**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility NURSING HOME RESIDENT RIGHTS, the facility failed to ensure Resident Identifier (RI) #77 received their meal at the same time as their roommate, this was observed on 7/16/23 at the supper meal and 7/17/23 at the breakfast meal. This affected one of 24 sampled residents. Findings Include: A review of the facility NURSING HOME RESIDENT RIGHTS revealed Residents of Nursing Homes have rights that . promote and protect the rights of each resident and stresses individual dignity . Right to a Dignified Existence * Be treated with consideration, respect, and dignity, . RI # 77 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Dementia. A review of RI #77's Significant change Minimum Data Set (MDS) with an Assessment Reference Date of 6/16/23 revealed RI #77 was severely impaired with decision making and was total dependent on staff for eating. RI #77 was unable reply to the surveyor. On 7/16/2023 at 5:45 PM, RI #77's roommate was served their meal, RI #77 was not served. The surveyor asked staff if RI #77 was tube fed. the staff said no RI #77 was a feeder tray. On 7/16/2023 at 6:15 PM RI #77 still had not been served; the roommate had finished the meal. On 7/17/2023 at 7:51 AM, RI #77 was observed not having a breakfast meal. The roommate had been served. The breakfast was being served on the halls, those that were able to feed themselves received their trays. On 7/17/2023 at 8:02 AM, RI #77 was observed still without breakfast meal. The roommate was eating breakfast. On 7/17/2023 at 8:26 AM, the surveyor asked (CNA), Certified Nursing Assistant, Employee Identifier (EI) #5 when was RI #77's tray coming, she said RI #77's tray was on the feeder cart and they would bring it around soon. On 7/17/2023 at 8:33 AM CNA, EI #6 brought RI #77's breakfast tray in the room, RI #77 required to be fed. When EI #6 was asked why RI #77 was not fed when the roommate received their tray. She said they give trays to those that feed their selves first, pull the curtain between the residents and then when the feeder trays come those that require to be fed are fed. On 7/18/2023 at 2:03 PM, during an interview with EI #5, CNA, she said residents requiring to be fed residing in a room with a resident that feeds themselves are fed after the trays were passed to those that fed themselves. EI #5 said those requiring to be fed were fed after those that fed selves trays were put out. EI #5 was asked if the resident that required to be fed was eating at the same time as the resident that feeds self. EI #5 said no, we pull the curtain between them once the person that needs to be feds tray comes, we feed them. EI #5 said RI #77 required total assistance with eating. EI #5 said the practice for serving resident trays was to pass those that feed themselves first, then when the cart comes for the ones needing to be fed, we do them. EI #5 stated we were doing that until today, now if one needs to be fed and other feeds their self those two come together. EI #5 was asked when a resident should receive a meal when the roommate was eating a meal. EI #5 said both residents should get the meal at the same time. EI #5 stated we were doing the ones that could feed self then returning with the one needing to be fed later. When EI #5 was asked why one roommate was not supposed to have a tray before the other roommate. She said because the roommate that was not eating could smell the food and it was a dignity issue. On 7/19/2023 at 11:46 AM an interview was conducted with EI #2, Director of Nursing. EI #2 was asked, when should a staff member give a meal tray to one resident in a room and not the other resident. EI #2 said only if the other resident was to receive nothing by mouth, and the curtain should be drawn between them. EI #2 said staff should not give a tray to one resident and not the other in the same room. EI #2 said the process for feeding two residents in a room where one requires to be fed, was to assist the one that fed their self first then feed the one that required to be fed. EI #2 said both residents should be getting a tray and fed at the same time. EI #2 said the concern of a resident requiring to be fed not being served at the same time as a resident that feeds themselves could potentially be a dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure Resident Identifier (RI) #40's Quarterly Minimum Data Set (MDS) assessment dated [DATE], was coded accurately to reflect RI #40 did not receive an antidepressant, medication during this assessment period. This deficient practice affected RI #40, one of 23 sampled residents whose MDS assessments were reviewed. Findings Include: RI #40 was admitted to the facility on [DATE] with a diagnosis of Mood Disorder due to known psychological condition with Depressed Features. A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated 10/2019, revealed the following: . SECTION N: MEDICATIONS . N0410C, Antidepressant: Record the number of days an antidepressant medication was received by the resident at any time during the 7-day look-back period . A Physicians Order for RI #40, dated 10/13/2022, revealed the Remeron was discontinued. RI #40's Quarterly MDS assessment, with an ARD (Assessment Reference Date of 03/21/2023, revealed RI #40 was coded for receiving an antidepressant medication during this assessment period. However, RI #40's March 2023 eMAR (electronic Medication Administration Record) revealed the resident was not receiving an antidepressant medication. On 07/19/2023 at 3:07 PM, an interview was conducted with Employee Identifier (EI) #7, the RN (Registered Nurse) MDS/Care Plan Coordinator. When asked, according to RI #40's most recent physician orders what antidepressant medication RI #40 was receiving, EI #7 said RI #40 was not receiving an antidepressant medication. EI #7 said RI #40 had received an antidepressant medication a while back. EI #7 said RI #40's Quarterly MDS assessment dated [DATE], which coded RI #40 as receiving an antidepressant medication, was not accurate and it was an error. The surveyor asked EI #7 why it was important to ensure MDS assessments were accurate. EI #7 replied it would show what kind of medications the resident was receiving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, a facility policy titled, Pre-admission Screening for Mental Retardation and Mental Illness, and review of Resident Identifier (RI) #57's PASARR (Preadmission Screening and Resident Review), the facility failed to ensure RI #57's PASARR was accurately marked with an admission diagnosis of Major Depression, which would have indicated a Level II. The facility further failed to resubmit a Level I or II when RI #57 was readmitted to the facility with a diagnosis of Psychosis. This affected one of one resident sampled for PASARR. Findings Include: A review of an undated facility policy titled Pre-admission Screening for Mental Retardation and Mental Illness revealed, . PURPOSE: To ensure that individuals with mental retardation and mental illness receive the care and services they need, in the most appropriate setting. On 7/17/2023 at 5:09 PM a review of RI #57's PASARR revealed only a Level I, also no diagnosis were marked. RI #57 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #57's diagnoses sheet included Major Deperessive Disorder, and Psychosis. On 7/19/2023 at 9:13 AM an interview was conducted with Employee Identifier (EI) #4, Social Services. When asked what the facility's process was for identifying residents with a level I or Level II need was she said once the referral was received, they looked at the diagnoses and medications, marked diagnoses and medications on the screening form, then submitted it to the screening office. EI #4 was asked what were RI #57's diagnoses. She replied, Major Depression on admission to the facility in August of 2020 and Psychosis was on a readmit in July 2021. When asked how those diagnoses were marked on the Level I she said they were not it was an oversight. She said RI #57's mental disorder or related condition prior to admission was Major Depression. EI #4 said the depression should have been included on the admission PASARR and the Psychosis on the readmission and another Level I or II should have been resubmitted. EI #4 said the submission for a Level II was an oversight and not done. EI #4 said the PASARR office would determine if a Level II was needed, and social services were responsible for submitting the information. EI #4 said the information should be submitted within a day or two after admission, and once the PASARR screening office reviews and determines the need it was faxed back to the facility indicating the need for a Level II. EI #4 said RI #57's should have been completed in August of 2020, then after the added diagnosis of Psychosis another should have been submitted in July 2021. EI #4 said social services was responsible for the newly added diagnosis in July. EI #4 said the concern in RI #57 not having a Level II completed was documentation and possibly not receiving additional mental health services On 7/19/2023 at 9:22 AM during an interview with EI #3, Registered Nurse, she said she was the nurse that signed the admission PASARR. EI #3 said RI #57 was diagnosed with depression on 8/4/20 at admission and diagnosed with Psychosis in July 2021. EI #3 said the Level I was not coded with depression and the nurse or Social Service was responsible in making sure accurate diagnoses were on the Level I. EI #3 said the concern in the Level I not having accurate diagnoses was there could be a concern in the resident receiving treatment. EI #3 said when the RI #57 received a new diagnosis of Psychosis in July 2021, it was the responsibility of social services to make the submission for a new Level I or II.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, and a facility's policy tilted, Care Plans the facility failed to ensure a care plan for depression was developed for RI (Resident Identifier) #72 a resident with a diagnosis of depression and a smoking care plan was developed for RI #74, a resident who was identified as a smoker. This deficient practice affected two of 23 sampled residents whose care plans were reviewed. Findings Include: A review of a facility's policy titled, Care Plans with a revised date of 09/2009 documented: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: According to federal regulation, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment . RI #72 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis to include: Depression, Unspecified. A review of RI's #72 Social assessment dated [DATE] documented: . (Resident's name) has a diagnosis of Depression . A review of RI's #72 Comprehensive Care Plan revealed there was no documentation of a problem/need for her/his diagnosis of Depression. On 07/19/2023 at 10:23 AM an interview was conducted with EI (Employer Identifier) #7 RN, MDS( Minimum Data Set)/Care Plan Coordinator. EI #7 was asked who was responsible for developing the care plan. EI #7 said she was responsible for developing the care plan for all residents. EI #7 was asked if RI #74 had a diagnosis of depression. EI #7 said yes, and the resident did not have a care plan for her/his diagnosis of depression. EI #7 further stated, the resident should have had a care plan developed for her diagnosis of depression. RI # 74 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of a smokers list provided by the facility identified RI # 74 as a smoker. A review of RI # 74's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/30/2023 documented in Section J RI # 74 was a current tobacco user. The MDS also documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated RI # 74 was cognitively intact. On 7/18/2023 at 2:22PM RI # 74 stated during an interview that she was still smoking and had been since her admission in March of this year. On 7/18/2023 at 4:27PM a review of RI # 74's care plans revealed no care plan for smoking. On 7/19/2023 at 10:48AM an interview was conducted with EI # 7, MDS/Care plan Coordinator. EI # 7 stated RI # 74 was a smoker and did not have a care plan. EI # 7 said RI # 74 should have a smoking care plan to show he/she was at risk of injury due to being a smoker. EI # 7 said he/she did not have a smoking plan due to it being overlooked. EI # 7 was asked what the problem was with not having a smoking care plan and she stated staff would not be able to look at interventions in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, and staff interview the facility failed to ensure a splinting device for Resident Identifier (RI) #3's hand was in place on 7/18/2023 to prevent decreased Range of Motion (ROM). This deficient practice affected RI # 3 one of two residents sampled for position/mobility concerns. Findings Include: Resident Identifier (RI) #3 was readmitted to the facility on [DATE] with diagnoses to include Intracerebral hemorrhage and muscle weakness. A review of RI #3's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 04/25/2023 revealed RI #3's Brief Interview for Mental Status (BIMS) score was 10, indicating moderately impaired. Section G of the MDS, for Functional Status documented RI #3 was totally dependent on staff for all activities of daily living (ADL) and Range of Motion (ROM) upper and lower extremity impairment on one side. A review of RI #3's Physician Orders documented . 2/6/2023 .RESIDENT PARTICIPATION TO HAVE PROM (Passive Range of Motion) TO THE RIGHT HAND-THEN APPLY SPLINT TO THE RIGHT HAND . On 07/18/2023 at 11:36 AM, RI # 3 was observed without a splint to the right hand. On 07/18/2023 at 2: 26 PM, RI # 3 was observed without a splint to the right hand. On 7/19/2023 at 1:49 PM, reviewed Restorative Roster for RI # 3. No documentation of splint/brace being applied on 7/18/2023. An interview with Employee Identifier (EI) # 9, Restorative Certified Nursing Assistant was conducted on 7/19/2023 at 2:45PM. EI # 9 said RI # 3 received services to include a splint to his/her right hand and range of motion (ROM) to his/her arms and legs. EI # 9 said RI # 3 received these serves daily to prevent contractures. EI # 9 said she documented when the right hand splint was applied and it was supposed to be worn daily. EI # 9 said RI # 3 complies with wearing the splinting device and it would not be normal for him/her to take it off. EI # 9 said the harm of not applying the splinting device would be his/her hand would close and contractures would worsen. An interview with EI # 8, restorative nurse was conducted on 7/19/2023 at 3:50PM. EI # 8 said the restorative certified nursing assistant (CNA) was responsible for applying splinting devices to residents. EI # 8 said EI # 9 was the only restorative CNA. EI # 8 said the importance of applying the splinting device to RI # 3 was to prevent decline of contractures. EI # 8 was asked should there be documentation for restorative services for RI # 3. EI # 8 said it should be documented to show the service was completed.

Based on observations, interviews, and review of facility policies titled, MACHINE WAREWASHING, SAFETY GUIDELINES, FOOD SERVICE OPERATION STANDARDS FOR PURCHASING, RECEIVING, COOKING AND STORAGE, OF FOOD and STORAGE OF FROZEN FOOD, the facility failed to ensure: 1. silverware in bags and in a silver ware holder were not wet at the tray line; 2. bowls were not wet and chipped; 3. new food was not poured over old food; and 4. chicken wings were labeled in the freezer. This had the potential to affect 88 of 88 residents who receive meals from the kitchen. Findings Include: 1) A review of a facility policy titled, MACHINE WAREWASHING with a reviewed date of 2/15, revealed: POLICY All dishes and utensils will be washed and sanitized after each use. PROCEDURE: .4. Wash dishes according to machine direction.d. All dishes, glassware, and silverware are air dried. On 10/9/2019 at 10:50 a.m., the surveyor observed a dietary worker bagging silverware ready to go out to the residents. A total of five bags had wet spoons, forks and knives. The surveyor observed wet utensils in a silverware holder. On 10/09/2019 at 12:11 p.m., an interview was conducted with (Employee Identifier) EI #1, Dietary Aide. EI #1 was asked what was her position in the kitchen. EI #1 replied, dietary aide. EI #1 was asked what was she packing wet today. EI #1 replied, silverware. EI #1 was asked why was the silverware wet. EI #1 replied she did not wash them. EI #1 replied, she thought they were dry when they brought them out of the dish room. EI #1 was asked who was responsible for making sure the utensils were dry. EI #1 replied, EI #2, the dishwasher. EI #1 was asked how many bags did she put wet silverware in to go out to the residents. EI #1 replied, five bags. EI #1 was asked why should utensils not be packed wet to give to the residents. EI #1 replied, they were supposed to be dry. EI #1 continued to say there must be enough space in the silverware holder for them to dry. EI #1 was asked what did the space in the silverware holder look like. EI #1 replied, it looked like it was piled up and there was no space in between silverware. EI #1 was asked was the silverware in the sliver ware holder crowded. EI #1 replied yes ma'am. EI #1 was asked what was the facility policy on wet nesting. EI #1 replied, wet utensils can not be sent out to the residents, the silverware must be dry. EI #1 was asked what was wet in the silver ware holder. EI #1 replied, wet spoons, forks and knives. EI #1 replied, she did not know how many were wet. On 10/9/2019 at 12:32 p.m., an interview was conducted with EI #2, Dietary Cook/Aide. EI #2 was asked who was responsible for making sure utensils were dry today. EI #2 replied, she washed all the dishes today. EI #2 stated that she brought the utensils out of the dish room for them to air dry. EI #2 replied, she put them on the cart until another worker finished her work. EI #2 was asked how should utensils be allowed to dry. EI #2 replied, air dry. EI #2 was asked how many spoons, forks and knives were packed in one section of the silverware holder. EI #2 replied, 15 to a section. EI #2 was asked why should silverware be dry before placing them in silver ware bags. EI #2 replied, to prevent cross contamination. 2) A review of a policy titled, SAFETY GUIDELINES with a revised date of 10/17, revealed: .PROCEDURE: .5. Food Service . d. Check dishes and glasses for defects before using. Discard all defective items On 10/9/2019, during the lunch trayline observation, the surveyor observed the cook putting rice in a chipped bowl. The surveyor observed seven bowls at the tray line and two bowls had water in them. On 10/09/2019 at 12:42 p.m., an interview was conducted with EI #3, Cook. EI #3 was asked what was chipped at the tray line. EI #3 replied, the ceramic bowl. EI #3 was asked what did she put in the ceramic bowl. EI #3 replied, rice and gravy. EI #3 was asked what had water in it at the tray line. EI #3 replied, a ceramic bowl. EI #3 was asked why was it important that residents did not receive wet or chipped bowls. EI #3 replied, wet bowls can cause cross contamination and with chipped bowls, the residents may swallow some of the chips. 3) A review of a facility policy titled, FOOD SERVICE OPERATIONAL STANDARDS FOR PURCHASING, RECEIVING, COOKING AND STORAGE OF FOOD with a revised date of 10/17, revealed: .PROCEDURE: 7. Holding .c. Never add new product to old product for serving . On 10/09/2019 at 10:35 a.m., the surveyor observed EI #3 pour a pot of new rice over old rice . The new rice was on the stove in a pot and the stove was not on. The old rice was in a pan on the steam table. On 10/09/19 at 12:42 p.m., an interview was conducted with EI #3. EI #3 was asked why did she pour new rice over old rice. EI #3 replied, because she was giving out of rice and needed some rice. EI #3 was asked how many residents did she serve from the new rice pot. EI #3 replied, 18 residents. EI #3 was asked why was it important that new food was not poured over old food. EI #3 replied, the old food was cold and cooling down the new food. EI #3 was asked how should she add new food items to the tray line. EI #3 replied, remove the old pan and put the new pan in. 4) A review of a policy titled, STORAGE OF FROZEN FOOD with a revised date of 10/17, revealed: POLICY: The facility ensures the quality and safety of frozen food through accepted storage practices. PROCEDURE: .7. Frozen foods that are stored in opened .packages are labeled with common name of the food, the date stored and the use-by or expiration date . On 10/08/2019 at 8:02 a.m., the surveyor observed in the freezer about 20 chicken wings in a large zip lock bag. There was no label or information on the bag. On 10/10/2019 at 9:29 a.m., an interview was conducted with the Dietary Manager, EI #4. EI #4 was asked what was in the freezer in a large plastic bag with no label on it. EI #4 replied, chicken wings. EI #4 was asked why was there no label on it. EI #4 replied, the label fell off. EI #4 was asked was she able to find the label. EI #4 replied, no ma'am. EI #4 was asked what was the facility policy on labeling food item. EI #4 replied, all foods must be labeled and dated. EI #4 was asked why should food items be labeled. EI #4 replied, to ensure the correct receiving date. EI #4 was asked who was responsible for labeling food items. EI #4 replied, everyone in the kitchen was responsible for labeling food items. EI #4 was asked how should food items be labeled. EI #4 replied, with a sticker, a label sticker or marker. EI #4 was asked what information should be on the label. EI #4 replied, the name of the food items, and the date the item came in.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure licensed staff did not clean the wound for Resident Identifier (RI) #8 then apply the skin prep and hydrocolloid dressing without changing gloves or washing hands. This was observed on 10/17/18 and affected one of three residents observed for wound care. Findings Include: RI #8 was admitted to the facility 11/14/03 and readmitted [DATE] with a diagnosis of Hemiplegia following Cerebral Vascular Disease. A review of RI #8's October 2018 Physician Orders revealed: .CLEAN WOUND TO LEFT BUTTOCK WITH WOUND CLEANSER .APPLY SKIN PREP .APPLY HYDROCOLLOID DRESSING . On 10/17/18 at 9:30 AM, the surveyor observed Employee Identifier (EI) #2, Registered Nurse (RN), performing wound care for RI #8. EI #2 gathered the needed supplies to include, wound cleanser, 4x4's, skin prep, barrier for overbed table, trash bag and a hydrocolloid outer dressing which she predated and initialed before entering the resident's room. EI #2 removed the soiled dressing washed her hands and put on new gloves. EI #2 cleaned the wound with wound cleanser, patted the area dry with a 4x4, then measured the wound. EI #2, with the same gloves she had on to clean the wound with, applied the skin prep around the wound. EI #2, with the same gloves, applied the hydrocolloid dressing. On 10/17/18 at 2:24 PM, an interview was conducted with EI #2. EI #2 was asked what was the policy on when to change gloves during wound care. EI #2 replied, after cleaning the wound. EI #2 was asked if she changed gloves after cleaning the wound. EI #2 replied, no and she had them laying there to do that. EI #2 was asked what was the harm in not changing gloves after cleaning a wound and before placing the clean dressing. EI #2 replied, contaminating the wound and cross contamination. On 10/18/18 at 9:21 AM, an interview was conducted with EI #1, Director of Nursing, (DON). EI #1 was asked what was the policy on when to change gloves during wound care. EI #1 replied, before starting the procedure, after cleaning the wound, then before placing the treatment and the dressing. EI #1 was asked should staff change gloves after cleaning a wound before applying the treatment and outer dressing. EI #1 replied, yes. EI #1 was asked what would the potential for harm be in a nurse not changing gloves and washing their hands after cleaning a wound and before applying the clean treatment and outer covering. EI #1 replied, it could slow the progress of wound healing.

Based on observation, interview and a review of a facility policy titled, TRAY ASSEMBLY, the facility failed to ensure the milk temperature was taken during the lunch meal on 10/17/18. This affected one of four meal carts and had the potential to affect any resident who received milk from Cart 4 during the lunch meal on 10/17/18. Findings Include: A review of a facility policy titled, TRAY ASSEMBLY with a date of 9/04, revealed: .PROCEDURE: .4. Cold hazardous food is held in a manner that maintains the temperature at 41 (degrees) F (Fahrenheit) or below . On 10/17/18 at 11:52 AM, the surveyor observed the staff preparing meals for Cart #4. The staff took a carton of 2% milk and placed it on a tray then placed the tray on the cart and did not tempt the milk. On 10/17/18 at 11:55 AM, before Cart #4 was to exit the kitchen, the surveyor asked Employee Identifier (EI) #3, Dietary Manager (DM) to check the temperature of the milk. The temperature was 50 degrees F. On 10/18/18 at 10:25 AM, an interview was conducted with EI #3. EI #3 was asked when the tray line was in progress, how did she ensure the milk maintained the required temperature. EI #3 said they placed it in a bowl with ice and the milk was on top of the foil wrap. EI #3 was asked when she and the surveyor tempted the milk off the tray that was placed on Cart #4, what was the temperature. EI #3 said 50 degrees F. EI #3 was asked what should the milk temperature be. EI #3 said the temperature should be 41 degrees or below. EI #3 was asked how would she expect it (the milk) to stay cold if it was on top of the ice. EI #3 said she could not answer that. EI #3 was asked why it was important for the milk temperature to remain 41 degrees F or below. EI #3 said so it would not reach the danger zone.