Every finding on record at Valley Health Center

Based on interview and record review, the facility failed to develop a care plan specific to the residents care needs in 1 (Resident #4) of 8 residents reviewed for care plans, resulting in the potential for unmet needs. Findings include: Review of an admission Record revealed Resident # 4 was originally admitted to the facility on [DATE] with pertinent diagnoses which included dementia and major depressive disorder. Review of Resident #4's Orders revealed that Resident #4 was enrolled to hospice services on 3/11/25. Review of Resident #4's current Care Plan did not reveal a focus related to hospice/end of life, or integration of hospice/end of life services into Resident #4's comprehensive plan of care. In an interview on 7/31/2025 at 8:42 AM, Director of Nursing (DON) B confirmed that Resident #4 was enrolled with hospice. DON B reviewed Resident #4's care plan with surveyor and confirmed that Resident #4's care plan did not have a focus related to hospice services that he was receiving. Review of the facility's Comprehensive Care Plan policy dated 1/2025 revealed, Policy: It is the policy of this community to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality Policy Explanation and Compliance Guidelines: 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to perform effective hand washing and complete hand hygiene between glove changes during resident care in 2 of 2 residents (Resident #11 & #19) reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population.Findings include:Resident #11 Review of an admission Record revealed Resident #11 was a female, with pertinent diagnoses which included multiple sclerosis (a disease in which the immune system causes damage to the protective covering of the nerve cells), anemia, vascular disease, lower extremity ulcers, anxiety, and depression. In an observation on 7/29/25 at 10:06 AM, Agency Shabaz (a term used for Certified Nursing Assistants (CNA's) in the [NAME] House model of care who provide direct care to the residents) I assisted Resident #11 with a brief change in the resident's room. Observed Agency Shabaz I don (put on) gloves and clean Resident #11's buttocks and perineal area with pre-moistened, disposable wipes. Noted Resident #11 had a bowel movement. After removing and discarding Resident #11's soiled brief, Agency Shabaz I removed and discarded the soiled gloves, then donned a new pair of gloves with no hand hygiene performed between the glove change. In an interview on 7/29/25 at 12:58 PM, Agency Shabaz I reported hand hygiene should be completed when changing gloves during resident care. In an observation on 7/30/25 at 3:13 PM, Shabaz G assisted Resident #11 with a transfer from her wheelchair to her bed, in the resident's room, to change a soiled brief and pants. Observed Shabaz G don gloves prior to assisting Resident #11 with a transfer using the dependent lift in her room. Observed Shabaz G remove Resident #11's pants, discard gloves, and perform hand washing at the sink in Resident #11's room for approximately 7 seconds. Shabaz G then donned a new pair of gloves and continued with resident care. In an observation on 7/30/25 at 3:56 PM, Shabaz G and Registered Nurse (RN) D completed wound care for Resident #11 while she was in bed, in her room. Observed RN D remove the soiled dressing from Resident #11's left leg and clean the wound bed. RN D discarded the soiled dressing and removed her gloves, then applied a new pair of gloves with no hand hygiene performed between the glove change. Once the new dressing was applied, RN D discarded her gloves, taped/dated and initialed the dressing, and donned a new pair of gloves with no hand hygiene performed between the glove change. After examining and removing the soiled dressing from Resident #11's right elbow, RN D removed and discarded her gloves, and donned a new pair of gloves with no hand hygiene performed between the glove change before moving to examine Resident #11's left elbow. When finished with the assessment of Resident #11, RN D discarded her gloves and performed hand washing in the resident's bathroom for approximately 5 seconds. In an interview on 7/30/25 at 4:30 PM, RN D reported hand hygiene should be completed with each glove change. RN D reported hand washing should be performed for a minimum of 20 seconds. Review of the policy/procedure Hand Hygiene, revised 1/2025, revealed .All team members will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Hand hygiene technique when using soap and water .Wet hands with water. Avoid using hot water to prevent drying of skin .Apply soap to hands, using enough to create a good lather and cover all surfaces .Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers .Rinse hands with water .Dry thoroughly with a single-use towel .Use towel to turn off the faucet .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Resident #19 Review of an admission Record revealed Resident #19 was originally admitted to the facility on [DATE] with pertinent diagnoses which included non-pressure chronic ulcer of other part of left foot with unspecified severity. Review of Resident #19's Orders revealed, left lateral foot: monitor area for signs of infection and/or changes, notify provider. Change dressing on Wednesday's and document presentation of wound. Monitor dressing every shift every shift change dressing if soiled or dislodged. Start date: 6/18/25. In a wound care observation on 7/30/2025 at 11:37 AM, Registered Nurse (RN) D applied gloves and removed Resident #19's sock and soiled dressing from her left foot. RN D then threw away the soiled dressing and removed her gloves. RN D then applied new gloves and began cleaning Resident #19's wound. It was noted that RN D did not wash her hands after removing the soiled gloves and before applying new gloves.

Based on interview, and record review, the facility failed to develop a comprehensive care plan with person-centered interventions for paranoia in 1 resident (Resident #7) of 16 residents reviewed for comprehensive care plans, resulting in the potential for inadequate mental health care. Findings include: Review of an Admission Record revealed Resident #7 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: alzheimer's disease and dementia. Review of Resident #7's Care Plan revealed, .FOCUS: I have diagnoses of depression and anxiety. Date Initiated: 3/4/2019. Revision on: 3/4/2019. INTERVENTIONS: Administer medications as ordered .Date initiated 3/4/2019. Allow me to express thoughts, feelings, and concerns. Listen with non-judgmental acceptance. Revision on 4/6/2019. Encourage family and friends to visit regularly. Date initiated: 3/4/2019. I am followed by Behavioral Care Solutions for medication management .Date Initiated: 9/14/2023. Introduce me to peers and encourage participation in activities. Revision: 4/6/2019. In an interview on 08/07/24 at 02:13 PM, Social Services Coordinator (SS) I reported that Resident #7 suffers from anxiety and paranoia and takes multiple medications to manage her symptoms. SS I reported that Resident #7 failed a GDR (gradual dose reduction) with Remeron (medication for depression and anxiety), because she became extremely paranoid and anxious. SS I reported that Resident #7's care plan does not include her paranoia, and is not personalized for her anxiety and depression needs. SS I reported that the care plan does not include her known triggers related to paranoia, and/or the interventions that are in place. SS I reported that when Resident #7's paranoia starts to escalate, staff should redirect her to activities that she is personally interested in. In an interview on 08/08/24 at 11:32 AM, Shahbaz (care giver) N reported that Resident #7 occasionally became paranoid, and in those instances staff would offer her a magazine to read, provide her fidget apron (with buttons and zippers), and/or to watch a movie. Shahbaz N reported that Resident #7 is easily redirect with those specific interventions. In an interview on 08/08/24 at 02:18 PM, Director of Nursing (DON) B reported that she had been working on personalizing care plans, but that Resident #7's care plan was generic and did not reflect the resident's personal needs.

Based on observation, interview, and record review the facility failed to maintain standard infection control practices for wound dressings in 1 resident (Resident #3) of 1 resident reviewed for wound care, resulting in the potential for delayed wound healing and infection. Findings include: Review of an Admission Record revealed Resident #3 was originally admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) assessment for Resident #3, with a reference date of 7/12/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #3 was cognitively intact. During an observation on 08/06/24 at 10:39 AM in Resident #3's room, the resident's left hand was observed swollen, dark red, warm to touch, and with multiple Steri Strips (thin sticky bandages used to seal wounds by pulling the two side of the skin together without making any contact with the actual wound) covering a presumed wound. The steri strip's edges were peeled up, dry, crusted with old blood, and only partially attached in the center. The underlying wound was not visible, but the steri strips appeared to be stuck to the wound because of dried up blood and wound drainage. Resident #3 reported that she bumped her hand a while back, resulting in a skin tear and the facility put the steri strips on it then, and it had not been touched since. Resident #3 reported that occasionally the wound is painful. According to manufacturers instructions for Steri Strips dated July 2009, .Intended use: Steri-Strip skin closures are indicated for use as a skin closure device in the treatment of lacerations and surgical incisions. Steri-Strip skin closures may also be used in conjunction with skin sutures and staples or after their removal for wound support. Contraindications: 1. Steri-Strip skin closures are contraindicated where adhesion cannot be obtained. Potential causes of inadequate adhesion are presence of exudate (drainage), skin oils, moisture, or hair. 2. Use of Steri-Strip skin closures on infected wounds is contraindicated . Review of Resident #3's Skin assessment dated [DATE] revealed, .Back of left hand 4.5 cm skin tear, well approximated (edges pulled together) with steri strips, curved measuring 4.5 cm from end to end . Review of Resident #3's Progress Note dated 7/23/24 at 3:27 AM revealed, .applied steri strips to skin tear on left hand well approximated and covered wit a cosmopor dressing .(Provider) to review orders 7/23/24 . Review of Resident #3's Physician Orders revealed, order date 7/23/24, Monitor skin tear to back of left hand, steristrips and open to air, inform provider of an s/s (signs and symptoms) of infection d/c (discontinue) when healed . During an observation on 08/08/24 at 11:37 AM in Resident #3's room, the resident's left hand was observed swollen, with the same steri strips in place. The steri strips were partially pulling away from the wound and the ends were detached. In an interview on 08/08/24 at 11:45 AM, Shahbaz N reported did not pay close attention to Resident #3's left hand wound, as the licensed nurse monitors wounds. Shahbaz N reported that Resident #3's hand usually looks better than it did at that time. In an interview on 08/08/24 at 01:02 PM, Licensed Practical Nurse (LPN) C reported that Resident #3 tends to get a lot of skin tears, and had a standing order to apply steri strips to the wounds and then allow the strips to fall off the their own. LPN C reported that Resident #3 had the steri strips applied over a skin tear on her left hand about 2 weeks ago, and she could not remove the steri strips, because it would remove the scab and reopen the wound. LPN C reported that the dried, brown crust and the detached edges of the steri strips were normal. The steri strips had been in place, serving as the only wound care, for 17 days. In an interview on 08/08/24 at 02:04 PM, Director of Nursing (DON) B reported that she assessed wounds in the facility along with the phsician, but that she had not gotten a chance to see Resident #3's wound on her left hand. DON B reported that Resident #3 had sustained the skin tear wound on 7/22/24 while she was out of the facility with family. DON B reported that the physician had seen the resident a couple days ago, but DON B was not able to provide documentation of the visit. DON B reported that Resident #3's skin is very moist, and a regular wound dressing would create maceration (moist fragile skin), and that was the reason steri strips were used for the skin tear. DON B reported that Resident #3 had been treated with an antibiotic for cellulitis (skin infection) on her left hand in June 2024, and that monitoring for signs of infection in the current wound was important. DON B reported that the wound was not visible due to being covered with steri strips, but that staff monitor for swelling, redness and warmth of the left hand. According to an article by Cleveland Clinic dated 6/14/24, .If you notice blood soaking through the Steri-Strips, seek medical care .Steri-Strips typically stay on for up to two weeks. They should fall off on their own within that timeframe. If the edges of your Steri-Strips start to curl before two weeks are up, you can carefully trim them with small scissors. After two weeks, you can gently remove Steri-Strips Contact a healthcare provider if you ' re using Steri-Strips and notice: Discoloration, soreness or warmth around the wound. Drainage from the wound. A foul smell coming from the wound. These are signs of a wound infection, which you can ' t treat on your own. You need to seek medical care. Untreated wound infections can spread to other parts of your body and lead to serious complications like cellulitis or septicemia .

This citation pertains to intake MI00137971 Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls for 2 (Resident #13, Resident #11) of 3 residents reviewed for falls, resulting in a fall with major injury for Resident #13 and potential for additional falls with injury for Resident ##11. Findings include: Resident #13 Review of an Admission Record revealed Resident #13, was originally admitted to the facility on [DATE] with pertinent diagnoses which included repeated falls and alzheimers disease (disease that destroys memory and important mental functions). Review of a Minimum Data Set (MDS) assessment for Resident #13, with a reference date of 4/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 2/15 which indicated Resident #13 was severely cognitively impaired. In an observation on 6/26/23 at 10:38 AM, Resident #13 had a large bandage across her forehead and dark bruising under both of her eyes and on the bridge of her nose. An abrasion was also noted on the bridge Resident #13's nose. During an interview on 6/27/23 at 1:16 PM, Registered Nurse (RN) N reported that she was called by CNA I to assess Resident #13 because she had just fallen off the toilet. RN N' reported that when she entered Resident #13's bathroom, CNA C and CNA I were in the bathroom with Resident #13, and reported that Resident #13 had fallen off the toilet when CNA C left Resident #13 alone in the bathroom to grab a brief. RN N reported that Resident #13 was bleeding from her head. RN N reported that Resident # 13 required 1 staff member assistance in the restroom and should not have been left alone in the rest room. During an interview on 6/27/23 at 1:40 PM, CNA I reported that she was assisting other residents in the main dining area when she heard CNA C calling out for help. CNA I reported that she went into Resident #13's bathroom and was instructed by CNA C to call the nurse for assistance because Resident #13 had just fallen off the toilet. CNA I reported that Resident #13 was on the floor and bleeding from her head. CNA I reported that Resident #13 required a staff member to stay with her in the restroom and should not have been left alone Review of Resident #13's Nurse Progress note dated 6/25/23 revealed, . (Resident #13) had a fall on 6/24 requiring 7 sutures to forehead, bruising on left elbow, and bruising across nose and eyes . Review of Resident #13's Incident Report dated 6/24/23 revealed, Incident Description: Nurse was notified by staff that (Resident #13) fell off the toilet and hit her head. Immediate action taken: .dressing applied to gash on forehead. (Resident #13) sent to (Local Hospital) ED (emergency department) . Notes: Gash to forehead. 6/25/23 Bruise to left elbow, abrasion to bridge of nose, bruising across nose and under/around eyes . Review of Resident #13's Post fall huddle report completed by CNA C revealed, .I did not follow the care plan, I made a big mistake I should have asked my team member to get the brief out of the closet instead of leaving the bathroom to get the brief . Review of Resident #13's Care Plan revealed, I am at risk for falls r/t (related to) . Confusion/dementia,Gait/balance problems, History of Falling, Hx (History) of attempts at self transfers, Impaired balance, Impulsivity,balance problems, Unaware of safety needs . Date initiated 1/20/2023. Interventions . Do not leave me alone in the bathroom. Date initiated: 01/20/2023 . Attempts were made to contact CNA C on 6/27/23 and 6/28/23. No return call was received prior to survey exit. During an interview on 6/27/23 at 2:45 PM, Director of Nursing (DON) B reported that Resident #13's care plan indicated that she (Resident #13) should not be left unattended. Review of Resident #13's Orders Revealed, . Keep the wound dry for the first 24 hour. Clean wound once a day with soap and water, rinse, pat dry. After wound cleansing apply a thin layer and cover with nonstick bandage. One time a day .Order date: 6/24/23 . Remove stitches in about 7 days . Order date 6/24/23. Resident #11 Review of an Admission Record revealed Resident #11, was originally admitted to the facility on [DATE] with pertinent diagnoses which included muscle weakness and difficulty in walking. Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 4/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 8/15 which indicated Resident #11 was moderately cognitively impaired. Review of Resident #11's Nursing Admission assessment dated [DATE] indicated that Resident #11 had 22 falls prior to admission. Review of Resident #11's Incident Reports revealed 9 reports of witnessed and unwitnessed falls between 3/2023- 6/2023 Review of Resident #11's Care Plan revealed, I am at risk for falls r/t Adaptive device .confusion/dementia, Gait/balance problems, History of Falling, Hx (history) of attempts at self transfers, Impaired balance,disorientation, balance problems, Shuffling gait, Unaware of safety needs . Date initiated: 3/24/23. Interventions: Assist me to a calm/quiet environment if I am noted to be anxious. Date initiated 3/24/23. Check on me frequently throughout the day and night (24 hours) to assist me with change in position, transferring and ask me if I have any needs . Date initiated: 3/24/23 . During an observation on 06/26/23 at 11:10 AM, Resident #11 was in her wheelchair at the dining room table, then stood up and started to walk around the table unassisted. Resident #11 was unsteady and holding onto the side of the table. CNA G was in the kitchen approximately 30 feet away with her back turned to Resident #11 and was unaware of Resident #11 ambulating unassisted. During an observation on 6/27/23 at 1:27 PM, Resident #11 was sitting in her wheelchair in the dining room area removing a gait belt that was placed around her and attempting to stand up out of wheelchair. There were no staff members observed in the area. Surveyor notified CNA H who entered the dining room area and asked Resident #11 to wait for staff to assist her. CNA H then left the dining room and returned to another resident's room. Resident #11 continued to attempt to stand up at counter.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty eight consecutive hours a day, seven days a week resulting in the potential for negative clinical outcomes affecting all 16 residents at the facility. Findings include: Review of the current facility Nursing schedules indicated that on 6/26/23 there were no RN's scheduled to work. This did not meet the requirements for RN hours of 8 consecutive hours in a 24 hour period everyday. In an interview on 06/27/23 at 11:52 AM, NHA reported that the facility currently had a shortage of RN's and did not have an RN waiver. NHA reported that the facility had not been able to ensure 8 hours of RN coverage everyday since the DON was currently working remotely due to leave of absence. NHA reported that the DON has been working remotely since 5/16/23, and was unsure of the DON's return to work date. NHA reported that the DON is available by phone, but is not able to provide direct care. Review of Time clock detail indicated less than 8 hours consecutive hours of RN coverage on the following days: 5/13/23, 5/15/23, 5/19/23, 5/21/23, 5/23/23, 5/24/23, 5/25/23, 5/29/23, 6/5/23, 6/9/23, 6/11/23, 6/12/23, 6/13/23, 6/14/23, and 6/26/23. In an interview on 06/28/23 at 12:32 PM, DON reported that she had not been working at all from 5/16/23 through 6/15/23, and then had been working remotely since 6/16/23. DON reported was aware that the facility had days without 8 hours of RN coverage in the past, and that DON had tried to be available for tasks that required an RN, such as initiating IV (intravenous fluids) and/or pronouncing a death.

Based on observation, interview, and record review, the facility failed to maintain safe and sanitary conditions in the kitchen and food storage areas in regard to labeling, dating, and discarding of expired food items, and general cleanliness, potentially affecting all those who receive meal services from the kitchen, resulting in the potential for cross-contamination of food and development of food-borne illness. Findings include: In an observation on [DATE] beginning at 9:19 a.m., reviewed the 100 building kitchen area. Observed the following items in the fridge: Cheese slices wrapped in Saran wrap with no label, open date, or use by date. A bottle of mustard with an open date of [DATE] and a use by date of [DATE]. A 32 ounce bottle of French vanilla creamer with no open date or use by date. A 38 ounce bottle of ketchup with no open date or use by date. A 16 ounce bottle of ranch dressing with no open date or use by date. A 30 ounce container of mayonnaise with no open date or use by date. A 16 ounce bottle of Caesar dressing with no open date or use by date. A 15 ounce bottle of lemon juice with no open date or use by date. An 18 ounce bottle of barbeque sauce with no open date or use by date. In an observation on [DATE] beginning at 9:19 a.m., reviewed the 100 building kitchen area. Observed the drawers to the right of the center/island sink, which contained clean utensils used for serving resident food items. Noted crumbs/debris and bits of foil within the drawers. Observed two 16 ounce bottles of olive oil in a drawer along the window section of the kitchen, with no open dates or use by dates noted on the bottles. In an observation on [DATE] beginning at 9:19 a.m., reviewed the 100 building kitchen area. Observed the following items in the tall cupboard containing spices and dry food items: A 28 ounce box of cream of wheat, with an open date of [DATE] and a use by date of [DATE]. An open bag of brown sugar, with no open date or use by date on the package. A 31.9 ounce bag of dry mashed potatoes with no open date or use by date. An open container of rosemary leaves with an open date of [DATE] and a use by date of [DATE]. An open container of black pepper with an open date of [DATE] and a use by date of [DATE]. An open 4.5 ounce container of lemon pepper seasoning with no open date or use by date. A 5 ounce container of onion powder with no open date or use by date. An open gallon of vegetable oil with no open date or use by date. An open gallon of white distilled vinegar with no open date or use by date. In an observation on [DATE] beginning at 9:58 a.m., reviewed the 100 building pantry/food storage area. Observed the following items on the shelves in the dry storage section of the pantry: A small plastic bag of penne noodles with an open date of [DATE] and a use by date of [DATE]. Two 7.25 ounce cans of vegetable soup with an expiration date of [DATE]. A plastic bag of white rice with no label, open date or use by date. A plastic bag of spaghetti noodles with no label, open date or use by date. A plastic bag of brown rice with no label, open date or use by date. Two plastic bags of Cake Mix, with a use by date of [DATE]. Observed the following items in the fridge within the pantry: A plastic bag of parmesan cheese with a use by date of [DATE]. Observed multiple dark brown bananas within a clear drawer. Noted the drawer appeared to be broken and would not open. Noted the interior surfaces of the pantry fridge were heavily soiled with spilled food debris. In an interview on [DATE] at 10:20 a.m., Certified Nursing Assistant (CNA) D reported all opened food items should be labeled with open dates and use by dates. In an observation on [DATE] beginning at 10:20 a.m., reviewed the 200 building kitchen area. Observed the interior surface (top) of the microwave was soiled with splattered/dried food debris. Observed multiple clear glass baking dishes in the cupboard with baked on food debris/discoloration. Noted a drawer with a lock on the south side of the kitchen, which contained the pizza cutter and blender attachment. Noted the lock was not functional, and the drawer was easily opened without a key. Observed the following items in the tall cupboard containing spices and dry food items: An open 24 ounce bottle of syrup with no open date or use by date. A 1.1 ounce container of ground nutmeg with a discard date of [DATE]. An open 17 ounce bottle of olive oil, with no open date or use by date. A plastic container of an unlabeled white substance. Noted the floors in the kitchen area were tacky/greasy, and the pocket door blocking the kitchen area from access by residents was soiled/sticky to the touch. In an observation on [DATE] beginning at 10:37 a.m., reviewed the 200 building pantry/food storage area. Observed the following items on the shelves in the dry storage section of the pantry: An unlabeled dry grain in a plastic bag, with no open date or use by date. A plastic bag of a white substance with no label, open or use by date. Observed the following items in the fridge within the pantry: A plastic bag with an unlabeled herb, with no open date or use by date. A plastic bag of uncooked sausage links, with a use by date of [DATE]. Two carrots in a plastic bag with no open date or use by date. In an interview on [DATE] at 12:11 p.m., CNA H reported third shift staff are supposed to review the fridge/food items for appropriate labeling/dating and discard items as necessary. CNA H reported all open food items should be labeled with open dates and use by dates. In an interview on [DATE] at 12:28 p.m., Director of Dining Services T reported all open food items should be labeled with open dates and use by dates. Review of the policy/procedure Date Marking for Food Safety, dated [DATE], revealed .The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food .Refrigerated, ready-to-eat, time/temperature control for safety food (i.e. perishable food) shall be held at a temperature of 41 F or less for a maximum of 7 days .The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded .The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared .The marking system shall consist of an adhesive label, the day/date of opening, and the day/date the item must be consumed or discarded .The discard day or date may not exceed the manufacturer's use-by date, or six days plus today, whichever is earliest. The date of opening or preparation counts as day 1 .The Lead Cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly .The Director of Dining Services, or designee, shall spot check refrigerators weekly for compliance, and document accordingly. Corrective action shall be taken as needed . Review of the policy/procedure Food Safety Requirements, dated 2019, revealed .It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared and served in accordance with professional standards for food service safety .Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following .Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms .Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food .Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage .Practices to maintain safe refrigerated storage include .Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded .All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination . Review of the policy/procedure Sanitation Inspection, dated [DATE], revealed .It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and in compliance with applicable state and federal regulations .All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects .The sanitation program will provide for inspections to be conducted of the food service areas .Inspections will be conducted but not limited to the following areas: a. Dry storage b. Freezer c. Refrigerator d. Dish room e. Pot wash f. Main production area g. Food preparation area h. General dietary observations .

Based on observation, interview and record review the facility failed to ensure residents received care in accordance with professional standards in 1 of 9 residents (Resident #1) reviewed for quality of care, resulting in the potential for delay in care for a hypotensive (low blood pressure) event and further decline in physical condition. Findings include: Review of an Admission Record revealed Resident #1 was originally readmitted to the facility on [DATE], with pertinent diagnoses which included: hypotension. In an interview on 06/26/23 at 12:35 PM, Resident #1 reported that she did not feel well and was not able to walk on her own since she returned from the hospital. In an interview on 06/26/23 at 12:37 PM, Licensed Practical Nurse (LPN) L reported that Resident #1 had returned from the hospital on 6/21/23 (5 days ago), after a 4 day stay for hypotension (low blood pressure). LPN L reported that she had not worked with Resident #1 since the resident had returned from the hospital. In an interview on 06/27/23 at 01:37 PM, LPN M reported that Resident #1 had gone to the hospital the week before and was diagnosed with hypotension. LPN M reported that the facility started the protocol for an admission from the hospital immediately following the resident's return, to include monitoring of vital signs twice daily (every shift). Review of Resident #1's Physician Orders revealed, .Re-admission vital signs every shift for 14 days post hospitalization . every shift for monitoring post-hospitalization until 07/04/2023. Start date 6/25/2023 at 18:00 (6:00 PM). This order was placed 4 days after Resident #1 had returned to the facility. Review of Resident #1's Vital Signs Record on 6/27/23 at 2:30 PM revealed the following Blood Pressure (BP) results: 6/17/23 at 7:00 AM 86/58 mmHg (this was the day the resident was sent to the hospital) 6/21/23 at 5:40 PM 141/98 mmHg (this was upon re-admission from the hospital) 6/22/23 at 5:02 AM 110/50 mmHg (only one time this day) 6/23/23 at 2:59 PM 116/62 mmHg 6/23/23 at 7:35 PM 120/58 mmHg 6/24/23 No record of vital sign results. 6/25/23 at 10:36 AM 102/60 mmHg (only one time this day) 6/26/23 at 8:20 PM 132/70 mmHg (only one time this day). Review of Resident #1's Hospital Course Summary indicated that the resident had admitted on [DATE] and discharged on [DATE]. The presenting problems were confusion, hypotension and leukocytosis (high white blood cell count, could indicate inflammation or infection). In an interveiw on 06/28/23 at 10:32 AM, Certified Nursing Assistant (CNA) E reported that the nurses complete vital signs for residents, unless it is delegated to a CNA and stated, .no, I am not doing vitals on (Resident #1) . In an interview on 06/28/23 at 11:45 AM, LPN L reported that it was facility protocol and a physicians order to complete vital signs BID (twice a day) for 14 days for new admissions and re-admission from the hospital. LPN L reported that Resident #1 returned from the the hospital on 6/21/23, but the order for vital signs was not entered until 6/25/23, and should have been entered immediately upon return. In an interview on 06/28/23 at 12:26 PM, DON reported that Resident #1 should have had orders entered by the admitting nurse on the day of re-admission for BID vital signs as protocol for admissions, and that it was specifically important due to the resident's recent hospitalization for low blood pressure. Review of the facility policy Vital signs (no date) revealed, .Vital signs are indicators of health status, including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain .Vital signs shall be obtained at least in the following circumstances: a. Upon admission/readmission. Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, Hypotension is present when the systolic BP falls to 90 mmHg or below .for most people low blood pressure is an abnormal finding associated with illness .record any signs of BP alteration in nurses notes. Report abnormal findings to nurse in charge or health care provider. [NAME], P. A., [NAME], A. G., Stockert, P. A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St. [NAME]: Mosby. p. 461 and 465.

Based on interview and record review, the facility failed to discontinue psychotropic as needed (PRN) medications after 14 days and/or document rationale for extended prn psychotropic medication use in 2 of 5 residents (Resident #13 and #165) reviewed for unnecessary medications, resulting in the potential for unnecessary medication use with a potential for adverse side effects and inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence. Findings include: Resident #13 Review of an Admission Record revealed Resident #13, was originally admitted to the facility on [DATE] with pertinent diagnoses which included repeated falls and alzheimers disease (disease that destroys memory and important mental functions). Review of Resident #13's Orders revealed, LORazepam (Anti-anxiety medication) Oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 1 tablet by mouth as needed for anxiety May be administered two times a day. Order date: 1/21/2023. End date: Indefinite. Review of Resident #13's Medication Administration Orders indicated documentation that Resident #13 had received one dose of the PRN Lorazepam in January 2023, one dose in February, two doses in March, zero doses for the month of April, one dose in May, and zero doses in June. During an interview on 6/27/23 at 11:32 AM, Medical Director (MD) V reported that Resident #13 was admitted with the order for Lorazepam and he (MD V) chose to continue the order because Resident #13 was on hospice. Medical Director V was unable to provide documentation of rationale for the PRN lorazepam order. MD V reported that he was aware that the pharmacy had recommended discontinuing the Lorazepam PRN order in January. MD V was unable to report the specific benefits of continuing the Lorazepam medication for Resident #13. MD V was unable to report how often the need for the Lorazepam was being assessed. During an interview on 6/27/23 at 2:52 PM, Social Worker (SW) Q reported that Resident #13's Lorazepam order was not discontinued after 14 days, and was unable to provide any rationale of benefits for continued use of the medication. During an interview on 6/27/23 at 2:45 PM, Director of Nursing (DON) B reported that PRN psychotropic medication orders are monitored by the DON, Physician and Pharmacist. DON B was unable to provide rationale for Resident #13's Lorazepam order not being discontinued after 14 days. Review of Resident #13's Medical office visit dated 6/13/2023 completed by Medical Director V revealed, Problem list: .Anxiety: Continue on Zoloft. Not having behaviors of calling out . Medications listed within visit notes did not include Lorazepam. Review of Resident #13's Medical Visit dated 2/21/23 revealed .She remains on hospice for alz (alzheimers) dementia. Relying on staff for all her adls (activities of daily living). patient was able to give short sentence answers today. denied she was in pain, asked to be excused when provider attempted ROS (Review of symptoms). Overall remains stable and have transitioned well to the (facility) . The original visit note did not address PRN Lorazepam. This visit note was amended on 6/27/23 with the following information: .remains on Ativan (Lorazepam) PRN, recommendation per hospice. would continue for management of anxiety/MDD (Major Depressive Disorder). Benefit outweighs the risk, can re-evaluate down the line . In an email correspondence on 6/28/23 at 9:17 AM, DON B reported that MD V updated Resident #13's Medical Visit dated 2/21/23 based on the review of Lorazepam on 6/27/23. Review of Resident #13's Pharmacy Consultation Report dated 4/18/23 revealed, (Resident #13) has a PRN order for an anxiolytic (drug used to reduce anxiety), without a stop date: Lorazepam. Recommendation: Please discontinue PRN Lorazepam, tapering as necessary (e.g., decreasing the dose by no more than 25%, or 10-12% in high risk residents, every two weeks). If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period .Physician Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: due to goal of care as comfort and likely need to control symptoms. Will keep Medicine and review for need at future visits. Signature: (Medical Director V). Date: 4/18/23. There was not an indication for duration of therapy and/or specific time frame for review of medication. Review of Resident #13's Pharmacy Consultation Report dated 1/23/23 revealed, (Resident #13) has a PRN order for an anxiolytic (drug used to reduce anxiety), without a stop date: Lorazepam. Recommendation: Please discontinue PRN Lorazepam, tapering as necessary (e.g., decreasing the dose by no more than 25%, or 10-12% in high risk residents, every two weeks). If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period .*Please fax back response. Physician's Response: (No response). Physician Signature: (No signature) . Review of Resident #13's Progress Note Completed by Hospice nurse dated 1/25/23 revealed, . Ativan (Lorazepam) has been used x1 in the past 7 days but was then discontinued . 41027 Resident #165 Review of an Admission Record revealed Resident #165 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: insomnia (trouble sleeping), Alzheimer's disease and dementia with behavioral disturbances. Review of Resident #165's Care Plan revealed, .I use antidepressant medication r/t (related to) poor sleep. I am prescribed Trazodone r/t insomnia diagnosis .Interventions: Administer antidepressant medication as ordered by physician. Date initiated: 6/14/23 . Review of Resident #165's Physician Orders revealed, Trazodone (psychotropic medication) HCl (helps the pill to disolve in water) Oral Tablet 50 MG Give 50 mg by mouth at bedtime for insomnia and give 50 mg by mouth as needed for sleep. Active date: 6/6/2023, End date: Indefinite. Review of Resident #165's Medication Administration Record (MAR) indicated an order for Trazodone 50mg to be given at bedtime, and an additional order for Trazodone 50mg to be given as needed (PRN) for sleep. Review of Resident #165's Medical Visit dated 6/7/23 revealed, .New admit .dx (diagnosis): Alzheimer/dementia with behaviors .Plan: reviewed patient's medical chart stable and shown advancement in dementia in the last year .will continue to monitor behaviors .She is on Risperdone (antipsychotic medication) for behaviors. There was no mention of Trazodone and/or rationale for PRN order of psychotropic medication, or a diagnosis of insomnia. In an interview on 06/28/23 at 11:04 AM, Social Worker (SW) Q reported that she was not made aware that Resident #165 had a PRN order for Trazodone. SW Q reported that all PRN psychotropic medications should have a stop date of 14 days or less. SW Q reported that the nurses enter the medication orders into the computer. Review of a facility policy Antipsychotic Medication Use revised December 2016 revealed, .13. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. 14. The need to continue PRN orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. 15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication .

Based on interview, and record review, the facility failed to develop policies and procedures to include current standards of practice in regard to pneumococcal immunizations, resulting in the potential for eligible residents to not be offered either the PCV15 (15-Valent Pneumococcal Conjugate Vaccine) or PCV20 (20-Valent Pneumococcal Conjugate Vaccine), therefore increasing the risk of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. Findings include: Review of the policy/procedure Resident Pneumococcal Vaccination, dated January 2021, revealed .It is our policy to offer our residents immunization against pneumococcal disease in accordance with current CDC (Centers for Disease Control and Prevention) guidelines and recommendations .Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization upon admission unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders. 3. Prior to offering the pneumococcal immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. a. The individual receiving the immunization, or the resident representative, will be provided with a copy of CDC's current vaccine information statement relative to that vaccine. b. If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding. 4. The resident/representative retains the right to refuse the immunization. A consent (form) shall be signed prior to the administration of the vaccine and be placed in the individual's medical record. 4. (sic) The type of pneumococcal vaccine (PCV13, PPV) offered will depend upon the recipient's age and susceptibility to pneumonia, in accordance with current CDC guidelines and recommendations. 5. Usually only one (1) pneumococcal polysaccharide vaccination (PPSV) is needed in a lifetime. However, based on an assessment and practitioner recommendation, additional vaccines may be provided. 6. A series of vaccinations will be offered to immunocompetent* adults (aged 65 or greater), depending on current vaccination status and practitioner recommendation: a. No previous vaccination (or vaccination status is unknown): PCV13 first, then PPSV23 one year later. b. Previously received PPSV23 at age (65 or greater): PCV13 at least 1 year after receipt of PPSV23. c. Previously received PPSV23 before age [AGE] years who are now aged (65 or greater): PCV13 at least 1 year after receipt of PPSV23, then PPSV23 after 5 years of previous vaccination (no earlier than one year of PCV13). (* Residents who are immunocompromised may receive the series of vaccinations within a shortened interval in accordance with current CDC guidelines and practitioner recommendation, but no sooner than 8 weeks. These residents may receive up to 3 doses of PPSV23.) 7. The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization. b. The resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal Note the policy/procedure was not updated to reflect the current CDC recommendations in regard to PCV15 and PCV20 immunizations. In an interview on 6/28/23 at 1:30 p.m., Director of Nursing (DON) B reported she was aware of the CDC recommendations in regard to PCV15 and PCV20 immunizations, but was unsure if the policy had been updated to reflect the current guidance. Note an updated policy/procedure was not provided prior to survey exit. Review of the Centers for Disease Control and Prevention (CDC) Pneumococcal Vaccine Recommendations, page dated 2/13/23, revealed .CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults [AGE] years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown .If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak .If PCV20 is used, a dose of PPSV23 is NOT indicated . Retrieved from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html Review of the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR), Vol. 71 No. 4, dated 1/28/22, revealed .In 2021, 20-valent pneumococcal conjugate vaccine (PCV) (PCV20) .and 15-valent PCV (PCV15) .were licensed by the Food and Drug Administration for adults aged ([AGE] years and older), based on studies that compared antibody responses to PCV20 and PCV15 with those to 13-valent PCV (PCV13) .Antibody responses to two additional serotypes included in PCV15 were compared to corresponding responses after PCV13 vaccination, and antibody responses to seven additional serotypes included in PCV20 were compared with those to the 23-valent pneumococcal polysaccharide vaccine (PPSV23) .On October 20, 2021, the Advisory Committee on Immunization Practices (ACIP) recommended use of either PCV20 alone or PCV15 in series with PPSV23 for all adults aged ([AGE] years and older), and for adults aged 19-[AGE] years with certain underlying medical conditions or other risk factors who have not previously received a PCV or whose previous vaccination history is unknown .Use of PCV20 alone or PCV15 in series with PPSV23 is expected to reduce pneumococcal disease incidence in adults aged ([AGE] years and older) and in those aged 19-[AGE] years with certain underlying conditions. Findings from studies suggested that the immunogenicity and safety of PCV20 alone or PCV15 in series with PPSV23 were comparable to PCV13 alone or PCV13 in series with PPSV23. Cost-effectiveness studies demonstrated that use of PCV20 alone or PCV15 in series with PPSV23 for adults at age [AGE] years was cost-saving. The new policy simplifies adult pneumococcal vaccine recommendations .and is expected to improve vaccine coverage among adults and prevent more pneumococcal disease . Retrieved from https://www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7104a1-H.pdf

Based on observation, interview, and interview the facility failed to ensure the kitchen's sanitizer was at the appropriate concentration, test the sanitizer correctly, and place in correctly labeled containers for two of two kitchens resulting in the potential for foodborne illness, off-flavors and/or odors in foods, and/or contaminated food contact surfaces. Findings include: During an observation on 06/22/22 at 07:30 AM, Certified Nurse Aide (CNA) G tested the sanitizer bucket in Building #2's kitchen sink by inserting the test strip in the solution for approximately one second. The test result was 500 ppm (parts per million) for the quaternary sanitizer. CNA G presented the sanitizer's manufacturer's bottle/label, and it indicated the sanitizer was to be at 150 ppm. During an observation on 06/22/22 at 08:57 AM, Certified Nurse Aide (CNA) C tested the sanitizer solution in Building #1's kitchen sink contained in a bucket. The test strip was inserted into the green bucket. CNA C confirmed the sanitizer was in the green bucket and soap and water were in the red bucket that were in the kitchen's sink. When testing the sanitizer, the test strip was held in the solution for approximately 5 seconds. CNA C checked the sanitizer again and held the strip in the solution for approximately 6 seconds. The red bucket on the outside stated, Sanitizing Solution Bucket .Use appropriate concentration of solutions. The green bucket on the outside stated, Soap Solution Bucket. The sanitizer and soap solutions were dispensed into the wrong labeled containers. Review of the [Name Brand] quaternary sanitizer test strips manufacturer's label, expiration date 9/30/2023, stated, Immerse for 10 seconds, compare when wet .Dip paper in quat (quaternary) solution .for 10 seconds .Follow manufacturer's dilution instructions carefully. During an observation and interview on 06/23/22 at 07:55 AM, Certified Nursing Aide (CNA) F placed a test strip in the sanitizer solution bucket in Building #2's kitchen sink and held it immersed for approximately 6 seconds. The test result was 0 parts per million (ppm). CNA F presented the sanitizer bottle/label which stated, FOR SANITIZING FOOD CONTACT SURFACES .Use 1 oz (ounce) per 2 gallons of water (150 ppm quat) for a minimum contact time of 1 minute in a single application. CNA F reported the sanitizer was dispensed at approximately 6 or 7 AM that morning and went to get more sanitizer from Building #1 returning at 08:11 AM with new sanitizer solution. CNA F tested the concentration of the sanitizer solution with a test strip and the test result was 500 parts per million. The temperature of the sanitizer solution was tested , and it was 89 degrees Fahrenheit. Once the sanitizer reached a temperature of 72 degrees Fahrenheit at 08:33 AM, the sanitizer solution was tested again, and the test result was 500 parts per million. During an interview on 06/23/22 at 07:57 AM, Director of Nursing/Nursing Home Administrator A confirmed the quaternary solution [Name brand and product name] was dispensed into red buckets and confirmed the sanitizer was a quat (quaternary) sanitizer solution. During an interview on 6/23/22 at 08:47 AM, Dietary Manager I reported he tested the sanitizer, and it was 500 parts per million and confirmed that reading was too high. Dietary Manager I reported the test range should be 150-300 (parts per million) but would have to check the manufacturer's label to be sure. During an interview on 6/23/22 at 12:57 PM, Director of Nursing/Nursing Home Administrator B reported the manufacturers phone answering service reported the sanitizer solutions concentration should be 150-300 parts per million (ppm). The surveyor requested documentation to confirm this 150-300 ppm range, but none was provided by the end of the survey. The manufacturer's product label and the technical data sheet indicated 150 ppm for the product. Review of the Daily Sanitizing Checklist Green House Homes Dish Machine log for Building #2, dated 6/1/22 - 6/23/22, indicated the sanitizer bucket's solution concentration was 400 parts per million (ppm) 8 times and 450 ppm one time. Review of the facility's Preventing Foodborne Illness - Food Handling policy, revised 7/2014, stated, All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations. Review of the [Name Brand] sanitizer's manufacturer technical data sheet, dated 6/2021, At 150 ppm (parts per million) active quat, the ready-to-use product is used to sanitize hard, non-porous environmental surfaces. The product is also used for sanitizing food contact surfaces. and Food Contact Surfaces .Use 1 oz. (ounce) per 2 gallons of water (150 ppm quat) for a minimum contact time of 1 minute in a single application. Review of the 2013 Food and Drug Administration's Food Code stated, 7-102.11 Common Name. Working containers used for storing POISONOUS OR TOXIC MATERIALS such as cleaners and SANITIZERS taken from bulk supplies shall be clearly and individually identified with the common name of the material. Review of the 2013 Food and Drug Administration's Food Code stated, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness .A quaternary ammonium compound solution shall: .Have a concentration .as indicated by the manufacturer's use directions included in the labeling .

Based on observation, interview, and record review the facility failed to ensure timely nutrition assessment after a significant weight loss in 1 of 1 resident (Resident #7) reviewed for nutrition, resulting in a delay in nutrition assessment after a significant weight loss and the potential for further undesirable weight loss. Findings include: During an observation and interview on 06/22/22 at 11:25 AM, Resident #7 was seated upright in his wheelchair in the dining room waiting for his lunch. Resident #7 reported he had lost weight and was down to the 150lbs (pounds) and hadn't spoken to or seen the dietitian. During an interview on 06/23/22 at 08:50 AM, Registered Dietitian (RD) J confirmed Resident #7's most recent nutrition assessment was May 2022 and it had been three weeks since Resident #7's significant weight loss measurement. RD J reported she comes to the building on Thursdays only and wasn't there the week 6/5/22-6/11/22. RD J reported the interdisciplinary team talked about Resident #7 at a meeting on 6/16/22 but confirmed nothing was implemented to address the weight loss because she (RD J) wanted to see another weight and talk to the certified nurse aides. When asked if there were any assessments/interventions from 6/16/22 to 6/23/22 she reported she added shakes today (6/23/22; after the surveyor had questioned Resident #7's weights). When asked if it usually takes approximately 21 days to implement a nutrition intervention (after a significant weight loss) or a reweight RD J stated, sometimes it could. RD J stated, It is possible that he lost weight and reported Resident #7 had been the way he had been since he was admitted and had a stable weight prior. (This reflected there was no observable changes in Resident #7, but despite this he had still lost a significant amount of weight). RD J confirmed she had not seen Resident #7 or assessed him since his significant weight loss that was measured on 6/1/22 and 6/2/22. RD J stated, As soon as possible regarding how soon the Registered Dietitian should see a resident after a significant weight loss. RD J confirmed there was not any documentation of Resident #7's nutritional supplement acceptance but stated he is offered one if he eats less than half of his meal. RD J confirmed she doesn't usually wait three weeks to assess a resident after a significant weight loss. During an observation and interview on 06/23/22 at 10:38 AM, Registered Dietitian (RD) J reported a weight was obtained that day for Resident #7 and it was 157.4 pounds. 157.4 pounds reflected a 5.2 percent weight loss from 5/12/22. During an observation, RD J presented the interdisciplinary team's notes dated 6/9/22. Resident #7's weights were written on an order recap summary sheet, but there was no assessment or notes to indicate an assessment or interventions had been offered or completed. There was no indication the resident or resident representative had the weights discussed with them. During an interview on 06/23/22 at 10:59 AM, Nursing Home Administrator/Director of Nursing A reported the interdisciplinary team discussed Resident #7's weight on 6/9/22, but no interventions or assessment were completed at that time. During an interview on 06/24/22 at 01:38 PM, Resident #7's power of attorney M reported she had never been notified about Resident #7's significant weight loss, didn't know why he had lost weight, and his usual body weight used to be around 178 pounds. Review of Resident #7's weights vitals, dated 2/3/22 through 6/2/22, indicated a significant weight loss from 5/12/22 to 6/1/22 and 6/2/22. Resident #7 weighed 166 pounds on 5/12/22, 154.8 pounds on 6/1/22 (reflected a 6.75 percent weight loss; a significant weight loss), and 148.8 pounds on 6/2/22 (reflected a 10 percent weight loss; a significant weight loss). Prior to the significant weight loss Resident #7's weight had been 166-168.8 pounds from 2/3/22 to 5/12/22. Review of Resident #7's medical record, from 5/13/22 through 6/22/22, revealed no nutrition assessments or notes that addressed Resident #7's significant weight loss found on 6/1/22 and 6/2/22. Review of Resident #7's assessments, dated 2/1/22-6/21/22, revealed the most recent nutrition assessment was completed on 5/12/22. Review of Resident #7's progress notes, dated 2/1/22 - 6/23/22, didn't have any notes addressing Resident #7's significant weight loss, nutrition assessments, or nutrition interventions. Review of the facility's interdisciplinary team notes for Resident #7, dated 6/9/22, listed Resident #7's weights but there was no assessment or interventions addressing the weight loss. Review of Resident #7's nutrition care plan, dated 2/3/22, stated, I have a Nutrition problem/potential nutrition problem r/t (related to) variable meal intake, hx (history) of wt. (weight) loss . and included a goal of I (Resident #7) will maintain my weight +/-3% (within 3%) 169 lb (pounds), revised 5/11/22. The nutrition care plan included interventions of Monitor weight as ordered and as needed. Report any weight changes > (greater than) 5# or 5% to dietitian. and Offer supplement or alternate meal item if meal intake is <50%., both dated 2/3/22. The care plan included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #7's nutrition assessment completed by Registered Dietitian J, dated 5/12/22, stated, Nutrition Supplements: NA (not applicable), Average Food Acceptance in the last 7 Days: .Often 75-100%, Goals: Maintain wt. (weight) +/- 3% 166 lb (pounds), Maintain stable wt., Monitoring: Weights ., and At risk for unintentional wt. loss r/t (related to) hx (history) of wt. (weight) loss, dementia . Review of the physician's Medical Visit assessment for Resident #7, dated 6/21/22 stated, vitals reviewed: weight decreased . The most recent Medical Visit assessment was completed on 4/26/22. This was the first physician note addressing the significant weight loss noted on 6/1/22 and 6/22/22 per the vitals. Review of Resident #7's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This intervention was added after the surveyor asked about Resident #7's significant weight loss on 6/22/22 at 2:04 PM. Review of Resident #7's most recent minimum data set's brief interview for mental status, dated 5/8/22, was scored seven which reflected severe cognitive impairment. Review of the facility's Weight Assessment and Intervention policy, revised 9/2008, stated, Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing., The Dietitian will respond within 24 hours of receipt of written notification, The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met., and The threshold for significant unplanned and undesired weight loss will be based on the following criteria .1 month - 5% weight loss is significant; greater than 5% is severe. Review of the facility's Nutritional Assessment policy, revised 10/2017, stated, The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. and Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences.

Based on observation, interview, and record review, the facility failed to store [CONDITION(S)] equipment per facility policy in 1 of 1 residents (Resident #5) reviewed for respiratory care, from a total sample of 10 residents, resulting in an increased potential for respiratory infection and respiratory distress. Findings include: Resident #5 Review of an Admission Record revealed Resident #5 admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a current sleep apnea Care Plan revealed that Resident #5 utilized a [CONDITION(S)] (continuous positive airway pressure) device. In an observation on 6/22/2022 at 1:25 P.M., observed the [CONDITION(S)] mask of Resident #5 in a drawer of her bedside nightstand, open to the air and not covered or enclosed. In an observation on 6/23/2022 at 9:28 A.M., observed the [CONDITION(S)] mask of Resident #5 in a drawer of her bedside nightstand, open to the air and not covered or enclosed. In an interview on 6/23/2022 at 9:45 A.M., Licensed Practical Nurse (LPN) B reported that [CONDITION(S)] masks are washed every day and allowed to air dry, then stored in between paper towels or clean washcloths. In an observation on 6/23/22 at 2:15 P.M., observed Resident #5's [CONDITION(S)] mask sitting on the top of her bedside nightstand, on top of a washcloth, not covered or enclosed. In an observation on 6/24/22 at 10:50 A.M., observed Resident #5's [CONDITION(S)] mask hanging from the head of her bed, not covered or enclosed. In an interview on 6/24/22 at 11:00 A.M., Licensed Practical Nurse (LPN) D reported that [CONDITION(S)] masks are washed with soap daily and then left out to dry until being used again by the resident. LPN D was not aware of policy requirements for [CONDITION(S)] mask storage. Review of facility policy [CONDITION(S)]/[CONDITION(S)] Cleaning, dated May 2022, revealed .Clean mask frame daily after use with [CONDITION(S)] cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use .

Based on observation, interview, and record review, the facility failed to 1. Ensure proper use of the 3-sink compartment dish washing; 2. Properly dry dishes after washing; and 3. Ensure hand hygience during food preparation and serving. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected all 17 residents who consume food from the kitchens. Findings include: Review of facility policy How To Clean and Sanitize In A Three-Compartment Sink undated, revealed, Before you clean and sanitize items in a three-compartment sink, make sure that you clean and sanitize each sink and drain board. There are 5 steps for cleaning and sanitizing in a three-compartment sink. 1. Rinse, scrape, or soak all items before washing them. 2. Clean items in the first sink. Wash them in a detergent solution at least 100*F (43*C) .3. Rinse items in the second sink. Spray with water or dip them into it. Remove all traces of food and detergent. If dipping items, change rinse water when dirty or full of suds. 4. Sanitize items in the third sink. Soak in hot water or a sanitizer solution. Check the time and temperature requirements for the sanitizer you are using and use a test kit to check concentration. 5. Air dry all items. Place items upside down so they will drain. According to the 2013 FDA Food Code section 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be sanitized before use after cleaning. According to the 2013 FDA Food Code section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) (MONTH) not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. Review of a facility policy, Handwashing/Hand Hygiene revised (MONTH) (YEAR), revealed, Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .Washing Hands: 1. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. 2. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink . During an observation on 7/9//19 at 11:56 AM, Certified Nurse Aide (CNA) K washed hands for 9 seconds under running water without sudsing well (used soap under water entire time) while preparing lunch for House 1. During an obsevation on 7/9/19 at 12:00 PM, CNAI washed hands for 9 seconds under water without sudsing well (used soap under water entire time), without donning gloves, served bowls of fruit to 7 residents with bare thumbs touching inside of bowls. During an obervation on 7/9/19 at 12: 05 PM, CNAK washed hands for 9 seconds under running water without sudsing well (used soap under water entire time), opened refrigerator closed it, then washed hands 6 seconds under running water without sudsing well (used soap under water entire time). CNAK then moved a 3-ring binder from counter top area and began to prepare food without sanitizing food prep surface. During an observation on 7/9/19 at 12:10 PM, CNAI washed hands for 11 seconds under water without sudsing well (used soap under water entire time). CNAK dropped a serving utensil on floor, CNAI picked it up, placed it into sink, and then rinsed out 2 plastic containers. CNAI then went to handwashing sink, washing hands with suds for 7 seconds then rinsed for 9 seconds. During an observation on 7/09/19 at 12:25 PM, CNAK used a blender to puree salads then BBQ chicken. After each food was pureed, CNAK cleaned the same blender at the sink with blue dish soap for less than 15 seconds, rinsed for less than 6 seconds in same sink, and using a towel off countertop wiped out interior of blender with one swipe. Water used was not a sanitizing solution. During an observation on 7/09/19 at 12:47 PM, CNAK , washed hands 3 seconds under water without sudsing well (used soap under water entire time); rinsing for 5 seconds. Donned clean gloves, when taking a knife off counter top, the tip touched countertop. CNAK cut pie with knife, plated pie, took off gloves, covered pie with foil, put canned whipped topping on pie and served to residents at table. Then took resident's plates to sink, scraped off food into garbage, washed hands 5 seconds under water without sudsing well (used soap under water entire time). CNAK then donned clean gloves, uncovered pie, used same knife (sitting in pie plate) to cut pie, plated pie, and served to another resident. During an observation on 7/10/19 at 11:45 AM, CNAK washed hands 8 seconds under water without sudsing well (used soap under water entire time) while performing food preparation. During an observation on 7/10/19 at 11:47 AM, CNAK washed hands for 9 seconds with soap under water without sudsing well (used soap under water entire time) while performing food preparation. During an observation on 7/10/19 at 11:54 AM, CNAK cleaned blender in sink with blue dish soap for less than 15 seconds, rinsed under faucet and dried quickly with a dish towel. A sanitizing solution was not used. During an observation on 7/10/19 at 11:59 AM, CNAK cleaned blender that was used for blending strawberries, in sink with blue dish soap for less than 15 seconds, rinsed under faucet and dried quickly with a dish towel. A sanitizing solution was not used. During an observation on 7/10/19 at 12:07 PM, CNAK washed hands for 5 seconds with soap under water without sudsing well (used soap under water entire time) while performing food preparation. During an interview on 7/10/19 at 12:37 PM Registered Dietician (RD) N, stated Handwashing should be done by adding soap to hands and washing for 20 seconds following the standard handwashing protocol. Hands should not be washed under the water until they are ready to be rinsed. When using the blenders I encourage staff to use the multiple blender cups so they can be put in the dishwasher. If staff reuses the blender cup, it should be washed for at least 20 seconds and the blades thoroughly cleaned. We do not use 3 sinks (wash, sanitize, rinse) because the household dishwasher does the sanitizing. It only takes about a minute and a half. I'm not sure about the sanitizing if not using the dishwasher. I'll have to look at the protocol. At at 1:59 PM, RD N stated, We do have the ability to sanitize with 3 sinks. There is the sink in the middle island of the kitchen that could be used but staff would have to carry the dishes from island to main sink area. During an observation on 07/09/19 at 12:00 PM, Certified Nursing Assistant (CNA) M went to the sink in the kitchen put soap on her hands then placed her hands under the water for only 4 seconds dried her hands and turned the faucet off, then went back to care. CNA M delivered food to a resident left the table she washed her hands, by placing her hands under the waster with soap on them in the stream of water, but only for 4 seconds and using the same paper towel to dry her hands and turn off the faucet. During an observation on 7/9/19 at 1:50 PM, after the lunch meal dishes were started through the dishwasher they were removed from the dishwasher after the cycle was completed, then CNA G shock the water loose and used a towel to dry the remainder before she put the dishes away in the cabinets.

Based on observation, interview, and record review the facility failed to maintain and follow the standards for infection control, resulting in the potential for cross contamination. Findings include: During medication observations on 7/10/19 at 4:15 PM, Registered Nurse (RN) S went to a residents room opened the medication cabinet, dispensed medication, left the room, went back to the island where she kept her pudding, looked at her computer and determined what resident to go to next went to their room, opened the medication cabinet, dispensed medication, left the room, went back to the island where she kept her supplies, determined she needed ice , went to the pantry opened the door, got ice from the machine, went to the island put the ice down, went to the next building opened the garage door then into the employee entrance, then into the building, went to the narcotic drawer, signed out a narcotic, went to the island in this building where supplies are kept dated pudding then cleaned her hands with hand sanitizer, walked into the spa and stated she liked to alternate between hand sanitizer and hand washing the hand sanitizer dried out her hands. During an interview on 7/11/19 at 2:15 PM, Director of Nursing (DON) B reported that hands should be washed between residents, I would be alright if the nurse left the room without washing her hands if she/he went right back to the island where they work and cleaned their hands before they started something else.

Based on observation, interview, and record review the facility failed to maintain and follow the standards for infection control for 2 of 2 sampled residents (#5 and # 10), reviewed during medication pass, from a total sample of 11 residents, resulting in the potential for cross contamination. Findings include: Review of the Admission Record revealed Resident #5 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of the Admission Record revealed Resident #10 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. During medication observations on 8/1/18 at 4:06 p.m. and 4:19 p.m., Registered Nurse (RN) E went to the narcotic cupboard and removed the medication packet, pushed a pill out onto her right palm and placed it in a 30 ml medication pill cup went into Resident #5's room, left the room to get ice from ice maker (opening a door to access the ice maker) and then turning on the water at the from the sink off the kitchen, returned to the Resident #5's room gave the medication. RN E then removed the keys for the medication cabinet and used her right hand to unlock the medication cabinet and placed the keys in her pocket, RN E then opened the medication cabinet removed Artificial tears, went to the residents bathroom put on a pair of gloves, returned to Resident #5 who was in a recliner placed (1) drop in each eye, removed gloves, did not wash hands. Resident #5 wanted to visit so RN E assisted resident to move some items in her room and visited for a short while. RN E left Resident #5's room without washing her hands moved to Resident #10's room RN E then removed the keys for the medication cabinet opened the medication cabinet removed the medication packet and pushed medication into the palm of her right hand then put the medication into the 30 ml medication pill cup. and used her right hand to place the keys back in her pocket, left the room to go crush the medication and mix some pudding with the medication (leaving the pudding and crusher in a central location). RN E returned to Resident #10's room went to the got a glass from bedside went into the bathroom filled with water returned to encourage resident to finish take her medication. RN E did not wash her hands when she left the room. During an interview on 8/2/18 at 2:15 p.m., Director of Nursing reported that hands should be washed between residents and medications should be placed in the medication pill cup and not in the palm of the hand.

Based on observation, interviews, and record reviews, the facility failed to implement interventions and provide supervision to prevent falls for two residents (Resident #1 and 6), out of two residents reviewed for falls, from a total sample of 8 residents, resulting in the potential for falls and ongoing falls with major injury. The facility also failed to secure medications for one house (House 1) out of 2 houses resulting in the potential for all 10 House 1 residents to ingest unprescribed medication and have drug interactions and drug side effects. Findings include: Resident #6 According to a facility face sheet dated 8/3/17, no time noted, Resident #6 was a [AGE] year old male admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A fall risk assessment score completed on 8/27/17 for Resident #6 was 18 indicating Resident #6 was at high risk for a fall. A comprehensive Minimum Data Assessment for Resident #6 dated 7/21/17 reflected he had a Brief Interview for Mental Status score of 13 out of 15 indicating that he was mentally intact. Review of a facility document for Resident #6 titled, Skilled Nursing Incident Report Overview dated 8/27/17 at 3:30 p.m. reflected, Nurse was called to residents (Resident #6's) room and he was sitting in his recliner with the Shabaz (also known as a Certified Nurses Aid or CNA) standing by him. The Shabaz had come into his room and observed him kneeling on one knee next to his recliner. He stated he had been 'looking for his wedding ring' . His wedding ring was on his finger. It appeared to the nurse that he had been in the bathroom and was on his way back to the recliner when he lost his balance and fell . The call alarm bell was ringing in the bathroom which had alerted the Shabaz that he was in there. He was assessed for any injury and he had none apparent . The intervention to prevent another fall was to instruct Resident #6 that he should call for assistance to walk. During an observation in House 2 in the dining area on 8/29/17 at 11:15 a.m., Resident #6 was observed to be assisted out of the chair by his wife and walk approximately 8 steps to the dining room table. Resident #6 was not observed to have a gait belt on. Resident #6 was observed to have a shuffling walk. Resident #6's wife was observed to have a cast boot (an ankle high velcroed shoe worn over a foot injury) on her right foot. When Resident #6 reached the dining room table, he began to fall backwards and his wife was observed to put her shoulder into his back to keep him upright until he was seated in a chair. Resident #6 was not observed to be using his walker. Review of a care plan for Resident #6 dated printed on 8/1/17, no time noted, reflected, SBA (Stand by assist) of 1 (person) with gait belt and walker. Alerts/Misc. Comments: Elder at times will walk backwards which makes him at risk of falling. Elder also has a recent history of falling and (at) times his blood pressure may drop i.e. orthostatic hypotension. Gait belts are an assistive device which can and 'should' be used to help safely transfer a person in a weakened state from bed to chair, from sitting to standing, and even when entering and exiting a vehicle. The belt provides a 'handle,' of sorts, that allows whomever is escorting to weakened individual to easily grasp the belt and stabilize the patient if they lose balance. http://promotinghealthandpatienteducation.blogspot.com/2009/07/why-use-gait-belt.html Review of a facility document for Resident #6 titled, Skilled Nursing Incident Report Overview dated 8/30/17 at 4:55 p.m. reflected, The elder had been in his bedroom since staff arrived at 2:00 p.m. for the afternoon shift. the Shabaz had been into his room several times before 4:55 p.m. when the incident occurred. Nurse came to elders room to give him his medications and noted that his door was closed. She knocked and then entered the room to find the resident lying on his back just a few feet from the door. She began assessment, noted there was blood and called the Shabaz. The Shabaz called for more help and someone to get the Director of Nursing (DON) and also began taking vitals (signs). The DON came immediately and she called 911. The nurse noted the blood was coming from the back of the residents head but could not see exactly from where. The nurse applied direct pressure to the back of the elders head continuously until the paramedics arrived. The elder was confused stated he had gotten up to close the door because of the 'fighting in the hallway'. There had not been anything like that. However, he was able to tell the nurse he felt 'ok' and denied pain. He also answered other questions that the nurse asked him as she was monitoring his LOC (level of consciousness) His wife had arrived by then and accompanied him to the ER (emergency room ). During an interview with the facility Guardian (also known as a Nursing Home Administrator) A and DON B on 8/31/17 at 8:50 a.m. it was revealed that Resident #6 had a fall with a head laceration that required staples on the evening of 8/30/17. They stated Resident #6 was still in the hospital. They also stated that this event had been reported to the State Agency. During an interview with Guardian A on 8/31/17 at 10:20 a.m., it was revealed that during initial and quarterly care conferences with family, the care guide (or care plan) was reviewed with family so they were aware of the residents care needs (such as a gait belt and walker while walking). During an interview with Director of Nursing (DON) B on 8/31/17 at 10:55 a.m., it was revealed that there is no documentation that Resident #6's wife was informed by the facility that her husband required a gait belt and walker to walk. Resident #1: Findings include: Review of the Face Sheet and annual Minimum Data Set (MDS) assessment dated [DATE], reflected that Resident #1 was a [AGE] year old female, admitted to the facility 6/28/12, with [DIAGNOSES REDACTED]. The MDS reflected that Resident #1 scored 11 out of 15 on the Brief Interview for Mental Status (cognitive assessment), indicating that Resident #1 had moderate cognitive impairment. A fall risk assessment dated [DATE] reflected a score of 17, which indicated that Resident #1 was at high risk for falls. During the initial tour of the facility at 9:12 AM on 8/29/17, Resident #1 was observed ambulating (walking) out of her room with a 4-wheeled walker (4WW). A gait belt (a belt applied around the waist of people with balance impairments) was not being used. Hands-on assistance was not being provided to the Resident. On 8/30/17 at 9:30 AM, Paid Companion (PC) M was observed responding to Resident #1's call light. Resident #1 sat up from bed, put her shoes on, stood from bed and ambulated to the bathroom using a 4WW. PC M did not place a gait belt or provide hands-on assistance to Resident #1. On 8/30/17 at 3:28 PM. PC M was present while Resident #1 stood from bed and used her 4WW to ambulate to a standard chair in her room. PC M did not use a gait belt or provide hands-on assistance to Resident #1. The section for Balance During Transitions and Walking of the annual MDS dated [DATE] reflected that Resident #1 was coded for Not steady, only able to stabilize with human assistance in the following: -Moving from seated to standing position -Walking (with assistive device if used) -Turning around and facing the opposite direction while walking -Surface-to-surface transfer (transfer between bed and chair or wheelchair) Review of the document titled Resident Summary (care guide) dated 8/3/17 at 4:27 PM reflected that Resident #1 required stand-by assistance (SBA) (caregiver nearby and ready to assist) for ambulation while using a 4WW. The section titled Mobility reflected that Resident #1 required assistance of 1 person with a walker. Review of the Care Plan Report dated 8/30/17 at 12:10 PM reflected the following: -The Care Plan for continence reflected that Resident #1 ambulated with 4WW and SBA. -The Care Plan for fall risk reflected that Resident #1 used a rolling walker and SBA of 1 person for ambulation. -The Care Plan for decreased ADL (Activities of Daily Living) ability reflected that Resident #1 required Contact Guard Assist (CGA) (hands-on assistance) and assist of 1 person with a walker. -The Care Plan for toileting reflected that Resident #1 ambulated with a 4WW and CGA to limited assist (hands-on assist). During an interview on 8/31/17 at 10:50 AM, Director of Nursing (DON) B stated that SBA meant there was someone right there with the Resident. DON B stated if someone required CGA, a gait belt should have been placed on them. House 1 Residents On 8/29/2017 at approximately 3:20 PM a folded up paper was viewed on the middle of the top of a shelving unit in the den of House 1. The paper was taped together and had IB written on it in pen. The paper was unfolded and was viewed to have 3 round pills that were brown in color and imprinted with the numbers 44 and 291. An interview was completed with Director of Nursing (DON) B at 3:35 PM on 8/29/2017. The packet of pills and information on where they were found was shared with DON B. DON B was unsure of the origin of the pills and stated she would investigate the situation immediately. At approximately 3:37 PM on 8/29/2017 DON B continued the interview and stated they had determined that Shahbaz/Certified Nursing Assistant (CNA) F had left the pills on the shelf on Sunday, 8/27/2017. DON B stated CNA F left the pills there when getting unexpectedly called away to assist a resident and then had forgotten them. DON B stated that the pills were ibuprofen (a non steroidal pain medication). An interview was completed with Shahbaz/Certified Nursing Assistant (CNA) F at 3:55 PM on 8/29/2017. CNA F stated she had received 6 pills of ibuprofen from the nurse on Sunday 8/27/2017. CNA F stated she took 3 of the pills and was going to take the other 3 home with her since she did not need them. CNA F stated that she had placed the pills of the shelf in the den of House 1 because she was called away due to a resident needing immediate assistance. CNA F stated that after assisting the resident, she did not remember to get the pills. A search of epocrates.com pill identifier confirmed that the pills found in the den of House 1 were 200 mg ibuprofen tablets.

Based on observation, interview, and record review the facility failed to: 1. Properly store raw animal product; 2. Ensure areas of general sanitation were free of dust and food debris; and 3. Maintain equipment in good repair. These conditions resulted in an increased risk for contaminated foods and an increased risk of food borne illness that affected all 19 residents that resided in the facility. Findings include: 1. During the initial tour of the kitchen starting at 9:00 AM on 8/29/17 it was observed that raw unpasteurized shell eggs were found on an upper middle shelf in the reach in refrigeration unit in House One. These eggs were stored over containers of juice and milk. Raw animal products must be stored below and away from products that are ready to eat or need little to no cooking. When asked if this is how the refrigeration unit is normally set up, Shahbaz / CNA (Certified Nurse's Assistant) D stated that was how it was normally set up. According to the 2009 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(c) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD .(b) Cooked READY-TO-EAT FOOD; . 2. During the initial tour of the kitchen starting at 9:00 AM on 8/29/17 it was observed that some areas of general sanitation showed accumulation of food and dust debris. These areas in particular were the gap below the over / under ovens in House One and House Two. Particulate matter of bacon, dried food particles, and dust were present. It was also observed that the back wall behind the air gap of the food prep sinks in House One and Two showed heavy staining from routine splash that had accumulated over time. According the 2009 FDA Food Code section 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 3. During the initial tour of the kitchen starting at 9:00 AM on 8/29/17 it was observed that the light in the top back of the refrigeration unit in the kitchen of House Two was not working. According to the 2009 FDA Food Code section 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2.

Based on interview and record review, the facility failed to perform [DIAGNOSES REDACTED] (TB) surveillance for 1 (Resident #5) of 7 residents reviewed for TB monitoring out of a total sample of 8 residents, and the facility failed to perform TB surveillance for 5 employees (Shabaz Q, R, S,T and Social Work Coordinator U) out of 14 personnel reviewed for TB monitoring, resulting in the potential for the spread of TB infection to all 19 of the facility residents. Personnel Review: Findings include: Review of personnel files with Human Resources (HR) L on 8/30/17 at 1:44 PM reflected the following: -Shabaz Q had an employment hire date of 7/6/17. [MEDICATION NAME] skin test (TST) #1 results were negative on 6/28/17. TST #2 was administered 7/21/17 (23 days after TST #1 was read). -Shabaz R had an employment hire date of 6/19/17. TST #1 results were negative on 6/16/17. TST #2 was administered 6/21/17 (5 days after TST #1 results were read). -Shabaz S had an employment hire date of 8/7/17. TST #1 results were negative on 6/8/17. TST #2 was administered 8/4/17 (57 days after TST #1 results were read). -Shabaz T had an employment hire date of 11/8/16. TST #1 was administered 11/4/16. Results were negative on 11/6/16. There was not documentation to support that Shabaz T had a two-step TST. -Social Work Coordinator (SWC) U had an employment hire date of 3/20/17. TST #1 was administered 3/11/17, and results were negative on 3/13. TST #2 indicated that it was administered 3-2 and read 3/24/17. The documentation did not clearly indicate the date that TST #2 was administered. The facility document titled [DIAGNOSES REDACTED], Employee Screening for with a revision date of July 2010 reflected the following: All employees shall be screened for [DIAGNOSES REDACTED] (TB) infection and disease, using a two-step [MEDICATION NAME] skin test (TST) or blood assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] (BAMT) and symptom screening, prior to beginning employment .If the reaction to the first test is negative, the facility will administer a second skin test 1 to 2 weeks after the first test . According to the article titled, Guidelines for Preventing the Transmission of [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] in Health-Care Setting, 2005, found online at www.cdc.gov/mmwr/pdf/rr/rr5417.pdf, If the first-step TST ([MEDICATION NAME] skin test) result is negative, the second-step TST should be administered 1-3 weeks (7 to 21 days) after the first TST result was read. Resident #5 According to a face sheet dated 7/20/17 at 2:17 a.m., Resident #5 was an [AGE] year old female admitted to the facility on [DATE] at 10:35 a.m. with the Diagnoses: [REDACTED]. During review of Resident #5's chart on 8/29/17 at 1:35 p.m., the chart revealed that Resident #5 had a history of [REDACTED]. On 4/5/11 a chest X-ray was performed to see if there was active [DIAGNOSES REDACTED] for Resident #5 and the chest X-ray was negative for active disease. Review of a facility document for Resident #5 titled, Standing Orders dated 7/7/14, no time noted, reflected, PPD skin test: Two step test to be administered upon admission. One Step Test to be administered annually thereafter (See policy). Elders with a positive skin test will receive an annual chest x ray, and no further skin testing. This document was signed by the resident's physician on 7/7/14. During an Infection Control interview with DON B on 8/31/17 at 9:00 a.m. it was revealed that in February 2017 all 19 resident's had a [DIAGNOSES REDACTED] (TB) Questionnaire completed to assess for TB. DON B reviewed the Standing Orders and stated she had just had the physician review the orders for accuracy. During an interview with Director of Nursing (DON) B on 8/30/17 at 4:00 p.m., DON B revealed that she would need to look at the policy regarding the surveillance needs of a resident with a positive [MEDICATION NAME] skin test. Review of a facility policy dated revised on July 2013 reflected, If the risk classification is identified as medium risk for transmission of TB, residents will receive an annual TST ([MEDICATION NAME] Skin Test) with the exception of known 'converters' (those whose previous skin tests are positive). For known positive skin test converters, the physician will complete and review a symptoms questionnaire annually (yearly). A physician's orders [REDACTED]. The physician's orders [REDACTED].#5 was not followed.

Based on observation, interview, and record review the facility failed to adequately plan for the proper distribution of food and food supplies during an emergency or disaster. This resulted in an increased risk of illness, malnutrition, and unrest for all 19 residents residing in the facility. Findings Include: During the tour of the kitchen at 9:00 AM on 8/29/17 it was observed that no food supply was labeled as emergency use in either House One or House Two. Upon asking Shahbaz / CNA (Certified Nurses Assistant) D about the storage of emergency food supply she stated that she didn't know where that would be located. During the Emergency Preparedness Interview with Administrator A at 1:35 PM on 8/29/17, it was asked if there was any information in the facilities Emergency Disaster Plan, Rev. 6/16, about food distribution during an emergency or a disaster and he stated he didn't think there was anything in the Emergency Disaster Plan regarding food.