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Based on observation, interview, and record review, the facility failed to ensure patient care supplies were safely maintained and readily available for a universe of 14 patients presented to the Emergency Department (ED) from June 3, 2024, through June 4, 2024, when multiple expired medical supplies were found in the patient care areas.

This failure had the potential for medical supplies not being readily available during an emergency situation and result in the use of an expired medical device which could compromise the integrity of the device and lead to delayed care, infection and patient harm.

Findings:

During a concurrent observation and interview on June 4, 2024, at 9:20 AM, with the Chief Nursing Officer (CNO), in the ED supply storage area, the following items were found to be expired:
- Two [Name of manufacturer] size 7 sterile gloves with an expiration date of November 28, 2023
- Five Rapid RSV swabs (a nasal swab used to quickly test for [RSV] Respiratory Syncytial Virus - a serious respiratory infection) with expiration date of April 30, 2024
- One Multi lumen Central Line kit (kit with sterile supplies used by physician to put a device into a patients veins to deliver medications) with expiration date of March 31, 2023
- Two chlorhexidine (chemical used to disinfect the skin) applicators with expiration date of March 2024. The CNO confirmed the supplies were expired and stated, expired supplies should be removed from patient care areas and not available for patient use.

During a continued concurrent observation and interview on June 4, 2024, at 9:35 AM, with the CNO, in the ED Crash Cart (a mobile cart that can be moved to the patient's bedside and contains lifesaving medication and equipment), the following items were found to be expired:
- One size 7 sterile gloves with expiration date of November 28, 2023
- Numerous alcohol preparation pads with the expiration date of October 26, 2021
- Two adult End Tidal Co2 (devices used to detect carbon dioxide at the end of a breathing tube to ensure placement) monitoring devices with expiration of February 15, 2024. The CNO confirmed the supplies were expired and stated, expired supplies should be removed from patient care areas and not available for patient use.

During an interview with the Quality, Risk Case Manager (QRM) on June 6, 2024, at 9:10 AM, the QRM stated, the emergency department is responsible for identifying expired items proactively so that they will not be used for patient care. The QRM further stated, in the event of an emergency having an expired patient care supply or having to check an expiration date on a patient care supply means that supplies are not readily accessible for patient use.

During a review of the facility's policy and procedure titled, "Expiration Dates", dated January 2023, the P&P indicated, " ...Expiration dates shall be assigned according to this policy ...Expiration dates shall be assigned to all prepackaged products. Expiration dates shall be assigned in accordance with the laws and regulations of this state. In no case shall the assigned date exceed the manufacturer's expiration date ...The expiration dates of all medical surgical care products and devices shall be checked upon receipt. Expired medical surgical care products and devices with 6 month short dating shall be returned to the supplier. Expiration dates shall be checked monthly."

Based on interview and record review, the facility failed to ensure the Governing Body (GB- a committee that oversees the facility's compliance and quality oversight efforts) provided adequate and effective oversight when:
1. the facility was unable to provide the documentation to show the quality assurance program was established, implemented and monitoring of expired food and patient care supplies, certification of infection preventionist, a clean and sanitary environment, and employee annual Tuberculosis (a highly contagious lung disease) skin testing to ensure the provision of quality health care for a universe of 25 patients admitted to the facility from May 1, 2024, through June 6, 2024. (Refer to C-962)

The cumulative effect of these systemic problems resulted in the facility's inability to deliver care in compliance with the Condition of Participation for GB which jeopardized the provision of quality patient care in a safe environment.

Based on interview and record review, the facility failed to ensure the effective oversight of the Governing Body (GB) when the GB was unable to effectively implement and monitor operational policies to ensure provision of quality health care as evidenced by identified deficiencies including; storage and use of food and medical supplies, certification and qualifications of the Infection Control Preventionist (ICP), annual health screening of the employees and the maintenance of a clean and sanitary environment in the kitchen, inhibiting safe and appropriate health care for a universe of 25 patients admitted to the facility from May 1, 2024, through June 6, 2024. These failures resulted in the facility's inability to ensure a safe care environment and impaired efforts to improve or sustain quality of care for patients.

Findings:

During a review of the facility's "Quality / Patient Safety / Performance Improvement Plan 2024" (QPSPI), dated May 2024, the QPSPI indicated, "QI/IC/S/PR [Quality Improvement / Infection Control / Safety / Performance Review] Committee provides a quarterly summary report of trended data, as well as measurable improvement, to the GB."

During an interview on June 6, 2024, at 10:38 AM, in the conference room, with the Health Information Management Director (HIMD), the HIMD stated, "We do a quarterly meeting with QAPI [Quality Assurance and Performance Improvement] where they report their activities. The main ones they monitor are: medical documentation, Emergency Department patient turnaround times, lab blood contamination, nursing quality reports and approval of the minutes of the previous meeting."
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During a concurrent interview and record review on June 6, 2024, at 10:40 AM, with the HIMD, the "Board of Director's Meeting Minutes" (MM), dated January 2023 to November 2023, were reviewed. The MM indicated, in May, the Quality Improvement Plan was approved with no changes. In November, the board reviewed and accepted the 'Quality/Patient Safety Committee Report" (presented in Oct 2023). The GB MM made no other mention of QAPI reporting or their activities of data collection, analysis or reporting. activity. No evidence could be found to support a quarterly QAPI meeting with the GB. The HIMD stated, the QAPI report should be quarterly but there has been a lot of personnel changes recently, and the facility only recently hired a new Infection Preventionist. Many things have been delayed this year.

During an interview on June 6, 2024, at 10:45 AM, in the conference room, with members of the Governing Board, the Chief Executive Officer (CEO) stated that the GB committee was unaware of the issues identified by the survey (storage and use of food and medical supplies, certification and qualifications of the infection preventionist, annual health screening of the employees and the maintenance of a clean and sanitary environment in the kitchen). The CEO stated, it would be better if the quality program monitor, track and report these issues so they are kept aware. The CEO further stated, "We could use more information about the issues throughout the hospital. More prompt, actual reports of QAPI activities will help us to be more effective as a board."

During a concurrent interview and record review on June 6, 2024, at 11:00 AM, with members of the board, the "QPSPI Plan 2024" dated May 2024, was reviewed. The QPSPI indicated, "X. Summary. The ultimate responsibility for Quality Management / Performance Improvement is the Governing Body." The CEO stated, "Yes, we have to provide more oversight to ensure QAPI is effective. The Board is responsible."

Based on interview, and record review, the facility failed to ensure the infection prevention program demonstrate adherence to control the transmission of infectious disease and was coordinated and lead by a qualified Infection Control Preventionist (ICP), for a universe of 25 patients admitted to the facility from May 1, 2024, through June 6, 2024, when:

1. The facility did not ensure the appointed Infection Control Preventionist had the certification in infection prevention and control to create and sustain a safe health care environment (Refer to C-1204).

2. The facility did not ensure six (6) of eight (8) sampled employees Tuberculosis (TB - contagious infection spread through the air affecting the lungs) Skin Testing (Purified Protein Derivative - PPD- skin test used to determine if a person has been exposed to TB) were performed annually by employee health (Refer to C-1206).

3. Expired food items were found in the kitchen refrigerator, including five dozen (60) eggs, a container of leftover pasta salad and a packaged ham sandwich (Refer to C-1206).

4. The facility did not ensure to maintain a clean and sanitary environment in the facility's kitchen when, severe corrosion of the kitchen washroom floor and rough mineral deposits on two of three stainless sinks prevented proper cleaning and sanitizing of these work surfaces, and a missing disposal drain cover seal left an exposed surface covered with slimy, dark colored deposits (Refer to C-1208).

5. The facility did not ensure a preventative infection control program was established and maintained when there was no process to identify and monitor infection control practices to minimize the risk of Hospital Acquired Infection (HAI--an infection acquired when receiving health care that was not present during the time of admission) (Refer to C-1225).

The cumulative effects of these systemic problems resulted in the hospital's inability to ensure a safe, sanitary environment and a quality infection control program.

Based on interview and record review, the facility failed to ensure the appointed Infection Control Preventionist (ICP) had the certification in infection prevention and control to create and sustain a safe health care environment for a universe of 25 admitted patient between May 1, 2024, through June 6, 2024. This failure resulted in an Infection Prevention Program that did not meet regulatory standards and had the potential for increased patient risk of hospital acquired infection .

Findings:

During a phone interview with the ICP on June 5, 2024, at 8:30 AM, the ICP stated, she was appointed to the Infection control Nurse position approximately one month ago and does not have specific training or certification in infection prevention and control in an acute care hospital setting.

During a concurrent phone interview and record review on June 5, 2024, at 4:40 PM, with the ICP, the ICP's employee file was reviewed. There were no certificates or documentation related to higher education regarding infection control and prevention. The ICP, stated she did not have documentation of specific education regarding infection control and prevention.

During an interview with the Chief Executive Officer (CEO) on June 6, 2024, at 10:35 AM, the CEO stated, he was not aware that the Infection Control Preventionist needed specific training and certification in infection prevention and control. The CEO further stated, the facility administrators should have been familiar with the regulations regarding the qualifications for infection preventionist position.

During a review of the facility's document, "Position Summary: Infection Control/Employee Health", dated May 2024, the "Position Summary: Infection Control/Employee Health Nurse" indicated, " ...The Infection Control/Employee Health Nurses' focus is the delivery of health care in a clean, safe, protected environment. Position responsibilities include ...assuring compliance with established policies and procedures, ongoing surveillance and evaluation of infections in patients and personnel ...Updates the Infection Control plan annually to continually enhance the program ... Actively surveys all areas of the hospital for potential infectious/hazardous environments and takes steps for the immediate correction and resolution of any areas identified. Implements strategies designed to reduce the risk of nosocomial, epidemic infections, including initiating cultures on employees, patients or environment and may initiate or enforce isolation procedures to control infection or conduct outbreak investigations... Special Skills & Qualifications ...Must be able to assist in orientation and training for staff and must function as a resource for all hospital employees. Ability to demonstrate knowledge of the nursing process, as well as California Regulatory agencies ...".

Based on observation, interview and record review, the facility failed to ensure infection control and prevention policies and procedures (P&P) were followed when:

1.Six of eight sampled employees Tuberculosis (TB - contagious infection spread through the air) Skin Testing (Purified Protein Derivative - PPD- skin test used to determine if a person has been exposed to TB) were performed annually by employee health. This failure had the potential to put all patients, visitors and staff in the medical center at increased risk of exposure to unsuspected cases of infectious tuberculosis which could jeopardize the health and safety of the vulnerable populations.

2. Expired food items were found in the kitchen refrigerator, including five dozen (60) eggs , a container of leftover pasta salad and a packaged ham sandwich. This failure had the potential to result in patients and staff being served food contaminated with harmful molds or bacteria that could severely compromise the health and safety of patients and staff in the facility.

Findings:
1. During a concurrent interview and record review, on June 5, 2024, at 3:50 PM, with the Quality Assurance Performance Improvement Assistant (A-QAPI), eight sampled employee files (a confidential file that includes information about a specific employee) were reviewed. Six of eight sampled employee files sampled did not contain documentation of annual TB Skin Testing. A-QAPI confirmed there were no annual TB skin tests performed on current employees since 2021 and stated the previous ICP (Infection Control Preventionist) had told her that staff no longer needed to do an annual TB skin test. The A-QAPI further stated, a TB skin test would only be administered to a new employee upon hire, and she did not know if the policy and procedure had been changed or when a TB skin test would be indicated for an employee that was not newly hired.

During a concurrent interview and record review, on June 5, 2024, at 4:46 PM, with the Infection Control Preventionist (ICP), the facility's policy and procedure (P&P) titled, "Employee Health: TB Skin Testing", dated August 2022, was reviewed. The P&P indicated, " ...Purpose: To prevent the spread of Tuberculosis (TB) within the healthcare environment. Policy: Name of the hospital] Employee Health has established a mandatory TB skin testing for all Employees, to evaluate transmission, provide follow-up protocols and permit evaluation of the effectiveness of current Infection Control/Employee Health practices ...Periodic PPD Testing: All PPD negative employees will undergo mandatory annual PPD testing ...Documentation: Results of PPD tests will be recorded in the confidential employee health record for employees ...". The ICP stated, the previous infection preventionist said employees did not require an annual TB skin test and only needed to do the TB Risk Assessment Questionnaire (RAQ - questions regarding common symptoms of TB) annually. The ICP further stated, she was told by the previous infection preventionist that annual TB skin testing was no longer necessary, The ICP stated, she assumed what she was told by the previous infection preventionist was in the policy. The ICP further stated, upon reviewing the policy now, all staff should be tested for TB annually. The ICP stated, the facility was not following their P&P and all staff needed to have a TB skin test performed immediately.

During a review of the facility's "Position Summary: Infection control/Employee Health Nurse", dated May 2024, the "Position Summary: Infection Control/Employee Health Nurse", indicated, " ...The infection Control/Employee Health Nurses' focus is the delivery of health care in a clean, safe, protected environment. Position responsibilities include ...assuring compliance with established policies and procedures, ongoing surveillance and evaluation of infections in patients and personnel ...Monitors and maintains compliance on all employee health files, immunizations, etc ...".

2. During a concurrent observation and interview on June 4, 2024, at 8:20 AM, with the Dietary Manager (DM) in the kitchen walk-in refrigerator, there was a ready-to-eat ham and cheese sandwich found on the shelf dated May 30, 2024. The DM stated "Yes, this is expired. It should have been removed. I can't serve this."

During an observation on June 4, 2024, at 8:22 AM, in the walk-in kitchen refrigerator, there were five full cartons of unpasteurized eggs (60 eggs), dated May 16, 2024, sitting on the shelf. The DM inspected the cartons and quickly gathered up the eggs and threw them in the trash.

During a concurrent observation and interview on June 4, 2024, at 8:24 AM, with the DM, in the kitchen walk-in refrigerator, a container of left-over pasta salad was observed on the shelf dated May 25, 2024. The DM stated, "This is still good, it should be good for over a week. I may throw it away tomorrow."

During a concurrent interview and record review on June 5, 2024, at 9:00 AM, with the DM, the facility's policy and procedure (P&P) titled "Storage and Use of Leftovers" dated May 2020, was reviewed. The P&P indicated, "Leftover items which are not frozen are held no longer than two days before they are used or disposed of." The DM stated, "Yes, the policy states that leftovers should only be kept two days. The items you found were expired and should not be used. I threw them away already."

During an interview on June 5, 2024, at 9:05 AM, with the DM, in the kitchen walk-in refrigerator, the DM stated, there should not be any expired food in the fridge. It should be thrown away. The danger is that it could grow bacteria and cause illness if eaten.

During a phone interview on June 5, 2024, at 10:45 AM, with the Registered Dietician (RD), the RD stated "All eggs should be pasteurized. When we order eggs from the company, my expectation is that they should be delivering pasteurized eggs. There should not be raw eggs in the fridge. Especially if they are over 2 weeks old."

During a follow up phone interview on June 5, 2024, at 10:50 AM, with the RD, the RD stated, pasta salad stored for a week was unsafe. It should never be kept in the fridge. The policy states leftover storage for only two days. The RD further stated, "Improper storage of foods can cause food-borne illnesses, they can result in diarrhea, nausea, dehydration."

Based on observation, interview and record review, the facility failed to ensure a clean and sanitary environment was maintained when;

1a. A missing disposal drain cover seal left an exposed surface covered with slimy, dark colored deposits,

1b. Severe corrosion and degradation was found over a large area of the kitchen washroom floor.

1c. Mineral deposits were noted on two stainless steel sinks, all of which prevented proper cleaning and sanitizing of these work surfaces.

These failures had the potential to result in growth and transmission of bacteria which can contaminate food and spread diseases that can severely compromise the health and safety of patients and staff in the facility.

FINDINGS:

1a. During a concurrent observation and interview on June 4, 2024, at 9:05 AM, with the Dietary Manager (DM) in the kitchen washroom, an in-sink macerator (food waste disposal) drain was observed to be missing the rubber splash guard with the bare opening covered in a thick, wet layer of moldy black slime. The DM stated, this drain cover has been gone for a long time. The DM stated, the rubber disintegrated and should be replaced. The DM further stated, "There are probably germs living there. It is not possible to clean that."

1b. During a concurrent observation and interview on June 4, 2024, at 9:10 AM, with the DM, in the kitchen washroom, the cement floor under the dish sanitizer was found to be severely corroded, encrusted with mineral deposits over an uneven surface containing deep fissures. The DM stated, the cracks and bumps made it difficult to clean. It was not a cleanable surface. The DM stated, "We can't really mop under that dishwasher, the floor is too corroded. It is not smooth enough to really clean." The DM further stated "I would agree that the floor is not suitable for food service if it is not cleanable."

1c. During a concurrent observation and interview on June 4, 2024, at 9:35 AM, with the DM, in the kitchen, two stainless steel sinks were observed with areas of crusted white colored mineral deposits that were rough to the touch. The DM stated, the facility's water was very hard, it does leave deposits. The DM further stated, This would impede disinfecting. It should be a smooth surface.

During a follow up interview on June 4, 2024, at 9:37 AM, with the DM, in the kitchen, the DM stated, kitchen surfaces should be without stains or deposits. The DM further stated, Surfaces that are not smooth can be hard to clean and could potentially harbor germs. The kitchen should have smooth, clean surfaces.

During a phone interview on June 5, 2024, at 10:47 AM, with the Registered Dietician (RD), above survey findings in the kitchen were discussed. The RD stated, "Yes, I have seen the corrosion on the floor. I have mentioned to them it needs resurfacing. I would agree that this floor is not suitable for food service if it is not cleanable. It needs to be cleanable and sanitizable." The RD stated, corrosion on sinks or stainless-steel surfaces can harbor germs and grow bacteria. A surface that cannot be properly cleaned can be a source of germs. This corrosion on surfaces prevents proper cleaning. The RD further stated, "A negative outcome would be illness. We try to prevent any negative outcomes through proper food storage, handling, and by disinfecting surfaces."

During a review of the facility's policy and procedure (P&P) titled, "Food and Nutrition Services: Infection Control." dated May 2020 , the P&P indicated, "To develop and maintain clean, sanitary work areas, storage areas and equipment for the handling of supplies in accordance with state and local health department standards."

Based on interview, and record review, the facility failed to ensure a preventative infection control program was established and maintained for a universe of 25 patients admitted to the facility from May 1,2024, through June 6, 2024, when there was no process to identify and monitor infection control practices to minimize the risk of Hospital Acquired Infection (HAI--an infection acquired when receiving health care that was not present during the time of admission.) This failure resulted in the facility's inability to track and evaluate the infection control program within the hospital and had the potential to compromise the quality of health care provided, which may result in a life-threatening infection and prolong the hospitalization of vulnerable patients.

Findings:

During an interview on June 5, 2024, at 8:30 AM, with the Infection control Preventionist (ICP), the ICP stated, there are no tools being used to monitor if staff are adhering to infection control policies and procedures or audits taking place regarding infection control, as in hand washing opportunities here at the facility. The ICP further stated, she does not know if the previous ICP was conducting infection control audits prior to her leaving the position one month ago.

During an interview on June 5, 2024, at 10:40 AM, with the Quality, Risk Case Manager (QRM), the QRM stated, there was no tracking for monitoring infection control practices in the facility. The QRM further stated, infection control surveillance and monitoring regarding staff following infection control standards and facility policies and procedures was not discussed in QRM and no data was collected by the prior infection control nurse .

During a concurrent interview and record review on January 5, 2024, at 4:46 PM, with the ICP, the "Position Summary" for "Infection Control/Employee Health Nurse", revised May 2024, was reviewed. The Job Description indicated, " ...The Infection Control/Employee Health Nurses' focus is the delivery of health care in a clean, safe, protected environment. Position responsibilities include ...assuring compliance with established policies and procedures, ongoing surveillance and evaluation of infections in patients and personnel ...Updates the Infection Control plan annually to continually enhance the program ... Actively surveys all areas of the hospital for potential infectious/hazardous environments, and takes steps for the immediate correction and resolution of any areas identified. Implements strategies designed to reduce the risk of nosocomial, epidemic infections, including initiating cultures on employees, patients or environment and may initiate or enforce isolation procedures to control infection or conduct outbreak investigations...". The ICP stated there was no system in place for monitoring staff performing patient care to ensure the facility infection control P&Ps are being followed. The ICP further stated, identifying infection control problem areas would provide an opportunity to implement safer practices which could decrease the risk of hospital acquired infection.

Based on interview and record review, the facility failed to develop and maintain an effective, ongoing, hospital wide, data driven Quality Assurance and Performance Improvement (QAPI) program for a universe of 25 patients admitted to the facility from May 1, 2024, through June 6, 2024, when:

1. The facility failed to identify, monitor and analyze the problem prone areas such as expired food and supplies, unclean and unsanitary environment, and safely maintain patient care supplies. (Refer to C-1306)

2. The facility failed to provide documented evidenced to show an ongoing effective QAPI program to monitor, analyze, and evaluate the provision of care. (Refer to C-1306)

The cumulative effect of the facility's failure to have a quality assurance system in place to ensure oversight of the hospital's QA program resulted in the facility's failure to deliver care in compliance with the Condition of Participation for QAPI and failure to provide care to their patients in a safe environment.

Based on interview and record review, the facility failed to establish and maintain an effective, ongoing, hospital-wide, data driven Quality Assurance and Performance Improvement (QAPI) program when the facility was unable to ensure the Infection Control Preventionist (ICP) nurse was trained and qualified, an effective infection control program, a clean and sanitary environment, accurate monitoring of inventory and the collection and analysis of hospital-wide clinical data and risk assessment issues used to evaluate the quality and appropriateness of the treatment and services provided for a universe of 25 patients admitted to the facility from May 1, 2024,through June 6, 2024.

These failures resulted in the facility's inability to identify and address important focus areas and proactively implement interventions that would ensure the provision of quality patient care in a safe environment for all patients who received services within the facility.

Findings:

During an interview on June 4, 2024, at 9:40 AM, with the Dietary Manager (DM) the DM stated, The Infection Control Preventionist (ICP) nurse does not look at the kitchen at all. The DM stated there was nobody else from the hospital to really check and monitor the kitchen. The DM stated, the Registered Dietician (RD) does come in every other month and audit with notes on what she finds. The DM further stated, a copy of RD's findings goes to QAPI, but the kitchen was responsible for addressing the issues ourselves. The RD findings are not included in the QAPI program at all.

During an interview on June 4, 2024, at 10:18 AM, with the Quality /Risk case Manager (QRM) the QRM stated, the ICP should be more integrated into QAPI, collecting data to monitor infection-control related issues. The QRM stated, It would be good if they also monitored the kitchen to ensure compliance with Infection Control standards and kitchen hygiene policies.

During an interview on June 5, 2024, at 8:30 AM, with the ICP, the ICP stated, there are no tools being used to monitor if staff are adhering to infection control policies and procedures or audits taking place regarding infection control, as in hand washing opportunities here at the facility. The ICP further stated, she does not know if the previous ICP was conducting infection control audits prior to her leaving the position one month ago.

During an interview on June 5, 2024, at 10:40 AM, with the QRM, the QRM stated, there was no tracking for monitoring infection control practices in the facility. The QRM further stated, infection control surveillance and monitoring regarding staff following infection control standards and facility policies and procedures was not discussed in the Quality Management meetings and no data was collected by the prior infection control nurse.

During a concurrent phone interview and record review on June 5, 2024, at 4:40 PM, with the ICP, the ICP's employee file was reviewed. There were no certificates or documentation related to higher education regarding infection control and prevention. The ICP, stated she did not have documentation of specific education regarding infection control and prevention.

During a concurrent interview and record review on June 5, 2024, at 4:46 PM, with the ICP, the "Position Summary" for "Infection Control/Employee Health Nurse", revised on May 2024, was reviewed. The Job Description indicated, " ...The Infection Control/Employee Health Nurses' focus is the delivery of health care in a clean, safe, protected environment. Position responsibilities include ...assuring compliance with established policies and procedures, ongoing surveillance and evaluation of infections in patients and personnel ...Updates the Infection Control plan annually to continually enhance the program ... Actively surveys all areas of the hospital for potential infectious/hazardous environments and takes steps for the immediate correction and resolution of any areas identified. Implements strategies designed to reduce the risk of nosocomial, epidemic infections, including initiating cultures on employees, patients or environment and may initiate or enforce isolation procedures to control infection or conduct outbreak investigations...". The ICP stated there was no system in place for monitoring staff performing patient care to ensure the facility infection control P&Ps are being followed. The ICP further stated, identifying infection control problem areas would provide an opportunity to implement safer practices which could decrease the risk of hospital acquired infection.

During an interview with the Chief Executive Officer (CEO) on June 6, 2024, at 10:35 AM, the CEO stated, he was not aware that the Infection Control Preventionist needed specific training and certification in infection prevention and control. The CEO further stated, the facility administrators should have been familiar with the regulations regarding the qualifications for infection preventionist position.

During a follow up interview on June 6, 2024, at 10:14 AM, with the QRM, the QRM stated, bi-monthly kitchen audit reports were submitted by the Registered Dietician (RD), but they were not included in any quality data or interventions. The QRM further stated the DM was expected to handle it internally in the dietary department.

During an interview on June 6, 2023, at 10: 22 AM in the conference room, with the Chief Nursing Officer (CNO) the CNO stated, the facility did not have any specific person assigned to check for expired supplies.

During a follow up interview on June 6, 2024, at 10:23 AM, with the QRM, the QRM stated, "We did not identify the issues you found in the survey. There are a lot of things that we are not really monitoring as we should." The QRM further stated, she was not fully aware that the scope of QA should be more comprehensive, monitoring all areas facility wide, including all departments and services. The survey revealed that there are some important areas like the kitchen that have not been included. The QAPI did not work closely enough with the ICP and incorporate all the data that they monitor.