitizer and continued to allow the kitchen to use the sanitizer. On March 26, 2024, at 4:00 p.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DSS). The DSS was observed testing the Quat sanitizer solution in the sanitizer bucket. The sanitizer test strip read between 100 -200 ppm. The DSS stated the test strip should read 100 -200 ppm and the sanitizer currently was at the right concentration. On March 27, 2024, at 12:22 p.m., a concurrent observation and interview were conducted with Dietary Aide 2 (DA 2). DA 2 was observed testing the Quat sanitizer solution in the sanitizer bucket. The sanitizer test strip read between 100 -200 ppm. DA 2 stated the test strip should read 200 ppm. DA 2 was unsure if the sanitizer was at the right concentration and sought guideline from CK 2. CK 2 stated the sanitizer was at the right concentration with under 200 ppm. On March 28, 2024, at 11:05 a.m., an interview was with the Registered Dietitian (RD) was conducted. The RD stated if the Quat sanitizer did not meet the right concentration requirements per manufacturer guideline, it would be ineffective to sanitize food preparation surfaces. On March 28, 2024, at 12:06 p.m., a concurrent observation, interview, and Quat sanitizer's bottle instructions review were conducted with the Registered Dietitian (RD). The RD was observed testing the Quat sanitizer solution. The sanitizer test strip read between 100 -200 ppm. The RD stated that is right concentration. A review of the Quat sanitizer bottle's instructions indicated, .To sanitize .apply 200 -400 ppm active quaternary (Quat) solution . During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Sanitizing - Basics, dated 2018, the P&P indicated, .Always refer to manufacturer's recommendation of dilution strength . During a review of the facility's Policy and Procedure (P&P) titled, Sanitizer bucket for cleaning cloths, dated 1/1/2017, the P&P indicated, .1. Sanitizer buckets are filled with . an appropriate sanitizer at a high concentration to ensure that the solution stays effective (Quat ppm at 200 .6 .While dispenser pumps set up by the chemical company may be used, it is the responsibility of the staff to ensure that sanitizing is at an effective level . 3. On March 26,2024, at 3:15 p.m., a concurrent observation and interview with the DSS was conducted, in the kitchen. The DSS confirmed brown debris was dust on the wall next to the entrance door. On March 26,2024, at 3:17 p.m., a concurrent observation and interview with the DSS was conducted, at the beverage Prep area. The DSS confirmed brown debris was dust underneath Prep table where clean serving cups stored on the bottom of the Prep table. On March 26,2024, at 3:19 p.m., a concurrent observation and interview with the DSS were conducted, next to oven. The DSS confirmed dust was hanging on silver shelves. On March 26,2024, at 3:20 p.m., a concurrent observation and interview with the DSS were conducted, in front of dish machine. The DSS confirmed black debris was dust hanging on the exhaustion fan above dish machine. On March 27,2024, at 3:13 p.m., a concurrent observation and interview with the DSS were conducted, inside the walk-in refrigerator. The DSS confirmed black debris was dust hanging on the wires inside walk-in refrigerator near the entrance door. The DSS stated dust should not be found in the kitchen which could cause cross contamination. On March 28,2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated dust should not be found in the kitchen and needs to be removed. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 4. On March 26,2024, at 3:15 p.m., a concurrent observation and interview with the DSS were conducted, in front of the reach-in refrigerator. The DSS confirmed there were four out of seven grey shelves had chipped paint. The DSS stated grey shelves not supposed to have chipped paint. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, food-contact surfaces and utensils are to be clean to sight and touch and utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to scratching, pitting, and decomposition. 5. On March 26,2024, at 3:15 p.m., a concurrent observation and interview with the DSS was conducted. Several equipment in the kitchen found to have buildup of grime. a. Microwave; b. The reach in refrigerator's door; c. The reach in refrigerator's hinge; d. Underneath Pre table next to dry storeroom where on bottom stored clean kitchen ware; e. Oven range; and f. Inside both oven. The DSS confirmed buildup of grime found on those equipments. The DSS stated buildup of grime was not supposed to be on those equipment because it could cause cross contamination. On March 28,2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated buildup grime not supposed be on the equipment, the equipment needed to be clean. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces , the Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 6. On March 26,2024, at 3:15 p.m., a concurrent observation and interview with the DSS were conducted. There was food debris found on the floor under oven. The DSS confirmed food debris found on the floor under oven. On March 26,2024, at 3:26 p.m., a concurrent observation and interview with the DSS were conducted. A dirty mug, a dirty cup, 4 oz shake, dust, condiments, and trash were found on the floor under the reach-in refrigerator. The DSS confirmed there was a dirty mug, a dirty cup, 4 oz shake, dust, condiments, and trash on the floor under the reach-in refrigerator. The DSS stated food debris and trash on the floor could attract pests to the kitchen. On March 28,2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated food debris, trash, and dust should not be on the floor. The kitchen floor needs to be kept clean. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 7. On March 26, 2024, at 3:15 p.m., a concurrent observation and interview with the DSS were conducted. There were food residuals found inside the pan used to stored clean lids. Food residuals were also found inside two plastic containers used to store clean scoops and utensils. The DSS confirmed food residuals were found inside the pan and two plastic containers used to store clean lids, scoops and utensils. The DSS stated pan and plastic containers should be clean. The DSS stated the potential risk having food residuals inside the pan and plastic containers was cross contaminate the clean lids, scoops, and utensils. On March 28, 2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated the pans and plastic containers used to store clean lids, scoops and utensils needed to keep clean. On March 28, 2024, at 4:00 p.m., an interview with the DSS was conducted. The DSS stated the facility did not have policy and procedure for sanitation or general cleanness of the kitchen. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces , the Food code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 8. On March 27, 2024, at 3:26 p.m., a concurrent observation and interview with the DSS was conducted. There was a broken tile found under the reach in refrigerator floor and utility area. The DSS confirmed the broken tiles under the reach in refrigerator floor and utility area. The DSS stated kitchen could not have broken tiles because the bacteria could get into the broken tiles and grow inside the broken tiles and then spread in the kitchen. On March 28, 2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated the kitchen should try to maintain good working floor condition so dietary staff could clean and sanitizer the floor properly. During a review of the U.S. FDA (Food and Drug Administration) Food Code 2022, Annex Section 6-201.11 Cleanability Floors, walls, and Ceilings the FDA Food Code indicated, .Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized . 9. On March 27, 2024, at 2:58 p.m., a concurrent observation and interview with CK 2 was conducted at the prep sink. There was a tub of ground meat only submerged 75 percent into running water in a small pan. CK 2 stated he was thawing the ground meat so he could use the ground meat for tonight dinner. On March 28,2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated when thawing of foods, they needed to fully submerged under running water. During a review of the facility's Policy and Procedure (P&P) titled, Thawing of Food, dated 1/1/2017, the P&P indicated, Time/Temperature control (TCS/PHF) foods shall be thawed only: .b. Completely submerged under potable running water ., and with sufficient velocity to agitate and flush off loose food particles into the sink drain. 10. During general food production observation on March 27, 2024, at 10:59 a.m., CK 2 was noted to have facial hair without covering. The DSS was confirmed CK 2 had facial hair without covering. The DSS stated CK 2 need to cover his facial hair while working in the kitchen. During a review of the facility's Policy and Procedure (P&P) titled, Hair Nets and Personnel Permitted in Food & Nutrition Services Department, dated 1/1/2017, the P&P indicated, Dietary (Food and Nutrition Services) staff must wear hair restraints (e.g., hairnet, hat, and/or beard restraint) to prevent their hair from contacting exposed food. 11. On March 26, 2024, at 11:35 a.m., an observation was conducted in kitchen. A big grey dirty trash can lined between a clean can opener and clean coffee cart. And they were touching each other. On March 26, 2024, at 3:15 p.m., an interview with the DSS was conducted. The DSS stated the big grey dirty trash can not supposed lined between a clean can opener and clean coffee cart and touching each other because it could cause cross contamination. On March 27, 2024, at 10:12 a.m., an observation was conducted in utility area. The same big grey dirty trash can touch the clean kitchenware stored in utility area. On March 28,2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated the big grey dirty trash can not supposed to touch any clean surface due to potential cross contamination. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 12. On March 26,2024, at 3:15 p.m., a concurrent observation and interview with the DSS were conducted. The white rack used to dry dome (a piece of kitchen equipment used as a cover to keep food hot) had brown grime. The DSS verified brown grime was rust. On March 26,2024, at 3:17 p.m., a concurrent observation and interview with the DSS was conducted in utility area. The silver shelves used to store clean kitchenware had rust. The DSS confirmed rust on silver shelves. The DSS stated rust could get into clean dome and clean kitchen ware which could cause cross contamination. On March 27,2024, at 3:13 p.m., a concurrent observation and interview with the DSS was conducted. There was brown grime inside the ice cream freezer. The DSS confirmed the brown grime was rust. On March 28,2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated rust not supposed found on drying rack, silver shelves and ice cream freezer. On March 28, 2024, at 4:00 p.m., an interview with the DSS was conducted. The DSS stated the facility did not have policy and procedure for rust. During a review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, food-contact surfaces and utensils are to be clean to sight and touch and utensils and food contact surfaces of equipment are to have a smooth, easily cleanable surface and resistant to scratching, pitting, and decomposition. 13. On March 27, 2024, at 10:21 a.m., a concurrent observation and interview with the DSS was conducted. There was an opened bag of beef [NAME] and an opened bag of dice chicken exposed to the air in the reach-in freezer. The DSS confirmed an opened bag of beef [NAME] and an opened bag of dice chicken not sealed. The DSS stated opened food items in freezer needed to be sealed otherwise could cause freezer burn. On March 28, 2024, at 4:00 p.m., an interview with the DSS was conducted. The DSS stated the facility did not have policy and procedure for food items that were open and exposed to the air in the reach-in freezer.

Based on interview and record review, the facility failed to electronically submit staffing information based on payroll data to the Federal (Center for Medicare & Medicaid Services- CMS) database for the first Fiscal Qaurter of the year. This deficient practice prevented the provision of complete and accurate direct care staffing information to the public. Findings: During a review of the CMS PBJ (pay roll based journal) Staffing Data Report CASPER (Certification and Survey Provider Enhanced Report) FY (fiscal year) Quarter 1 (October 1- December 31) indicated, .Failed to submit Data for the Quarter . During an interview on March 28, 2024, at 3:30 p.m., with the Business Office Manager (BOM), the BOM stated, the Payroll Manager (PM) was responsible for submitting the report to CMS. During an interview on March 28, 2024, at 3:35 p.m., the PM stated, she had outsourced the PBJ reporting to a third party. The PM stated, the company contracted to handle the PBJ reporting encountered difficulties in submitting the report on February 9, 2024. The PM stated, she did not take any action and relied on the company. The PM further stated, the deadline for submission for the first Fiscal Quarter was the 14th of February. The PM stated, the PBJ report was not submitted to CMS. According to the manual for PBJ submission, the deadline for each reporting period, indicated: .FISCAL QUARTER .1 .REPORTING PERIOD .October 1- December 31 .DUE DATE .February 14 . FISCAL QUARTER 2 .REPORTING PERIOD .January 1- March 31 .DUE DATE .May 15 . FISCAL QUARTER . 3 .REPORTING PERIOD .April 1- June 30 .DUE DATE .August 14 . FISCAL QUARTER . 4 .REPORTING PERIOD .July 1- September 30 .DUE DATE .November 14 .

Based on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Food service workers did not recognize that the Quat sanitizer concentration was not at the right concentration; (Cross referred F 812) This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. 2. Diet Aide 1 and Cook 2 were unable to properly clean working surface; This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. 3. Cook 2 did not follow the menu for serving on 3/27/24 lunch; (Cross referred F 803 and F 804) This failure had the potential for 30 out of 31 residents receiving food prepared in the kitchen do not meet their nutritional needs which may lead to nutritional related health complications. 4. Diet Aide served Jello to residents who require nectar thick consistency (Cross referred F 805); and This failure had the potential risk of aspiration for two of two sampled residents, Residents 6 and 24 who received nectar thick consistency from the kitchen. 5. Cook 2 did not know the right concentration of chlorine (sanitizer) for the dish machine. This failure had the potential to cause foodborne illness for 30 out of 31 sampled residents who received foods from the kitchen. Findings: 1. A review of the Quat sanitizer bottle's guidelines showed appropriate sanitizing levels were 200-400 ppm. On March 26, 2024, at 10:10 a.m., a concurrent observation and interview were conducted with Dietary Aide 1 (DA 1). DA 1 was asked to test the Quat sanitizer solution in the sanitizer bucket. The sanitizer test strip read between 100 -200 ppm (parts per million). DA 1 stated the test strip should read 100 -200 ppm and the sanitizer was at the right concentration. On March 26, 2024, at 11:06 a.m., a concurrent observation and interview were conducted with Cook 2 (CK 2). CK 2 was observed testing the Quat sanitizer solution in the sanitizer bucket. The sanitizer test strip read between 100 -200 ppm. CK 2 stated the test strip should read between 200-400 ppm. CK 2 hesitated for few seconds and stated the sanitizer was at the right concentration even thought was under 200 ppm. CK 2 did not throw away or change the sanitizer and continue let the kitchen used the sanitizer. On March 26, 2024, at 4:00 p.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DSS). The DSS was observed testing the Quat sanitizer solution in the sanitizer bucket. The sanitizer test strip read between 100 -200 ppm. The DSS stated the test strip should read 100 -200 ppm and the sanitizer currently was at the right concentration. On March 27, 2024, at 12:22 p.m., a concurrent observation and interview were conducted with Dietary Aide 2 (DA 2). DA 2 was observed testing the Quat sanitizer solution in the sanitizer bucket. The sanitizer test strip read between 100 -200 ppm. DA 2 stated the test strip should read 200 ppm. DA 2 unsure the sanitizer was in right concentration. DA 2 seek guideline with CK 2. CK 2 stated the sanitizer was in right concentration with under 200 ppm. On March 28, 2024, at 12:06 p.m., a concurrent observation, interview, and Quat sanitizer's bottle instructions review was conducted with the Registered Dietitian (RD). The RD was observed testing the Quat sanitizer solution. The sanitizer test strip read between 100 -200 ppm. The RD stated that is right concentration. A review of the Quat sanitizer bottle's instructions indicated, .To sanitize .apply 200 -400 ppm active quaternary (Quat) solution . During a review of the facility's Policy and Procedure (P&P) titled, Sanitizer bucket for cleaning cloths, dated 1/1/2017, the P&P indicated, 1. Sanitizer buckets are filled with . an appropriate sanitizer at a high concentration to ensure that the solution stays effective Quat ppm at 200 .6 While dispenser pumps set up by the chemical company may be used, it is the responsibility of the staff to ensure that sanitizing is at an effective level . 2. During a general food production observation on March 27, 2024, at 10:27 a.m., Diet Aide 1 (DA 1) was observed cleaning the Prep table after preparing raw chicken. DA 1 only used green bucket detergent to clean the Prep table. When interviewed, DA 1 stated the green bucket contained soap and she used the soap to clean the Prep table. During a general food production observation on March 27, 2024, at 11:08 a.m., Cook 2 (CK 2) was observed cleaning the Prep table after preparing mashed potatoes. CK 2 only used red bucket sanitizer to clean the Prep table. On March 28, 2024, at 11:05 a.m., an interview with the RD was conducted. The RD stated the proper way to clean the Prep table surfaces was to clean with detergent, rinse and sanitize to minimize the soil and microbial contamination. During a review of the facility's Policy and Procedure (P&P) titled, Cleaning and Sanitizing - Basics, dated 2018, the P&P indicated, When cleaning and sanitizing any food contact surface, it is extremely important .Clean and sanitize in place method (for .work table surfaces) 1. Clean items with warm water and detergent. 2. Rinse with clear warm water. 3. Sanitizer surfaces with .Quaternary Ammonia (Quat) 200 ppm/ 1 minute . During a review of the facility Job Description, titled Food and Nutrition Services Aide (kitchen Aide), dated 1/1/2017, the job description indicated, Primary function: Under general supervision performs a variety of simple, routine tasks related to the preparation and serving of foods; to clean kitchen area .Worked performed: .2. Cleans work area according to directions . During a review of the facility Job Description, titled Cook, dated 1/1/2017, the job description indicated, Primary function: .maintains area utilizing high standard of sanitation . 3. During a food production observation on March 27, 2024, between 10:00 a.m. until 12:30 a.m., Cook 2 did not follow menu for serving lunch on 3/27/24. a. Pureed chicken was being served to puree diets by using a # 8 scoop; whereas the menu specified a # 10 scoop; b. Three Potatoes wedges were being served to regular diets; whereas the menu specified four potato wedges; and c. Spinach was being served to all diets except pureed spinach using a #10 scoop; whereas the menu specified a # 8 scoop. d. CK 2 did not follow the pureed chicken and spinach recipes by adding water and thickener. e. CK 2 did not serve biscuit per menu for Regular diets, small portion, large portion, Mechanical soft diets, and Carbohydrate control diets (a meal plan for Diabetic resident). f. CK 2 did not serve gravy per menu for puree diets. On March 28, 2024, at 11:05 a.m., an interview was conducted with the RD. The RD stated cooks should follow the menu. During a review of the facility Job Description, titled Cook, dated 1/1/2017, the job description indicated, Primary function: Under general supervision prepared food for residents using menu and standardized recipes.Worked performed: .3. Follows menu and recipes . 4. On March 27, 2024, at 12:35 p.m., during a lunch tray assemby observation in the kitchen with DA 2, DA 2 served Jello to Residents 6 and 24 who required nectar thick liquids. On March 27, 2024, at 12:54 p.m., a concurrent observation and interview with the Activity Director (AD) was conducted in the dining room. The AD verified Resident 24 was on nectar thick consistency and received Jello on her meal tray. On March 27, 2024, at 1:14 p.m., a concurrent observation and interview with Certified Nurse Aide 1 (CNA 1) was conducted at Resident 6's bedside. CNA 1 stated Resident 6 received Jello with her meal and Resident 6 finished the Jello. On March 28, 2024, at 11:05 a.m., an interview was conducted with the RD. The RD stated residents on nectar thick consistency should not receive Jello because Jello melts in the mouth, it turned into a thin liquid. According to the International Dysphagia Diet Standardization Initiative (IDDSI) framework (is an international set of descriptors describing texture modified foods and thickened liquids for people with eating, drinking and swallowing problems (dysphagia) across the lifespan) describes edible gelatin, indicated, .Per testing and due to the challenging and variable nature of gelatin/Jell-O preparations across the USA, it is best practice to have gelatin/Jell-O only on the Regular, . Thin Liquid .https://iddsi.org/IDDSI/media/images/Posters/GELATIN-JELLO-FAQ-USIRG-CHART-FINAL.pdf During a review of the facility Job Description, titled Food and Nutrition Services Aide (kitchen Aide), dated 1/1/2017, the job description indicated, Primary function: Under general supervision performs a variety of simple, routine tasks related to the preparation and serving of foods .Work performed . 2. Sets up trays accurately . 5. On March 27, 2024, at 3 p.m., a concurrent observation, interview and dish machine Operational Requirements review were conducted with CK 2. CK 2 was observed checking the chlorine of the dish machine. The chlorine test strip read between 100 -200 ppm. CK 2 stated the test strip should read between 100-200 ppm and it was at the right concentration. During a review of the dish machine Operational Requirements posted on the dish machine, it was indicated that it required 50 ppm available chlorine. On March 28, 2024, at 11:05 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the dish machine chlorine should read bet 50 -100 ppm. During a review of the facility Job Description, titled Cook, dated 1/1/2017, the job description indicated, Primary function .maintains area utilizing high standard of sanitation .

Based on observation, interview, and facility document review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. Correct portion sizes were not followed; 2. The Cook did not serve biscuit during lunch on 3/27/2024; and 3. The Cook did not serve gravy for pureed diet during lunch on 3/27/2024. These failures had the potential for 30 out of 31 residents receiving food prepared in the kitchen do not meet their nutritional needs which may lead to nutritional related health complications. Finding: (Cross referred 802) 1. On March 27, 2024, at 12:21 p.m., an interview was conducted with Cook 2 (CK 2) in front of Trayline (a system of food preparation in which trays move along an assembly line). CK 2 stated he was going to use a grey scoop numbered 8 to serve pureed chicken, and an ivory scoop numbered 10 to serve Spinach. On March 27, 2024, at 12:30 p.m., an observation of the lunch meal plating service was conducted with CK 2. The following were observed: Pureed chicken was being served to the pureed diets using a # 8 scoop; Three Potatoes wedges was being served to the regular diet; and Spinach was being served to all diets except pureed spinach using a #10 scoop. A review of the facility document titled Daily Cook's Menu, dated Week 3, Wednesday, Standard Spring 2024, indicated, .# 10 scoop pureed chicken was to be served, 4 wedges Potato was to be serve to regular diet and # 8 scoop (1/2 cup) Spinach was to be served to all other diets . On March 27, 2024, at 3:16 p.m., an interview was conducted with the Dietary Supervisor (DSS). The DSS stated it was very important to follow menu's portion sizes when serving the residents because dietary staff did not want to over or underserve portions to the residents. The DSS explained underserved portion sizes could cause residents to not get enough nutrients while overserved portion sizes could lead to residents receiving many nutrient resulting in unplanned weight gain. On March 28, 2024, at 11:05 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated cooks should follow the menu. A review of the facility document titled, The Facility's Resident Diet List, dated March 26, 2024, indicated seven residents, Residents 1, 6, 8, 9, 10, 14, and 24 were on a pureed diet. A review of the facility document titled, The Facility's Resident Diet List, dated March 26, 2024, indicated eight residents, Residents 5, 13, 18, 22, 28, 30, 36, and 38 were on a regular diet. A review of the facility's Policy and Procedure (P&P) titled, Portion Control, undated, the P&P indicated, Policy: Individual will receive the appropriate portions of food as outlined on the menu. Control at the point of service is necessary to assure that accurate portion sizes are served. Procedure .2. The menu should list the specific portion size for each food item .3. Food should be served with .scoops .of standard sizes .a. Portions that are too small result in the individual not receiving the nutrients needed. b. Portions that are too large increase food costs as well as providing the individual with more food that needed . A review of the facility's Policy and Procedure (P&P) titled, Menu Guidelines, dated 1/1/2017, the P&P indicated, Policy: To prepare foods according to the menu .Procedures .a. Correct portion size will be given per menu pattern; . 2. On March 27, 2024, at 12:30 p.m., an observation of the lunch meal plating service was conducted with CK 2 in front of the trayline. There were no biscuits available in the trayline. A review of the facility document titled Daily Cook's Menu, dated Week 3, Wednesday, Standard Spring 2024, indicated, Biscuit was to be served to Regular diet, small portion, large portion, Mechanical soft diet, and Carbohydrate control diet [(CCHO) a meal plan for diabetic residents]. On March 27, 2024, at 3:16 p.m., an interview was conducted with the DSS. The DSS stated CK 2's usual assignment was preparing evening meal and today he was being asked to cook the noon meal, which was not his usual assignment. The DSS acknowledged that even though preparing the noon meal was not CK 2's usual assignment, CK 2 still needed to prepare and serve all food items on the menu to residents. On March 28, 2024, at 11:05 a.m., an interview was conducted with the RD. The RD stated cooks should follow the menu. A review of the facility document titled, The Facility's Resident Diet List, dated March 26, 2024, indicated Residents 2, 4, 5, 7, 12, 13, 16, 17, 18, 20, 21, 22, 23, 27, 28, 29, 30, 32, 35, 36, 38, and 93 were on a regular diet, small portion, large portion, Mechanical soft diet and CCHO diet. A review of the facility's Policy and Procedure (P&P) titled, Menu Guidelines, dated 1/1/2017, the P&P indicated, Policy: To prepare foods according to the menu . 3. On March 27, 2024, at 12:30 p.m., an observation of the lunch meal plating service was conducted with CK 2 in front of the trayline. There was no gravy available on the trayline. A review of the facility document titled Daily Cook's Menu, dated Week 3, Wednesday, Standard Spring 2024, indicated, Gravy was to be served to Pureed diet. On March 27, 2024, at 3:16 p.m., an interview was conducted with the DSS. The DSS stated CK 2 usual assignment was preparing evening meal and today he was being asked to cook noon meal which was not his usual assignment. The DSS acknowledged even though preparing noon meal was not CK 2's usual assignment, CK 2 still needed to prepare and serve all food items on menu. On March 28, 2024, at 11:05 a.m., an interview was conducted with the RD. The RD stated cooks should follow the menu. A review of the facility document titled, The Facility's Resident Diet List, dated March 26, 2024, indicated seven residents, Residents 1, 6, 8, 9, 10, 14, and 24 were on a pureed diet. A review of the facility's Policy and Procedure (P&P) titled, menu Guidelines, dated 1/1/2017, the P&P indicated, Policy: To prepare foods according to the menu .