Health inspection·May 18, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure that a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. for 1 of 12 residents (Resident #190) reviewed for Baseline Care Plans. The facility failed to ensure Resident #190 had a Baseline Case plan developed within 48 hours of a resident's admission. This failure placed resident at risk of not receiving immediate care if assistance was needed. Findings Included: Record review of Resident #190's Face Sheet, dated 05/17/23, revealed he was a 81 -year-old male admitted on [DATE]. Relevant diagnoses included chronic obstructive pulmonary disease (lung disease), chronic kidney disease (kidney failure), chronic congestive heart failure (heart failure), dementia, and repeated falls. Record review of Resident #190's MDS on 05/17/23 revealed no BIMS score or any other pertinent information referencing the care needs of the resident. Record review of Resident #190's assessments in the facility's system of records for care on 05/17/23, revealed no baseline care plan nor comprehensive care plan for the resident. Interview on 05/17/23 at 1:00 PM with MDS Nurse revealed Resident #190 did not have a baseline care plan nor did he have a care plan developed and implemented. She stated that whoever the admitting nurse was at the time, should have completed the resident's base line care plan. She stated the baseline care plan had to be completed within 48 hours of the resident admitting to the facility. She stated the risk of it not being completed could result in the resident not receiving all his required care. Interview on 05/18/23 at 11:00 AM with Regional Compliance Nurse (RC) revealed she stated that whenever a resident is admitted to the facility, the nurse on duty had to complete the baseline care plan for the resident. She advised the risk of not completing a base line care plan could result in the resident not receiving the proper care. Interview on 05/18/23 at 1:00 PM with Director of Nurses (DON) revealed she was made aware of Page 1 of 12 675292 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #190 not having a baseline care plan developed and she stated that whenever a resident is admitted to the facility, the nurse on duty has the responsibility of completing the baseline care plan for residents admitting to the facility. She was unable to advise who completed the admission paperwork for Resident #190. She stated the facility had 48 hours upon the resident being admitted , to complete a baseline care plan, which was not done for Resident #190. She advised the risk of not completing a baseline care plan could result in the resident not receiving the proper care. Interview on 05/18/23 at 1:15 PM with Interim Administrator revealed he was made aware of Resident #190 not having a baseline care plan developed. He advised it was solely the responsibility of the charge nurse on duty to complete the baseline care plan. He advised the risk of not completing a base line care plan could result in the resident not receiving the proper care. Record review of facility policy, Baseline Care Plans (undated) revealed Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident's safety, and safeguard against adverse events that are most likely to occur right after admission. 675292 Page 2 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for care plans. The facility failed to ensure for accuracy and effectively implement Resident #32's comprehensive care plan. This failure can result in the facility not meeting Resident #32's specific care needs related to her anti-hypertensive medication regimen. Findings included: Record review of Resident #32's face sheet dated 05/17/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her code status was full code. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, and toileting. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression. Record review of Resident #32's Care Plan dated 06/15/2023 revealed The resident has hypertension r/t uncontrolled blood pressures with a goal of The resident will remain free of complication related to hypertension through review date with interventions that included Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently, and The resident needs BP taken daily. Record review of Resident #32's vital signs from the last 5 months was not indicative of weekly nor daily blood pressure readings. Review of Resident #32's vital signs revealed: 3/24/2023 12:38 PM 148 / 78 mmHg 2/17/2023 05:02 PM 156 / 83 mmHg 2/3/2023 12:01 AM 88 / 42 mmHg 675292 Page 3 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0656 2/1/2023 10:00 PM Level of Harm - Minimal harm or potential for actual harm 115 / 78 mmHg 1/30/2023 09:26 PM Residents Affected - Few 112 / 68 mmHg 1/18/2023 06:19 AM 123 / 74 mmHg 1/11/2023 09:19 AM 100 / 60 mmHg Record review of Resident #32's physician orders reveale no evidence of physician orders related to frequency of blood pressure monitoring or parameters for notification related information were observed. Further review revealed: Amlodipine Tab 5 mg . give 1 tablet by mouth one time a day for primary hypertension . with a start date of 02/21/2023. In interview with Resident #32 on 05/18/2023 at 11:16 AM she stated she was taking medication for her blood pressure. She stated that the facility did not check her vital signs every day, and was not certain of the frequency. In interview on 05/17/2023 at 9:45 AM with Resident #32's NP she stated that [Resident #32] was a complicated patient with multiple co-morbidities. She stated Resident #32 was on anti-hypertensive medication and expected the resident's blood pressure to be obtained prior to daily administration. She stated she did not write specific orders for the frequency of vital signs because it was best and standard practice. She stated she did not feel like she should have to because the facility should be doing it. She stated if Resident #32's blood pressure was not obtained prior to medication administration, it was a safety issue for her and she as the provider would like to be notified of any blood pressure readings out of normal limits. In interview on 05/17/2023 on 10:07 AM with Resident #32's nurse, RN, she stated she provided the resident's medication yesterday and this morning. She stated that she would be responsible for obtaining blood pressures prior to medication administration. She stated she did administer her anti-hypertension medication but did not obtain her vitals prior to administration. She stated there was not an order to do so. When asked, she stated it would be best practice to obtain Resident's #32's blood pressure prior to medication administration, but she did not do so. She stated it was a risk to the resident as she could bottom out [her blood pressure] and suffer adverse reactions of hypotension. She declined to answer any further questions. In interview on 05/17/2023 at 10:19 AM with the facility's MDS nurse, MDS, she stated the previous MDS nurse at the facility updated Resident #32's care plan with the anti-hypertensive intervention. Upon further interview, she stated she did personally complete a review of the resident's care plan and must have missed the conflicting information regarding blood pressure monitoring and/or frequency on the care plan. Additionally, she stated that a quarterly review was completed on the resident's care plan on 03/17/2023, but she was not in attendance. In interview on 05/17/2023 at 11:53 AM with facility's social worker, SW, she stated she was in 675292 Page 4 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0656 Level of Harm - Minimal harm or potential for actual harm attendance at the quarterly care plan review on 03/17/2023 for Resident #35; but was not responsible for medical or pharmaceutical management and would not have reviewed her anti-hypertension medication care considerations. She stated it was important for each discipline to review resident care plans to ensure the needs of each resident were being met. She stated this responsibility would have been the ADON's, who was also in attendance at the meeting. Residents Affected - Few In interview on 05/17/2023 at 12:00 PM with facility ADON she stated that she was at the quarterly care plan meeting for Resident #32 and went over all her medications. She stated Resident #32 was on an anti-hypertensive medication regimen and she expected her blood pressure to have been obtained prior to daily administration. She stated this was because she could have become hypotensive, which was dangerous as someone could become unconscious and be sent out for emergent treatment. She stated that this must have been missed as she stated it was best practice to do so. She stated it was her responsibility to ensure care plans for each resident were up to date and accurate. In an interview on 05/17/2023 at 1:16 PM the Regional Compliance nurse, stated every morning it was the DON or ADON's responsibility to review new physician orders on all the residents from the previous day. She stated it was ultimately the DON's responsibility to ensure any orders with anti-hypertensives had the appropriate parameters and any additional orders for monitoring. She stated the facility policy was for the nurses to follow physician orders, but it was best practice and good nursing judgment to obtain blood pressure prior to anti-hypertensive medication and the physician should have been called for clarification. She stated this was an oversight and was a quality-of-care issue and could result in a change in health status for the resident. Additionally, it was nursing leadership's responsibility to work with the other disciplines at the facility to ensure the care plan was accurate, up to date, and meeting the resident's needs. In interview on 05/17/2023 at 1:16 PM with the facility's DON, she stated she just started working at the facility two weeks ago. She stated her expectations were for all residents who are on anti-hypertensive medications to have daily vital sign monitoring. She stated it was the DON's responsibility to complete audits of any new orders and seek clarification from the provider for any missing or incomplete information. She stated that it was also the DON's responsibility to ensure the care plan is accurate, up to date, and implemented effectively as resident care plans ensure the facility was meeting each resident's needs. Review of Medscape medication material, Drugs & Diseases, Amlodipine (Rx) , rev. 07/2022, revealed amlodipine is used to treat high blood pressure. It works by relaxing blood vessels to blood can flow more easily. Specific cautions include symptomatic hypotension. <https://reference.medscape.com/drug/katerzia-norvasc-amlodipine-342372#91> Review of facility policy, Medication Administration Procedures, 2003, revealed 13. When . indicated, include specific item(s) to monitor (e.g., blood pressure .) . and parameters for notifying the prescriber. 675292 Page 5 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs (Resident #32). Residents Affected - Few The facility did not shower Resident #32 regularly. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, feelings of poor self-esteem, lack of dignity and health. The findings included: Record review of Resident #32's face sheet dated 05/17/23 revealed she was a full code [AGE] year-old female originally admitted to the facility on [DATE]. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression. Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, toileting, and bathing. Record review of Resident #32's most recent Care Plan, dated 02/16/23, revealed the resident had an ADL Self Care Performance Deficit. The goals were to ensure the resident maintain or improve current level of function in personal hygiene. Also, to ensure the resident improve current level of function in personal hygiene through the review date. The care plan reflected Resident #32 required assitance from 1 staff for bathing. Record review of ADL care provided for Resident #32, dated March 2023, revealed the resident did not receive showers from 03/04/23-03/09/23. Record review of ADL care provided for Resident #32, dated May 2023, revealed the resident did not receive showers from 05/04/23-05/07/23. During an interview on 05/18/23 at 12:14 PM, Resident #32 stated she gets tired of being put off for showers. She stated showers are important to her. She stated she would like to have showers especially before her doctors' appointments and she rarely gets them. She stated if she did not get them on the scheduled day, it was ok, if she was to get it on another day. However, when she did not get her showers on the day of her appointments then that really bothered her. She stated she was supposed to get a shower on 05/17/23 and she did not get it. She stated she had not gotten a shower at the time of this interview. She stated she was upset because she had a doctor's appointment at 4:00 PM on this day and still had not had a shower. During an interview on 05/18/23 at 12:19 PM Resident #21 stated the aides said they were instructed to stick to the schedule and not deviate. She stated if they did not get a shower on their scheduled day and shift, then they would have to wait until the next scheduled shower day. 675292 Page 6 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 05/18/23 at 9:27 AM, C.N.A. A stated on certain days of the week, they had more staff on shift and they were able to shower the residents on schedule. However, when it was just a couple of aides on shift, it was hard to get to everyone, because call lights took priority and they had other duties that had to be done. During an interview on 05/18/23 at 12:49 PM, the Director of Nursing she stated she had begun an audit on showers. She stated the aides were prompted on the days of the residents' showers to be showered. She stated it was important to get soap and water on their skin. She stated the nurses received a report every morning and she could not verify that everyone was documenting. She stated lack of showers could affect their skin health and comfort. During an interview on 05/18/23 at 1:00 PM, the Administrator stated his expectation was that residents get their showers on their scheduled days. He stated some days they did have more staff on shift than others. He stated residents could feel frustrated and feel not cared for if they did not receive regular showers. Record review of facility policy on Resident Rights, revised 11/28/16, revealed The Resident has the right to be treated with dignity and respect , including the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences, except when to do so would endanger the health or safety of the resident. 675292 Page 7 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Potential for minimal harm Based on observation, interview and record review, the facility failed to ensure the activity program was directed by a qualified professional who was licensed, registered, had qualified work experience or had completed a training course approved by the State for one (AD) of one Activity Director. Residents Affected - Many The facility failed to have a qualified Activity Director. The previous Activity Director left employment five days prior and the facility did not fill the position, only having facility staff try to fill in who were not qualified or had the experience. This failure placed all residents at risk of receiving inappropriate activities. Findings included: During an interview on 05/16/23 @ 10:27 AM, the Administrator revealed they had just lost their Activities Director. He stated she resigned and Friday 05/12/23 was her last day. Review of the Active Employee List on 05/16/23 did not identify the presence of an Activity Director. During an interview on 05/17/23 at 11:15 PM, the Administrator stated they did not have a Corporate Activities Director. He stated staff were chipping in to carry on the activities for the rest of the month, as the former Activities Director had already completed the Activities Calendar for the month of May 2023. He stated he had not had a chance to fill the position yet. Observation of the Activities Calendar, located on the wall across from the common area, there was a full calendar for the month of May 2023. During an interview on 05/18/23 at 1:00 PM, the Administrator stated he believed the staff were doing a great job at carrying on the activities and stated staff were doing what they could to keep the residents engaged. He stated did, however, acknowledge understanding the need for a trained and certified Activities Director, because they would be able to engage with each resident, including the ones who had cognitive or behavioral challenges, which regular staff would not have the skills to perform, effectively. Review of the facility's policy titled, Activities Program (not dated), reflected, Purpose: To encourage residents to participate in activities to make life more meaningful, to stimulate and support physical and mental capabilities to the fullest extent, and to enable the resident to maintain the highest attainable social, physical and emotional functioning. 675292 Page 8 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #32) of five residents reviewed for quality of care. Residents Affected - Few The facility failed to sufficiently monitor Resident #32's blood pressure while she was taking anti-hypertensive medication Amlodipine and failed to implement Resident #32's comprehensive care plan intervention to take her blood pressures daily. This failure could place residents at risk for adverse effects of an anti-hypertensive medicine regimen. Findings included: Record review of Resident #32's face sheet dated 05/17/23 revealed she was a [AGE] year-old female originally admitted to the facility on [DATE]. Her code status was full code. Relevant diagnoses included hypertension, spinal cord compression, generalized muscle weakness, chronic pain syndrome, fusion of the spine, multiple sclerosis, major depressive disorder, and presence of a neurostimulator for pain management. Record review of Resident #32's most recent quarterly MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She utilized a wheelchair for mobility and required extensive assistance of two or more staff for bed mobility, transfers, and toileting. Resident #32's primary active diagnoses included other neurological conditions with additional diagnoses that included hypertension, multiple sclerosis, depression, and cord compression. Record review of Resident #32's Care Plan dated 06/15/2023 revealed The resident has hypertension r/t uncontrolled blood pressures with a goal of The resident will remain free of complication related to hypertension through review date with interventions that included Obtain blood pressure readings at least weekly unless ordered by the physician to be obtained more frequently, and The resident needs BP taken daily. Record review of Resident #32's vital signs from the last 5 months was not indicative of weekly nor daily blood pressure readings. Review of Resident #32's vital signs revealed: 3/24/2023 12:38 PM- 148 / 78 mmHg 2/17/2023 05:02 PM- 156 / 83 mmHg 2/3/2023 12:01 AM- 88 / 42 mmHg 2/1/2023 10:00 PM- 115 / 78 mmHg 1/30/2023 09:26 PM- 112 / 68 mmHg 1/18/2023 06:19 AM- 123 / 74 mmHg 675292 Page 9 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0684 1/11/2023 09:19 AM- 100 / 60 mmHg Level of Harm - Minimal harm or potential for actual harm Record review of Resident #32's physician orders revealed there was not a physician's order related to the frequency of blood pressure monitoring nor parameters for blood pressure notification. Further review revealed an order: Amlodipine Tab 5 mg . give 1 tablet by mouth one time a day for primary hypertension . with a start date of 02/21/2023. Residents Affected - Few In interview with Resident #32 on 05/18/2023 at 11:16 AM she stated she was taking medication for her blood pressure. She stated that the facility did not check her vital signs every day, and was not certain of the frequency. In interview on 05/17/2023 at 9:45 AM with Resident #32's NP she stated that she (Resident #32) was a complicated patient with multiple co-morbidities. She stated Resident #32 was on anti-hypertensive medications and expected the resident's blood pressure to be obtained prior to daily administration. She stated she did not write specific orders for the frequency of vital signs because it was best and standard practice. She stated she did not feel like she should have to write an order because the facility should be doing it. She stated if Resident #32's blood pressure was not obtained prior to medication administration, it was a safety issue for her and she as the provider would like to be notified of any blood pressure readings outside of normal limits. In interview on 05/17/2023 on 10:07 AM with Resident #32's nurse, RN, she stated she provided the resident's medication yesterday, 05/16/23, and the morning of 05/17/23. She stated that she would be responsible for obtaining blood pressures prior to medication administration. She stated she did administer Resident #32's anti-hypertension medication but did not obtain her vitals prior to administration. She stated there was not an order to do so. When asked, she stated it would be best practice to obtain Resident's #32's blood pressure prior to medication administration, but she did not do so. She stated it was a risk to the resident as she could bottom out [her blood pressure] and suffer adverse reactions of hypotension. She then declined to answer any further questions. In interview on 05/17/2023 at 10:19 AM with the facility's MDS nurse, MDS, she stated the previous MDS nurse at the facility updated Resident #32's care plan with the anti-hypertensive intervention. Upon further interview, she stated she did personally complete a review of the resident's care plan and must have missed the conflicting information regarding blood pressure monitoring frequency on the care plan. Additionally, she stated that a quarterly review was completed on the resident's care plan on 03/17/2023, but she was not in attendance. In interview on 05/17/2023 at 11:53 AM with facility's social worker, SW, she stated she was in attendance at the quarterly care plan review on 03/17/2023 for Resident #35; but was not responsible for medical or pharmaceutical management and would not have reviewed her anti-hypertension medication care considerations. She stated it was important for each discipline to review resident care plans to ensure the needs of each resident were being met. She stated this responsibility would have been the ADON's, who was also in attendance at the meeting. In interview on 05/17/2023 at 12:00 PM with facility ADON she stated that she was at the quarterly care plan meeting for Resident #32 and went over all her medications. She stated Resident #32 was on an anti-hypertensive medication regimen and she expected her blood pressure to have been obtained prior to daily administration. She stated this was because she could have become hypotensive, which was dangerous as someone could become unconscious and be sent out for emergent treatment. She stated that this must have been missed as she stated it was best practice to do so. She stated it was her 675292 Page 10 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0684 responsibility to ensure care plans for each resident were up to date and accurate. Level of Harm - Minimal harm or potential for actual harm In an interview on 05/17/2023 at 1:16 PM the Regional Compliance nurse, stated every morning it was the DON or ADON's responsibility to review new physician orders on all the residents from the previous day. She stated it was ultimately the DON's responsibility to ensure any orders with anti-hypertensives had the appropriate parameters and any additional orders for monitoring. She stated the facility policy was for the nurses to follow physician orders, but it was best practice and good nursing judgment to obtain blood pressure prior to anti-hypertensive medication and the physician should have been called for clarification. She stated this was an oversight and was a quality-of-care issue and could result in a change in health status for the resident. Additionally, it was nursing leadership's responsibility to work with the other disciplines at the facility to ensure the care plan was accurate, up to date, and meeting the resident's needs. Residents Affected - Few In interview on 05/17/2023 at 1:16 PM with the facility's DON, she stated she just started working at the facility two weeks ago. She stated her expectations were for all residents who are on anti-hypertensive medications to have daily vital sign monitoring. She stated it was the DON's responsibility to complete audits of any new orders and seek clarification from the provider for any missing or incomplete information. She stated that it was also the DON's responsibility to ensure the care plan is accurate, up to date, and implemented effectively as resident care plans ensure the facility was meeting each resident's needs. Review of Medscape medication material, Drugs & Diseases, Amlodipine (Rx) , rev. 07/2022, revealed amlodipine is used to treat high blood pressure. It works by relaxing blood vessels to blood can flow more easily. Specific cautions include symptomatic hypotension. <https://reference.medscape.com/drug/katerzia-norvasc-amlodipine-342372#91> Review of facility policy, Medication Administration Procedures, 2003, revealed 13. When . indicated, include specific item(s) to monitor (e.g., blood pressure .) . and parameters for notifying the prescriber. 675292 Page 11 of 12 675292 05/18/2023 Cottonwood Nursing and Rehabilitation 2224 N Carroll Blvd Denton, TX 76201

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for food storage. The facility failed to ensure expired foods were discarded upon expiration date. This failure could place residents at risk for food-borne illnesses. Findings include: Observation on 05/16/23 at 9:00 AM in the walk-in refrigerator, revealed the following: One opened ½ gallon Jar of Maraschino Cherries Halves dated 11/03/22, and no expiration date was observed on the container. One 1-gallon container of Nacho sliced jalapeno peppers dated 04/07/21 and expired 09/16/22. One 64-ounce container of Enchilada Sauce dated 07/14/22, and expired 05/12/23 Two 1-gallon jars of Balsamic Vinaigrette Dressing dated 12/12/ (No year), and no expiration was observed on the container Interview with Dietary Manager on 05/17/2023 at 1:00 PM revealed she was responsible for the dating and storage of foods as they are delivered to the facility. She was shown the photos of the expired foods and she stated the items should have been discarded and she will discard them. The Dietary Manager stated the risk of not discarding expired foods could result in food-borne illnesses. Interview with Administrator on 05/18/2023 at 11:50 AM revealed she was made aware of the findings in the kitchen by the Dietary manager. She stated her expectation was for the kitchen staff to ensure that they are following proper procedures for storing and cooking foods while practicing sanitary conditions and the risk to the residents could be that they contract an air-borne illness. Record Review of facility's policy and procedures for Dietary Services Policy & Procedure Manual 2012 (undated), revealed Perishable items that are refrigerated are dated once opened and used within 7 days (if they do not have an expiration date or bet by/use by date), but non-perishable items that are refrigerated once opened should be dated when opened but do not need to be discarded until their expiration date or until the quality deteriorated. Review of FDA Food Code 2022 under Disposition revealed, A FOOD that is unsafe, ADULTERATED, or not honestly presented as specified under § 3-101.11 shall be discarded or reconditioned according to an APPROVED procedure. 675292 Page 12 of 12