Aspire Transitional Care

Based on document review and interview the facility failed to maintain, review, and update the Emergency Preparedness (EP) Plan annually. Failure to develop an emergency plan may cause harm to the patients and staff during an emergency and failure to ensure the EP plan was reviewed annually poses a potential risk that all required revisions to the plan will not be recognized and revised as needed. Findings include; Based on document review and interview on September 16-17, 2024, revealed the facility did have a document named Emergency Plan, however, the correct staff would be on one page and staff that were no longer with the facility on another. The risk assessment contained in the facility Emergency Preparedness manual has no facility name or date as to when it was created. The only date on the risk assessment was the form date of 2009. There was no documentation as to how the risk assessment was created. The management team confirmed during the exit conference on September 17, 2024, that the document was missing a lot of the required details.

Based on record review and staff interview the facility failed to develop and implement policies and procedures that address a system of medical documentation that preserves patient information, protects the confidentiality of patient information, and secures and maintains availability of records. The policies and procedures failed to be reviewed and updated at least annually Findings include: Based on record review and staff interview on September 17, 2024, revealed the plan did not include policies and procedures to address a system of medical documentation that preserved patient information, protected the confidentiality of patient information, and secured and maintained the availability of records. The management team confirmed during the document review and exit conference on September 17, 2024, that the facility Emergency Plan did not include policies and procedures to address a system of medical documentation.

Based on record review and staff interview the facility failed to develop a facility-based and a community-based risk assessment prior to developing the facility's emergency plan. Failure to develop emergency plans based on community-based risk assessment poses a potential risk and may cause harm to the patients and staff during an emergency if the specific needs of both the patient and/or staff are not identified as part of the EP plan. Findings include: Based on record review and staff interview on September 16-17, 2024, revealed the facility was unable to demonstrate how a community-based risk assessment was used to create the facility's Emergency Plan. The risk assessment contained in the Emergency Plan manual has no facility name, no date as to when it was created or documentation as to how the risk assessment was conducted. The only date on the risk assessment is the form date of 2009. The management team confirmed during the exit conference on September 17, 2024, that the facility was unable to demonstrate how a community-based risk assessment was used to create the facility's Emergency Plan.

Based on record review and staff interview the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population which includes delegation of authority and succession plans may disrupt services to patients/clients during an emergency which could lead to harm. Findings include: Based on record review and staff interview on September 16-17, 2024, revealed the facility was unable to locate any documentation addressing the needs of the patient population within the current written plan. Additionally, the facility did not have a succession plan that would be used for emergency operations that also included the required delegation of authority. Management confirmed during the exit conference on September 17, 2024, that the facility was unable to locate any documentation addressing the needs of the patient population or a succession plan with a delegation of authority within the current written plan.

Based on staff interview and record review the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. Failure to include a process for cooperation and collaboration could lead to harm to both patients and staff if all collaborating parties are not aware of the specific needs of the facility involved and affected by the emergency. Findings include: The facility's Emergency Plan was reviewed on September 16-17, 2024. The Emergency Plan did not indicate, with supportive documentation, a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials. The management team confirmed during their exit conference on September 17, 2024, that the facility emergency plan did not indicate a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials.

Based on record review and staff interview the facility failed to develop facility policies and procedures that correspond with a current risk assessment. Failure to develop emergency plans based on a facility-based risk assessment may cause harm to the patients and staff during an emergency. Findings include: Based on record review and staff interview on September 16-17, 2024, revealed the policies provided, were not based on a current risk assessment. CFR 494.62 requires both facility and community hazard assessments utilizing an all-hazards approach. The policies provided did not correspond with a current risk assessment. Management confirmed during the document review and exit conference on September 17, 2024, that the facility did not have the necessary documentation that a facility-based risk assessment was used to create the policies and procedures

Based on record review and staff interview the facility failed to develop and implement emergency preparedness policies and procedures, based on the subsistence needs of staff and patients. Failure to develop subsistence needs for staff and patients during an emergency could cause harm to staff and patients if immediate needs like food, water, medical and pharmaceutical supplies, and alternate sources of energy are not planned for and available. Finding include Based on record review and staff interview September 16-17, 2024, it was revealed that the facilities did not have the needed amounts of water to sustain the staff patients, and visitors for the three days as described in their plan. The facility had a total of 18 gallons of water on hand. The facility's policy states that they should have 180 gallons of water on hand. The management team confirmed during the exit interview conducted on September 17, 2024, that the amount of water on hand would not be sufficient in the event of an emergency.

Based on record review and staff interview the facility failed to develop and implement policies and procedures for tracking of sheltered/evacuated residents and staff during an emergency. Failure to adequately track residents and staff during an emergency could lead to harm to both residents and staff. Findings include: Observations during the document review on September 17, 2024, revealed the facility's Emergency Plan specifically relating to the facility process for the tracking of sheltered/evacuated residents and staff during an emergency showed the emergency plan did not identify a process for the tracking of sheltered/evacuated patients and staff during an emergency. The management team confirmed during the document review and exit conference on September 17, 2024, that the emergency plan did not identify a process for the tracking of sheltered/evacuated residents and staff during an emergency.

Based on record review and staff interview the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the emergency and standby power systems. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of patients and/or staff. Findings include: Based on record review and staff interview on September 17, 2024, revealed that the facility's Emergency Preparedness Plan documentation related to the emergency and standby power systems did not contain policies and procedures and the necessary maintenance documentation, i.e. load transfer or transfer times. The management team confirmed during interviews and the exit conference on September 17, 2024, that the facility did not have documentation on the emergency and standby power systems.

Based on staff interview and record review, the facility failed to develop a written emergency communications plan that contains how the facility coordinates resident care within the facility, across the healthcare providers, and with state and local public health departments, and emergency management systems. Failure to develop an emergency communications plan could cause harm to the residents during an emergency as needed information may not be able to be transmitted or received. Findings include: Observations made during the document review on September 17, 2024, revealed the facility could not provide evidence of a written emergency communications plan with its accompanying policies and procedures. The management team confirmed during the document review and exit conference on September 17, 2024, that the facility did not have a written communications plan and policies as part of its Emergency Preparedness program.

Based on record review and staff interview the facility failed to have a primary and alternate means of communication, and the accompanying policies and procedures, during an emergency. Failure to have a primary and alternate means of communication during an emergency could lead to harm to both patients and staff if all involved in the emergency situation do not know how to communicate their needs to others in the community. Findings include: Based on record review and staff interview on September 16-17, 2024, revealed the Emergency Plan did not identify a primary and alternate means of communicating with providers, staff, or Federal, State, tribal, regional, and local emergency management agencies, and the accompanying policies and procedures, during an emergency. The management team confirmed during the record review and exit conference on September 17, 2024, that the facility EP did not identify a primary and alternate means of communicating with providers, staff, or Federal, State, tribal, regional, and local emergency management agencies, and did not have policies and procedures regarding communications during an emergency.

Based on record review and interview the facility did not have documentation in the emergency preparedness communication plan that complies with Federal, State, and local laws that included a method for sharing information. Failure to have a means to share private information to assist in patient care could result in miss information being provided to other providers providing care for the facility's patients. Findings include: Based on record review and interview on September 17, 2024, of the facility's Emergency Plan did not include policies and procedures, in the communication plan for the following: 1) Sharing information and medical documentation for patients under the facility's care, as necessary, with other health care providers to maintain the continuity of care. 2) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510. 3) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510. The management team confirmed during the record review and exit conference on September 17, 2024, that the facility did not identify a method for sharing information and medical documentation for patients under the facility's care as necessary and develop policies and procedures that address the means the facility will use to release patient information to include the general condition and location of patients.

Based on record review and staff interview the facility failed to develop policies and procedures for a means for sharing information on occupancy/needs, and its ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in patients not receiving care and services as needed. Findings include: Based on record review and staff interview on September 16-17, 2024, revealed the facility's Emergency Plan documentation related to requirements for a method to share occupancy levels and/or facility needs with other facilities or to the authority having jurisdiction or the Incident Command Center did not include policies and procedures for a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center. Management confirmed during the exit conference on September 17, 2024, that the EP plan for the facility did not include policies and procedures for a method for sharing occupancy levels and/or facility needs with other facilities or with the authority having jurisdiction or the Incident Command Center.

Based on staff interview and facility record review the facility failed to develop and implement emergency preparedness policies and procedures for providing information from the emergency plan to the residents and their families or representatives. Failure to develop policies and procedures for providing information from the emergency plan to the residents and their families or representatives may result in higher levels of anxiety and confusion during an emergency. Finding include: Based on staff interview and facility on September 17, 2024, revealed the facility's Emergency Plan did not include policies or procedures for providing information from the emergency plan to the residents and their families or representatives. The management team confirmed during the exit conference on September 17, 2024, that the facility did not have policies and procedures for providing information from the emergency plan to the residents and their families or representatives

Based on record review and staff interview the facility failed to participate in required emergency drills as required. Failure to participate in drills may lead to untrained staff in an emergency situation and may result in harm to the residents during an emergency. Findings include: Based on record review and staff interview on September 17, 2024, revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was facility-based and one that was a community-based exercise or tabletop drills. The management team confirmed during the exit conference on September 17, 2024, that the facility did not participate in the required full-scale facility-based and community-based exercises.

Based on a record review and staff interview the facility failed to have written documentation of the Annual Inspection and Testing of Door openings in accordance with NFPA 80, 2010 Edition, "Standard for Fire doors and Other Opening Protective's ". Failing to inspect and test fire-rated door assemblies in accordance with NFPA 80 annually could cause harm to the patients. NFPA 101 2012 Life Safety Code Section 8.3.3. Fire door and Windows Section 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening protective, except as otherwise specified in this code. NFPA 80 Section 5.2* Inspections Section 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for the AHJ. Section 5.2.3 Functional Testing. Section 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. NFPA 80 Section 13.4 Automatic closing Section 5.2.5 Horizontal sliding, Vertically Sliding, and Rolling Doors. Section 5.2.14.3 All horizontal or vertical sliding or rolling fire doors shall be inspected and tested annually to check for proper operation at frequent intervals to ensure operation. Findings include: Based on a record review and staff interview on September 17, 2024, revealed the facility did not have written records of the annual fire door inspection. During the exit conference on September 17, 2024, the management team confirmed that the facility did not have written documentation of the annual door inspection.

Based on interview and record review the facility failed to document monthly testing of the emergency lights in the facility to confirm the lights would operate in a loss of power to the facility. Failing to test the emergency lighting could result in failure when the power goes out which could result in injury to staff and patients. NFPA 101, Life Safety Code, 2012, Chapter 18, Section 18.2.9.1 "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " Section 7.9.3.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows: (1) Functional Testing shall be conducted monthly with a minimum of 3 weeks and a maximum of 5 weeks between tests. , for not less than 30 seconds except as otherwise permitted by 7.9.3.1.1. (2) The Test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction. ( 3) Functional testing shall be conducted annually for a minimum of 1/1/2 hours if the emergency lighting system is battery-powered. (4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3). (5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. (sic) Findings include: Based on interview and record review on September 17, 2024, revealed the facility failed to perform and document monthly testing of the emergency lights in the facility. During the exit conference on September 17, 2024, the management team confirmed that the facility had not been performing and documenting the monthly testing of the emergency lights in the facility.

Based on observation and staff interview the facility failed to ensure the electrical breaker for the fire alarm system has visual markings to distinguish it from other breakers. Failure to properly identify/mark the fire alarm system could lead to the harm of residents and staff in an emergency. NFPA 101 - 2012 Edition, Section 18.3.4.5.1, Detection systems, where required, shall be in accordance with 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code,. unless it is an approved existing installation, which shall be permitted to be continued in use, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. NFPA 72-2010 Edition, Section 10.5.5.2. For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT." Findings include: Observations made in the electrical room on September 17, 2024 revealed the electrical breaker for the fire alarm system did not have visual markings to distinguish it from other breakers. During the exit conference on September 17, 2024, the management team confirmed that the electrical breaker for the fire alarm system did not have visual markings to distinguish it from other breakers.

Based on observations and record review, the facility failed to inspect and test the alarm system monthly in the facility. Failure to inspect and test the fire alarm system could cause harm to staff and residents during an emergency. NFPA 101, Life Safety Code, 2012 Edition, Chapter 9, Section 9.6.1.3 "A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use". NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition, Chapter 14, Section 14.2.2.1, "The property or building or system owner or the owner ' s designated representative shall be responsible for inspection, testing, and maintenance of the system and for alterations or additions to this system". Chapter 26, Section 26.3.5.2.2 "The subsidiary facility shall be inspected at least monthly by central station personnel for the purpose of verifying the operation of all supervised equipment, all telephones, all battery conditions, and all fluid levels of batteries and generators". Findings include: A review of the facility's documentation and interviews on September 17, 2024, revealed that the facility had no documentation for monthly fire alarm system inspections and testing. During the exit conference on September 17, 2024, the management team confirmed that the facility had no documentation of monthly fire alarm system inspections and testing.

Based on record review and interview the facility failed to provide the required sprinkler inspections and ensure a current hydraulic plate on the sprinkler riser. Failing to inspect, test, and maintain the sprinkler system. and ensure that the sprinkler riser hydraulic plate was in place could result in errors during modifications and failure of the sprinkler system. Failing to inspect test and maintain the sprinkler system could cause the system to be inoperable due to lack of maintenance during a fire and could cause harm to the patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, 2011 Edition, "Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems." NFPA 25, 2011 Edition, "Water Based Extinguishment Systems," requires monthly, quarterly, and annual testing of automatic sprinkler systems. NFPA 25 2011 Standard for the inspection, testing, and maintenance of water-based fire protection systems. 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. A.5.2.6 The hydraulic design information sign should be secured to the riser with durable wire, chain, or equivalent. (See Figure A.5.2.6.) Paragraph 5.2.6 requires that the hydraulic design information sign (also called a nameplate or placard) be inspected on a quarterly basis. NFPA 13 requires a hydraulic design information sign on hydraulically designed systems so that the design criteria and system demand can be readily determined. The hydraulic design information sign can provide useful information to the owner. If the design information sign is missing, the owner should contact a design professional to determine the demand for the system, which can be written on a new design information sign. The details are also documented on the approved plans and hydraulic calculations, but these plans can be misplaced and may not be available when the property changes owners. A hydraulic design information sign that is securely fastened to the riser can provide the details when these other data are missing (see Exhibit 5.21). If the sign becomes loose or is difficult to read, it must be repaired or replaced. Findings include: Observation, records review, and interview on September 17, 2024, revealed the facility failed to provide documentation for the monthly fire sprinkler system inspections as required and to ensure that a current hydraulic plate was in place on the sprinkler riser. The management team confirmed during the exit conference on September 17, 2024,

Based on observation the facility failed to provide a fire extinguisher near the generator. Failing to have an available fire extinguisher during an emergency could result in harm to the patients and/or staff. NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.5.12 "Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1" Section 9.7.4.1 "Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for portable Fire Extinguishers." 9.7.4 Manual Extinguishing Equipment. 9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. NFPA 10 2010 Edition 6.3.1.1 Minimum sizes of fire extinguishers for the listed grades of hazard shall be provided in accordance with Table 6.3.1.1, 6.3.1.2 Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in Table 6.3.1.1. Findings include: Observations made while on tour on September 16-17, 2024, revealed the following: There was not a fire extenguish installed within 50 feet of the generator. During the exit conference on September 17, 2024, the management team confirmed that there was not a fire extinguisher within 50 feet of the generator.

Based on observation the facility failed to properly fill penetrations in multiple areas of the fire/smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the fire/ smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire. NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke. Findings include: Observations made during a facility tour conducted on September 16-17, 2024, revealed that the facility failed to maintain the fire/ smoke barrier in the following areas: 1. Hole in the ceiling above the fire doors at the junction of rooms 101 and 120. 2. Hole in the firewall at the junction of rooms 101 and 120. 3. Hole in the firewall above room 101. During the exit conference on September 17, 2024, the management team confirmed the holes in the walls and ceiling.

Based on record review and interview with the maintenance staff, the facility failed to document the required thirty minute (30) testing of the emergency generator under load once a month. Failure to test the emergency generator under load for thirty minutes once a month could result in harm to patients during emergency system failures. NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes... Findings Include: A records review and interviews on September 16-17, 2024, revealed the facility failed to ensure monthly under load transfer tests (30 minutes) were documented on the generator form for the following months: 1. January 01, 2024 through September 17, 2024 During the exit conference on September 17, 2024, the managment team confirmed that the facility failed to maintain documentation of monthly under load transfer tessts for the generator.

Based on observation the facility failed to maintain oxygen cylinders in a code-compliant and safe manner. Failure to maintain oxygen in a safe environment could result in injury or death of staff and Residents. NFPA 99: Health Care Facilities Code, 2012 Edition - Chapter 11 Gas Equipment 11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following: 1. Minimum distance of 6.1 m (20 ft) 2. Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13 3. Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1? 2 hour. 11.3.4 Signs. 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING. 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: 1. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. 2. Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them. 3. Cylinders shall be protected from tampering by unauthorized individuals. 4. Cylinders or cylinder valves shall not be repaired, painted, or altered. 5. Safety relief devices in valves or cylinders shall not be tampered with. 6. Valve outlets clogged with ice shall be thawed with warm - not boiling - water. 7. A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device. 8. Sparks and flame shall be kept away from cylinders. 9. Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them. 10. Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1 11. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. 12. Cylinders shall not be supported by radiators, steam pipes, or heat ducts. Finding include: Observations made on September 16-17, 2024, revealed the following: 1. Five oxygen cylinders being stored in cardboard containers 2. No signage of empty or full 3. Combustible materials in the oxygen room, i.e. paper/plastics, hanger bracket with a wooden base 4. Seven forty-five liter canisters and one slightly smaller being stored unsecured. During the exit conference on September 17, 2024, the management team confirmed that the oxygen in the oxygen room was not being stored correctly.

Based on personnel file review, staff interviews, facility policy review, the facility failed to ensure that two of ten sampled staff (Staff # 19 and #49) had current Cardio Pulmonary Resuscitation (CPR) certification. Findings include: Review of the personnel file records for a Licensed Practical Nurse (LPN/ Staff #49) revealed a hire date of October 18, 2023 with a valid CPR certification issued on May 27, 2022, however, the CPR expired on May 2024. Further review revealed no evidence of current CPR certification. Review of the personnel file for a Certified Nurse Assistance (CNA/Staff #19), revealed a hire date of November 30, 2022 with valid CPR certification issued on February 18, 2022, however, CPR certification expired on February 28, 2024. Further review revealed no evidence of current CPR certification. Review of staff #49 punch detail revealed that the Staff #49 worked as LPN at this facility after CPR certification had expired. Staff #49 worked shifts from March 29, 2024-March 31, 2024, and July 4, 2024-July 7, 2024. Review of staff #19 punch detail revealed that the Staff #19 worked as CNA at this facility after CPR certification had expired, Staff #19 worked on March 31, 2024. An interview was conducted with the Business Office Assistant (Staff #52) on August 20, 2024 at 11: 25 AM reviewed LPN employment records and stated the LPN did not have current CPR certification. Further, the Business Office Assistant (Staff #52) stated that she is responsible for monitoring the CPR certification for staff and she did not think the LPN or CNA should be working on the floor without current CPR certification. An Interview was conducted on August 21, 2024 at 1:49 PM with the Director of Nursing (DON/Staff #32), who stated she expected staff to complete CPR certification upon hire. She also stated that risk of staff not having CPR certification could result in patient suffering. She further states that she was aware that they were not compliant. Review of the facility policy titled, CPR- Providing Basic Life Support revised on October 21, 2023, revealed that CPR certified staff will be available at any time and staff will maintain current CPR certification for healthcare providers through CPR provider.

Based on personnel record reviews, staff interview, facility document and policy review, the facility failed to ensure that four of ten sampled staff (Staff #s 67, 16, 23, 19) had evidence of freedom from infectious tuberculosis (TB) upon hire. The deficient practice could may result increase the risk for infectious tuberculosis. Findings include: -Review of personnel record for a Registered Nurse (RN/Staff #67), revealed a hire date of June 29, 2022 with no evidence of freedom of TB. -Review of personnel record for a Registered Nurse (RN/Staff #16), revealed a hire date of January 24, 2022 with no evidence of freedom of TB. - Review of personnel record for a Licensed Practical Nurse (LPN/Staff #23), revealed a hire date of September 06, 2023 with no evidence of freedom of TB. -Review of personnel record for a Certified Nurse Assistant (CNA/Staff #19), revealed a hire date of November 30, 2022 with no evidence of freedom of TB. An interview was conducted on August 20, 2024 at 11:25AM with the Business Office Assistant (Staff #52). She stated that they conduct a 2-step Purified Protein Derivation (PPD) to determine if a protein has been exposed to the bacteria that causes TB for all the staff members. She further stated that the second step should be completed in 14-21 days after the first step done, otherwise it would be as invalid. She further stated that if the TB test is negative the staff members are able to work. An interview was conducted with the Director of Nursing (DON/Staff #32) on August 21, 2024 at 1:49 PM. She stated that she expected TB testing to be completed and HR payroll responsible for tracking the TB testing. The DON further stated the risk of not completed TB testing could result in risks to residents and the staff members in the facility. The DON also stated that she was aware that TB testing requirements have not been followed at the facility. Review of the facility policy titled, TB Screening (Staff and Resident) revised on August 08, 2023, revealed that all individuals that are employed by the health care institution should be screened initially for TB by conducting TB risk assessment including sign/symptoms and by obtaining documentation of freedom from infectious TB in baseline screening.

Based on personnel records, staff interviews, and policy review, the facility failed to ensure that three of ten sampled staff (Staff #23, #26, and # 49) were complaint with the fingerprint clearance. The deficient practice could result in inadequate background checks and/or potential danger to residents. Findings Include: Review of the personnel records revealed that License Practical Nurse (LPN/Staff #23) was hired on September 06, 2023, with a fingerprint clearance card application submitted on September 26, 2023, that is still in process. Review of the staff schedule and punch detail for LPN (Staff #23) revealed that she worked on March 32, 2024 and July 4, 2024 in the facility. Review of an Activities Assistant (Staff #26) personnel records revealed she was hired on December 28, 2023. Further review revealed the application for fingerprints clearance card was submitted on August 20, 2024. Review of staff #26 punch detail revealed she worked at this facility on March 29, 2024-March 31, 2024 and July 6, 2024-July 7, 2024 with no current fingerprint clearance card. Review of Housekeeping (staff #63) personnel records revealed that she was hired on May 29, 2024 with no valid fingerprint card. Further review revealed that she requested the facility to pay the fee for the fingerprint clearance card, but there is no evidence that the fee was payed. Review of the staff #63 punch details, revealed that she worked as housekeeper at this facility on July 5, 2024-July 7, 2024, with no valid fingerprint clearance card. An interview was conducted with Business Office Assistant (Staff #52) on August 08,2024 at 11:25AM, she stated that it is requirement to have current fingerprint cards, and she is unsure if the staff members should be working if they do not have current fingerprint card. She further stated that Staff #26 should have had fingerprint clearance application done before August 20, 2024. She also stated that she does not have current fingerprint clearance cards for staff members #23, #26, and #63. An interview was conducted with the Director of Nursing (DON/Staff #32) on August 21, 2024. She stated she expected on Fingerprint clearance card is that it should be completed in the first 20 days of hire, or the application needs to be filled out and in progress, otherwise staff would not be qualified to work. Review of the facility policy titled, Fingerprinting revised on January 11, 2024, revealed that individuals who have access to a resident, resident medical file, have a contract with facility, and one-on-one with resident require fingerprint clearance card.

Based on record review, observations, staff and resident interviews, and policy review, the facility failed to ensure that the environment remained free from accident hazards for 3 residents (#281, #26, and #482). Findings include: - Regarding Resident #281 Resident #281 was admitted on August 3, 2024. Record review of the medical diagnoses for resident #281 revealed type two diabetes mellitus accompanied by unspecified dementia and a need for assistance with personal care. Review of the admission MDS (Minimum Data Set) assessment dated August 10, 2024 revealed that resident #281 had a BIMS score of 08 that indicated moderate cognitive impairment. Within the same MDS assessment it was documented that resident #281 was able to utilize a walker and wheelchair to mobilize. On August 19, 2024 at 2:08 p.m, an observation of the resident environment revealed a blood glucometer and an opened container of lancets on a table in the room of resident #281. An interview was conducted on August 22, 2024, at 8:37 a.m with resident #281 who stated that nurses had left lancets and the blood glucometer in his room without explaining their purpose. Resident #281 stated the equipment was already in his room when he arrived at the facility. Resident #281 stated that he used the needles once to "get the blood out" and obtain a reading for the nurses without any staff present at that time. Resident #281 stated that staff did not inform him that he could not use the needles, nor were they aware that he had used them. The resident recalled that staff had asked him once if he had used a needle, to which he responded "yes". No further action was taken, and the resident was not assessed. - Regarding Resident #26 Resident #26 was readmitted on July 30, 2024. Record review of the medical diagnoses for resident #26 revealed type two diabetes mellitus. Review of the admission MDS from August 6, 2024 revealed that resident #26 had a BIMS score of 13 that indicated resident cognition was intact. Within the same MDS assessment it was documented that resident #26 was able to utilize a walker and wheelchair to mobilize, and many of his ADLs were done independently with the exception of supervision for showering, toileting, and dressing of the lower body. On August 22, 2024 at 9:40 AM, an observation of the resident environment revealed resident #26 had a blood glucometer, lancets, and supplies on the table in the room. - Regarding Resident #482 Resident #482 was readmitted on August 13, 2024. Record review of the medical diagnoses for resident #482 revealed type two diabetes mellitus. Review of the admission MDS from August 18, 2024 revealed that resident #482 had a BIMS score of 13 that indicated resident with no cognitive impairment. Within the same MDS assessment it was documented that resident #482 was able to utilize a wheelchair to mobilize, and many of his ADLs were done independently with the exception of supervised showering, toileting, and dressing of the lower body. On A

Based on closed record review, staff interviews, and policy review the facility failed to ensure that proper documentation was provided to responsible parties and the receiving facility(short-term general hospital) for 1 of 2 sampled residents (#29) and one of two sampled residents ( #29) received proper notice of discharge. Findings include: Resident #29 was initially admitted on July 20, 2024, with a diagnosis that included unspecified fracture of left foot, subsequent encounter for fracture with routine healing. An admission Minimum Data Set (MDS) assessment dated July 27, 2024 revealed a Brief Interview for Mental Status (BIMs) assessment score of 15 identifying no cognitive impairment. A discharge MDS dated August 1, 2024, revealed a discharge code 04 indicating that Resident #29 was discharged on August 1, 2024 to a short-term general hospital (acute hospital, inpatient prospective payment system (IPPS)). Review of the resident's clinical record revealed no evidence of provider orders, progress notes, or care plan related to the discharge, or of notification to the receiving facility. Further review of the clinical record revealed a faxed request from the receiving facility (short-term general hospital) on August 5, 2024 requesting a discharge summary. There was no evidence that the facility responded to the request. Review of a police report dated August 1, 2024 revealed that Resident #29 allegedly stole a phone from staff. The report revealed that the Executive Director (ED/staff #59) stated they no longer wanted the resident on the premises. The report revealed that due to necessary health care needs, the resident was transferred to the hospital. The report also included that nursing staff removed wound vac before transfer. Further review of the police report revealed evidence of other contraband (meth, syringes, weapons) being found. A late entry progress note dated August 20, 2024, by the Director of Nursing (DON/staff #32) revealed that the DON (staff #32) was notified at 0700 that a staff member's cell phone and pen were reported missing. The progress note indicated that a phone case was found by a Certified Nursing Assistant (CNA) in Resident #29's room. The progress note also indicated that police were notified. An officer arrived and conducted an investigation, and the cellphone was discovered in Resident #29 's room. An interview was conducted on August 20, 2024 at 1:23 PM, with the Medical Records Director (MRD/staff # 60), who reviewed Resident #29 ' s clinical record and stated there was no evidence of discharge documentation. An interview was conducted on August 20, 2024 at 1:29 PM with the DON(staff# 32), who alleged that Resident#29 had meth, syringes, and all kinds of weapons in his room, and that documentation can be found in the police report. The DON (saff #32) also reviewed clinical records and verified there was no documentation/ summary of discharge. An interview was conducted on August 21, 2024 at 11:19 AM with the

Based on clinical record review, staff interviews, facility documentation, and facility policy, the facility failed to ensure that clinical records accurately reflected care and services provided to two out of two sampled residents (#281 and #19), regarding fluid restriction, care interventions, and the use of an air mattress. Findings Include: - Regarding Resident #281 regarding fluid restriction: Resident #281 was admitted to the facility on August 03, 2024 with diagnoses that included unspecified injury of head, dementia, unsteadiness on feet, repeated falls, syndrome of inappropriate secretion of antidiuretic hormone, and hypo-osmolality and hyponatremia. Review of the care plan initiated on August 04, 2024, revealed that Resident #234 had potential for alteration in nutrition needs related to conditions associated with confusion, dementia, and related diagnoses. As an intervention, the care plan specified to "Encourage fluids." There was no evidence of any care plan regarding a fluid restriction for Resident #281. Review of the MD Admission Summary dated August 05, 2024 revealed that Resident #281's medical doctor (staff #117) documented that the resident had signs and symptoms "consistent with SIADH" (syndrome of inappropriate antidiuretic hormone secretion), and "Patient will need to abide by a fluid restriction". Under the note section "Assessment/Plan", staff #117 documented "Continue fluid restriction". Review of the Provider Progress Note dated August 06, 2024, revealed Resident 281's nurse practitioner (staff #118) documented under the note section "Assessment/Plan" to "Continue fluid restriction". Review of the Provider Progress Note dated August 07, 2024, revealed staff #118 again documented under the note section "Assessment/Plan" to "Continue fluid restriction" and added "8/7/24: stable at 128". Review of Resident #281's Admission Minimum Data Set (MDS) assessment dated August 10, 2024 revealed a Brief Interview of Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. Additionally, in section K, under "Nutritional Approaches", no evidence of a therapeutic diet or altered diet was specified. Review of the physician's orders revealed no evidence of orders regarding a fluid restriction for Resident #281. On August 19, 2024, an observation of Resident #281's room revealed "1.5 fluid restriction" written on the facility's whiteboard hanging on the wall. In an interview conducted on August 21, 2024, at 7:44 AM, a certified nursing assistant (CNA, staff #58), stated that CNAs or nurses are the staff members who write information on the whiteboards located in each of the residents' rooms. She stated that the information is in regard to that resident's care. Upon entering Resident #281's room to examine the whiteboard together, and when asked to clarify what the writing "1.5 fluid restriction" meant, staff #58 stated, "I don't know, I would have to ask the nurse". In an interview conducted on August 21, 2024, at 7

Based on observation, record review, interviews, and facility policy review, the facility failed to ensure one of one sampled resident (#19) had a baseline care plan and/or comprehensive care plan to address the resident's immediate needs within 48 hours of admission regarding his weightbearing status and proper use of orthostic. Findings include: Resident #19 was admitted into the facility on July 07, 2024, with diagnoses that included a history of left proximal tibia fracture, diabetes mellitus, hypertension, and acute anemia. A review of the Admission MDS (minimum data set) assessment dated July 14, 2024 for Resident #19 revealed a BIMS (brief interview of mental status) score of 12, which indicated the resident was moderately cognitively impaired. Upon review of the physical therapy initial evaluation dated July 08, 2024, under the section labeled "Precautions", it was documented for Resident #19 to remain "Touchdown Flat Foot Weightbearing" to the left lower extremity and to wear the "knee brace unlocked" and "on at all times". Review of all physical therapy daily encounter notes from the start of care on July 08, 2024 through August 18, 2024 revealed a continuation of the precautions for Resident #19 to remain "Touchdown Flat Foot Weightbearing" to the left lower extremity and to wear the "knee brace unlocked" and "on at all times". In an interview conducted August 20, 2024, a certified nursing assistant (CNA/ staff #19), reported that if a resident has a weightbearing restriction, or if a resident needs an orthotic device, that it would be communicated verbally in report and would also be documented within the care plan. When requested to view the care plan for Resident #19 together, staff #19 failed to identify anything documented within the care plan regarding the knee orthotic or the weightbearing status of the left lower extremity. On August 20, 2024 no evidence was found for the baseline care plan and comprehensive care plan to include any information regarding the touch down weightbearing status or the knee orthotic for the resident's left lower extremity. In an interview conducted August 20, 2024, the Director of Rehab (staff #116) stated that the process for admitting a resident from the hospital with orders for a weightbearing status or an orthotic device would include to ensure orders are transcribed accurately into the electronic medical record and to ensure that the supervising therapists collaborate with nursing and then update the baseline care plan to include that necessary information. Staff #116 stated that if that information was not added to the baseline care plan, there would be a risk of no clinical follow through with the rest of the interdisciplinary team and that there would be a risk of further injury for that resident's particular body part if an orthotic device was not worn or if a weightbearing status was not followed. When asked to view the care plan together, staff #116 could not find any information documente

Finding Include: Resident #432 was admitted on 08/04/2024 with Alzheimer's Disease, Dementia, Unspecified Severity with Anxiety, Acute Respiratory Failure with Hypoxia, Hypertensive Chronic Kidney Disease with stage 1 through 4 Chronic Kidney Disease, Unspecified Protein-Calorie Malnutrition, and Chronic Kidney Disease, Stage 3 Unspecified. Review of Nurse's note on 08/08/2024 revealed that the nurse was notified that resident #432 had tripped and fallen in her room, due to her long oxygen tubing that became trapped around the resident's wheelchair. The nurse's note also revealed that she was notified by the Certified Nursing Assistant (CNA) that housekeeping helped the patient off the floor into her wheelchair on 08/08/24 at 2:35PM. The admission Minimum Data Set (MDS) assessments was performed on 08/9/24 revealed a Brief Interview for Mental Status (BIMS) score of 15 signifying the resident had no cognitive impairment. MDS revealed the resident does not have Potential indicators of psychosis: Hallucinations, delusions. Also, no concerns on were stated for any behavioral symptoms such as no wandering -presence & frequency, and no change in behavior were indicated. Moreover, MDS revealed that the resident has shortness of breathing and is receiving pain medication regimen, and no presence of pain notated. During the interview with the resident (#432) on 08/19/24 at 01:43 PM, she stated that she tripped over her oxygen tubing when walking to the restroom and fell. An interview was conducted with the housekeeper (Laundry Assistant/ Staff #42) on 08/20/24 at 01:35 PM. Staff #42 stated that she should not have helped the resident. Further she stated that when this incident happened she was walking into the resident #432 room to give her laundry and the resident was going out to play bingo. The staff #42 stated that she observed that while the resident #432 was walking, her oxygen tubing got trapped into wheelchair and fell. Staff #42 stated she was unable to locate any clinical staff so she assisted the resident to stand up from the floor-she locked the wheelchair so the resident was able to sit in the chair. Then she stated she notified the CNA that resident #432 fell. An interview was conducted with Registered Nurse (RN/ Staff #27) on 08/20/24 at 1:49 PM. The Staff #27 stated the facility process when it comes to falls, first she will see if the resident is hurt, ensure if they are on blood thinner, contact the provider, and then contact the family member if resident wishes to. Staff #27 was aware of resident #432 fall that occurred on 8/8/24 assisted by the housekeeper. She also stated she was notified by the CNA immediately. Staff #27 further stated that residents fall was due to resident's oxygen tubing got trapped around resident's wheelchair. An additional interview was conducted with the RN (Staff #27) on 08/22/24 at 2:30PM. Staff #27 stated that she did post fall assessment on Resident #432 immediately upon being notified by the CNA approxim

Based on observations, staff interviews, and review of clinical records and policy the facility failed to ensure dialysis care and services, including nutrition, assessments, or coordination of care, were appropriately followed for 3 Residents (#15, #10, and #234). Findings include: -Regarding Resident # 15 Resident # 15 was admitted into the facility on August 01, 2024 with diagnoses that included dependence on renal dialysis, implants and grafts, and end stage renal disease. A review of the Admission MDS (minimum data set) assessment dated August 08, 2024 revealed a BIMS (brief interview of mental status) score of 8, which indicated the resident was moderately cognitively impaired. The care-plan initiated on August 06, 2024 revealed that Resident # 15 needs dialysis (hemo) related to renal failure. The goal was for resident to have no signs or symptoms through the review date. Interventions included to not draw blood or take blood pressure in arm with graft. Review of electronic medical records (EMR) revealed a physician order initiated on August 01, 2024 as follows: - No Blood Draws or Blood Pressure on Left Upper Extremity due to Shunt/Fistula. Review of EMR revealed three instances of staff measuring blood pressure on the left arm for Resident # 15 since his admission on August 01, 2024 as follows: August 16, 2024 at 04:53 AM reading of 129/48 mmHg lying left arm. August 20, 2024 at 05:32 AM reading of 140/51 mmHg sitting left arm. August 20, 2024 at 08:53 PM reading of 122/60 mmHg sitting left arm. An interview was conducted on August 21, 2024 at 02:11 PM with Certified Nursing Assistant (Staff # 28) who stated night shift will obtain blood pressure reading of the residents who are expected to be going out for dialysis in the morning. Staff # 28 stated that blood pressure readings for dialysis residents are not obtained from certain sites when there is a limb alert bracelet on the residents; and that, it is a reminder to avoid taking blood pressure at that area. An observation was conducted on August 21, 2024 at 02:16 PM which noted Resident # 15 wearing bracelet with lettering, "limb alert." An interview was conducted on August 21, 2024 at 02:17 PM with Registered Nurse (Staff # 16) who stated that prior to dialysis appointments vital signs are taken including blood pressure. Staff # 16 stated that taking blood pressure reading from an arm with shunt or fistula would result in inaccurate reading or deep vein thrombosis. Staff # 16 reviewed electronic medical records for Resident # 15 and confirmed that blood pressure readings should not be taken from left arm as per physician orders. Staff # 16 stated that the three blood pressure readings from the left arm would not meet facility's expectations. An interview was conducted on August 21, 2024 at 02:38 PM with Director of Nursing (DON/Staff # 32) who stated that taking resident's blood pressure measurement from an arm which had an alert bracelet and orders instructing not to be taken from wo

Based on observations, staff interviews, and policy review, the facility failed to ensure that medications and controlled substances were kept locked. Findings include: An observation of a medication cart on Hall A was conducted on August 19, 2024 at 11:58 AM. The medication cart was unlocked and unattended outside of room 136. An observation of a treatment cart on Hall A was conducted on August 21, 2024 at 10:30 AM. The treatment cart was unlocked in the 140 ' s hall. An interview was conducted with a Registered Nurse (RN/staff #36) on August 19, 2024 at 12:11 PM, and confirmed that the medication cart was left unlocked. The RN stated that medication carts are secured and keys are passed between staff each shift, and when leaving the unit. He further stated that the risk of leaving the cart unlocked could result in patients or visitors accessing the medication. An interview was conducted with an RN (Staff # 33) on August 21, 2024 at 9:53 AM, who stated that treatment carts were left unlocked. The RN further stated that the treatment carts should be locked, and she is unaware if there are keys to unlock the carts. An interview conducted with the Minimum Data Set Coordinator RN (MDS RN/Staff # 40) on August 21, 2024 at 10:30 AM, who stated the treatment cart was left unlocked. The MDS RN stated that RN ' s are responsible for treatment carts and have the keys to unlock the carts. The MDS RN further stated the risk could result in patients accessing medications. An interview was conducted with the Director of Nursing (DON/Staff #32) on August 22, 2024 at 9:31 AM, who stated that she expects nurses to ensure medication carts are locked. A facility policy titled, Medication Storage (Medication Cart/Narcotics), revealed that all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on the clinical review, interviews, facility documentation and policy review, the facility failed to maintain Enchanced -Based Precautions (EBP) for 2 of 5 sampled residents (#430, #234). Findings Include: - Regarding Resident #430: Resident #430 was admitted on August 8,2024 with diagnosis Type 2 diabetes mellitus, atherosclerotic heart, necrotizing fasciitis, chronic respiratory failure with hypoxia, acute on chronic systolic (congestive) heart failure, hypokalemia, hypomagnesemia and klebsiella pneumoniae. Physician orders included to wear PPE (Personal Protective Equipment) for Enhanced Barrier Precaution (EBP) and to use EBP sign as refers for direct care. The order also included that staff would need to wear non-sterile gown, gloves, every shift for wound care. The Progress notes for resident #430 revealed resident had first degree Av block & history of ESBL E coli infection. During an observation conducted on August 19, 2024 11:23 AM an EBP sign was posted outside Resident # 430's room. Staff # 62 ,Certified Nurse Assistant (CNA), was observed assisting with catheter tubing, and heard telling resident #430 that she would be transferred into her bed. Staff # 62 (CNA) was observed not wearing a gown while performing transfer. Staff # 67, Registered Nurse (RN), was helping during the transfer and was observed to be wearing a gown. The two staff turned Resident # 430 onto her right side, straighten out bed pad, then they turned the resident on her back, continued to reposition the resident, turning her onto her left side, and staff #19 certified Nurse Assistant (CNA) was observed not wearing gown entering the room to reposition Resident # 430. -Regarding Resident #234: Resident # 234 was admitted on August 17, 2024 with the diagnosis end stage renal disease, enterocolitis difficile, type 2 diabetes mellitus, dependence on renal dialysis, atherosclerotic heart disease. Progress notes dated on August 21, 2024 revealed that Resident # 234 is c-diff positive and Resident # 234 would be placed on Enhanced barrier precaution. Observation outside Resident #234 revealed that there were no precaution signs on the entrance door. An interview was conducted with Staff # 67, Regertister Nuser (RN), on 08/20/2024 at 12:29PM. Staff #67 stated that a way to tell that a resident is on Transmission- Based precaution would be to look at their orders which will include the reason why. Staff #67 stated staff can identify those on EBP by looking for signs outside the resident ' s door and the signs would state if the resident is droplets, airborne, or contact base precaution. Staff #67 stated resident #430 Transmission-Based Precaution was taken down by the request of staff # 32, Director of Nursing (DON). Staff #67 stated training on Infection control is done annually. An interview was conducted with Staff # 28, Certified Nurse Assistant (CNA), on August 20, 2024 12:21 PM. Staff #28 stated that the staff has worked at the facility for over 3 years, and compl

Based on observations, staff interviews, resident interviews, and policy review, the facility failed to ensure that food was stored under sanitary conditions that maintained freshness in the kitchen fridge and nourishment refrigerator. Findings include: An observation was conducted on August 19, 2024 at 10:44 a.m. of the walk-in fridge during the initial kitchen tour which revealed the Dining Services Director (staff#68) attempted to discard macaroni and cheese labeled with a discard date of "8/6 - 8/12", cheese sauce labeled with a discard date of "8/9 - 8/16", turkey gravy with a discard date of "8/13 - 8/19", and bread stuffing without a label or discard date. Moreover, a bowl of unlabeled cooked potatoes without a discard date was observed on the fridge shelf. A follow-up observation was conducted on August 19, 2024 at 11:05 a.m. which revealed a gallon of cow's milk labeled "August 18 2024" and another labeled "August 15 2024". On August 19, 2024 at 11:29 a.m., an observation by surveyor #51124 revealed a wait staff/server (staff#14) attempted to discard a personal milk carton with a discard date of July 6, 2024, another personal milk carton with a discard date of July 24, 2024, sushi with a discard date of August 16, 2024, and two yogurts with a discard date of July 25, 2024 from one of the nourishment refrigerators. During a follow-up visit to the kitchen on August 20, 2024 at 12:49 p.m., an additional observation of the walk-in fridge revealed a steel container with seven lemons, two of which were coated in a fluffy, white, greenish, and blueish substance on the peel. Additionally, a full bag of lemons was observed on the walk-in fridge shelf with one mushy, slimy, and sour-odored lemon at the bottom of the bag. An observation of the kitchen conducted on August 21, 2024 at 10:12 a.m. revealed multiple opened and used packages of bread and hot dog buns without labels and missing discard dates. During an interview conducted regarding the unlabeled breads, the dining services director (staff#68) stated the opened packages are "supposed to be labeled" and he "thought they were". Staff#68 stated that not labeling foods and failure to put a discard date would leave residents at risk for "foodborne illness". An interview was conducted with the Dining Services Director (staff#68) on August 19, 2024 at 10:50 a.m. who stated that once something is cooked, the kitchen staff will store it for seven days before they must discard it. An interview was conducted with the Dining Services Director (staff#68) on August 19, 2024 at 11:20 a.m. who stated that he was unsure of when the stuffing was cooked, or if the kitchen intended to use it later that day. On August 19, 2024 at 11:28 a.m., an interview with resident #235 revealed they had received grapes on August 18, 2024 that were "moldy". An interview was conducted with the wait staff/server (staff#14) on August 19, 2024 at 11:29 a.m. who stated that the foods have been "expired for some time", and that,