**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to shave, clean the hands and face, and change clothing for 1 (Resident #2) of 1 resident reviewed for dignity. Findings include: A review of a facility policy titled, Resident Rights, revised on 12/01/2016, indicated residents would have their existence dignified and would be treated with respect kindness and dignity. A review of Resident #2 ' s admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed supervision or touching assistance with personal hygiene; and partial to moderate assistance with upper body dressing. A review of Resident #2 ' s Care Plan, initiated on 12/26/2023, revealed the resident had an ADL deficit. Interventions included extensive assistance by one staff for personal hygiene and oral care and extensive assistance by one staff for dressing. A review of an Activity of Daily living task listed in the Documentation Survey Report, Personal Hygiene, revealed Resident #2 had personal hygiene every shift and staff were to layer clothing instead of applying loose articles such as a lap blanket to accommodate feeling cold when up to wheelchair related to mental awareness. A review of the MDS [NAME] Report, printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days, as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2 ' s room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face, and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch, and a large coffee stain around the neck of the shirt. When asked Resident #2 stated a preference to be clean and did not want to be dirty. During an interview on 10/30/2024 at 8:55 AM, the Certified Nursing Assistant (CNA) #4 stated Resident #2 did like to be shaved and that with dressing, it was extensive assistance that was needed. CNA #4 confirmed CNAs provide showers and sometimes Resident #2 will refuse to be shaved, only when not feeling good, but most of the time will allow staff to shave when it is needed. CNA #4 confirmed Resident #2 ' s face and hands should have been cleaned prior to leaving the dining room and the shirt should have been changed if Resident #2 agreed, and it should have been offered. During an interview on 10/30/2024 at 12:39 PM, Director of Nursing (DON) confirmed Resident #2 should have had his face and hands cleaned prior to leaving the dining room, and staff should have offered to change the soiled shirt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, and facility policy review it was determined that the facility failed to ensure accuracy of the assessments required for the Minimum Data Set (MDS) for 1 (Resident #2) of 2 residents reviewed for accuracy and assessment completion of the MDS. Findings include: A review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revised on December 2009 indicated, any personnel completing any section of the MDS must sign and certify accuracy of that assessment portion. A review of the admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with eating and oral care, supervision or touching assistance with personal hygiene; partial to moderate assistance with upper body dressing, toileting, bed mobility which included sit to lying, lying to sitting on the side of the bed, sit to stand position, and chair to bed transfer, toilet transfer and tub/shower transfer. A review of Resident #2 ' s Care Plan, dated on 12/26/2023, revealed the resident had an Activities of Daily Living (ADL) self-performance deficit. Statement in the care plan: the assistance needed for self-care performance fluctuates and Resident #2 may require more or less assistance, therefore the staff will provide the needed assistance at the time based on the circumstances. Interventions included being able to feed self after setting up, extensive assistance with oral care, personal hygiene, dressing, bed mobility, and transfers needed. A review of Resident #2 ' s MDS [NAME] Report printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. A review of an activity of daily living task in the Documentation Survey Report, bed mobility, revealed Resident #2 required partial to moderate assistance 3 out of 7 days and substantial to maximal assistance on 3 out of 7 days and total dependency on 1 out of 7 days. For the task of toileting, required substantial to maximal assistance 4 out of 7 days, 2 out of 7 days of total dependence and 2 out of 7 days for partial to moderate assistance. The task of transferring, 4 out of 7 days required substantial or maximal assistance, 3 out of 7 days required partial to moderate assistance and 1 day Resident #2 was independent with transfer. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2 ' s room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt that was being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch and a large coffee stain around the neck of the shirt. When asked, Resident #2 stated a preference to be clean and did not want to be dirty. During an observation on 10/30/2024, CNA#4 and CNA#5 transferred Resident #2 to bed after breakfast. A gait belt was placed around Resident #2 ' s waist, the wheelchair was placed beside the resident's bed on the left side. The resident ' s jacket was removed. CNAs were on either side of Resident #2 and resident was asked to lean forward, with the use gait belt, Resident #2 was brought to a standing position with body bent forward, scooted feet to pivot and was placed in a seated position on the side of the bed with CNA#4 and CNA #5 providing maximal support for Resident #2. Once on the side of the bed, both CNAs had to assist Resident #2 to scoot further up to the head of the bed, CNA#5 turned the top half of the body while CNA #4 brought Resident #2's legs up and placed on the bed. During an interview on 10/30/2024 at 12:14 PM, CNA #4 stated the closet care plan was used to determine what type of assistance was needed with care provided to Resident #2. CNA #4 confirmed Resident #2 needed assistance with cleaning up, shaving and changing clothing. Confirmation was given by CNA #4, that Resident #2 was an extensive transfer of 2 staff members. During an interview on 10/30/2024 at 12:14 PM, MDS Coordinator stated to complete the MDS, observations were made, staff and residents were interviewed, and the chart was reviewed. The MDS coordinator confirmed the care plan was updated once the MDS had been completed. The MDS coordinator stated Resident #2 must have had a significant change, and the resident would be reevaluated. The MDS coordinator gave confirmation that the MDS and the Care Plan did not match on Resident #2. During an interview on 10/30/2024 at 3:00 PM, DON stated the inaccuracy of MDS ' had been identified and were brought to the attention of the Quality Assessment and Assurance Committee in June 2024. An action plan was put into place which included 1) Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS the first time, 2) MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS, 3) The MDS coordinator will ensure the care plan was updated when completing the MDS, 4) MDS sections will be audited weekly to ensure all sections were being completed timely and accurately by the DON or designee, 5) hire new MDS coordinator, and 6) sign MDS coordinator up for training. DON stated the issue of MDS ' was discussed in the morning meetings and t the Administrator would have the minutes. When asked how the staff would know what plan to follow when caring for the residents, since the care plan, the closet care plan and the MDS did not match; DON stated the staff had a fall binder which would tell the staff what interventions had been put into place and what assistance would be required. During an interview on 10/30/24 at 3:10 PM, Administrator was asked to review the morning meeting minutes to see if there was any information regarding MDS inaccuracy issues. From June 2024 to October 2024, the Administrator confirmed there was no mention of MDS inaccuracy or care plan issues. Administrator confirmed there was a mention of the MDS inaccuracy in the July 2024 Quality Assurance meeting, but no further follow-up was documented in the following months. Administrator stated the DON had sent an email, titled Corrections/Plans from Mock Survey, dated 09/11/24 at 3:55 PM, stating five care plans would be reviewed in the morning start up. During an interview on 10/30/24 at 3:52 PM, DON provided paperwork showing care plan reviews but described no issues or how those issues were corrected. Most of the pages had no dates, no last names of residents and only 100 hall were provided. No other forms were provided to support any evidence that ongoing reviews for MDS and care plan inaccuracies were being completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure care plans were updated with accurate information and failed to resolve care plans that were no longer needed for 1 (Resident #2) of 3 residents reviewed for Care Plans. The findings are: 1. A review of a facility policy titled, Resident Rights, revised December 2016, indicated residents have the right to be informed of and participate in care planning and treatment. 2. A review of Resident #2 ' s admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with eating and oral care, supervision or touching assistance with personal hygiene; partial to moderate assistance with upper body dressing, toileting, and bed mobility which included: sit to lying, lying to sitting on the side of the bed, sit to stand position, and chair to bed transfer, toilet transfer and tub/shower transfer. A review of Resident #2 ' s Care Plan, dated on 12/26/2023, revealed resident had an Activities of Daily Living (ADL) self-performance deficit. Statement in the care plan: the assistance needed for self-care performance fluctuates and Resident #2 may require more or less assistance, therefore staff will provide the needed assistance at the time based on the circumstances. Interventions include being able to feed self after setting up, and extensive assistance with oral care, personal hygiene, dressing, bed mobility, and transfers. A review of Resident #2 ' s MDS [NAME] Report printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. A review of an activity of daily living task in the Documentation Survey Report, titled bed mobility, revealed Resident #2 required partial to moderate assistance 3 out of 7 days and substantial to maximal assistance on 3 out of 7 days and total dependency on 1 out of 7 days. For the task of toileting, required substantial to maximal assistance 4 out of 7 days, 2 out of 7 days of total dependence and 2 out of 7 days for partial to moderate assistance. The task of transferring, 4 out of 7 days required substantial or maximal assistance, 3 out of 7 days required partial to moderate assistance and 1 day Resident #2 was independent with transfer. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2 ' s room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch, and a large coffee stain around the neck of the shirt. When asked, Resident #2 stated a preference to be clean and did not want to be dirty. During an observation on 10/30/2024, CNA#4 and CNA#5 transferred Resident #2 to bed after breakfast. A gait belt was placed around Resident #2 ' s waist, the wheelchair was placed beside the resident ' s bed on the left side. The resident ' s jacket was removed. CNAs were on either side of Resident #2 and resident was asked to lean forward, with the gait belt, Resident #2 was brought to a standing position with body bent forward, scooted feet to pivot and was placed in a seated position on the side of the bed with CNA#4 and CNA #5 providing maximal support for Resident #2. Once on the side of the bed, both CNAs had to assist Resident #2 to scoot further up to the head of the bed, CNA#5 turned the top half of the body while CNA #4 brought Resident #2 ' s legs up and placed on the bed. During an interview on 10/30/2024 at 12:14 PM, CNA #4 stated the closet care plan was used to determine what type of assistance was needed with care provided to Resident #2. CNA #4 confirmed that Resident #2 needed assistance with cleaning up, shaving and changing clothing. Confirmation was given that Resident #2 was an extensive transfer of 2 staff members. During an interview on 10/30/2024 at 12:09 PM, the MDS Coordinator stated the treatment nurse and dietary are responsible for reviewing and updating care plans for their areas. The MDS Coordinator confirmed that the care plan was updated once the MDS has been completed. The MDS Coordinator stated Resident #2 must have had a significant change, and that resident would be reevaluated. Confirmation from the MDS coordinator was given that the MDS and Care Plan did not match on Resident #2. During an interview on 10/30/2024 at 3:00 PM, the Director of Nursing (DON) stated the inaccuracy of MDS ' had been identified and were brought to the attention of the Quality Assessment and Assurance Committee in June 2024. An action plan was put into place which included 1) Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS the first time, 2) MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS, 3) MDS coordinator will ensure care plan is updated when completing the MDS, 4) MDS sections will be audited weekly to ensure all sections are being completed timely and accurately by the DON or designee, 5) hire new MDS coordinator, and 6) sign MDS coordinator up for training. DON stated the issue of MDS ' was discussed in the morning meetings and the administrator would have the minutes. When asked how the staff would know what plan to follow when caring for residents, since care plan, closet care plan and MDS did not match, DON stated staff had a fall binder which would tell what interventions had been put into place and what assistance would be required. During an interview on 10/30/24 at 3:10 PM, the Administrator was asked to review the morning meeting minutes to see if there was any information regarding MDS inaccuracy issues. From June 2024 to October 2024, Administrator confirmed there was no mention of MDS inaccuracy or care plan issues. Administrator confirmed there was a mention of the MDS inaccuracy in the July 2024 Quality Assurance meeting, but no further follow-up was documented in the following months. The Administrator stated the DON had sent an email titled, Corrections/Plans from Mock Survey, dated 09/11/24 at 3:55 PM, stating five care plans would be reviewed in the morning start up. During an interview on 10/30/24 at 3:52 PM, the DON provided paperwork showing care plan reviews, but no issues were described and no details on how those issues would have been corrected. Most of the pages had no dates, no last names of residents and only 100 hall was provided. No other forms were provided to support any evidence that ongoing reviews for MDS and care plan inaccuracies were being completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure the care plans were updated within the appropriate time frame with accurate information and failed to resolve care plans that were no longer needed for 3 (Resident #2, #14, and #23) of 3 residents reviewed for Care Plans. The findings are: 1. A review of a facility policy titled, Resident Rights, revised December 2016, indicated, residents have the right to be informed of and participate in care planning and treatment. 2. A review of Resident #2 ' s admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed set up or clean up assistance with eating and oral care, supervision or touching assistance with personal hygiene; partial to moderate assistance with upper body dressing, toileting, and bed mobility which included: sit to lying, lying to sitting on the side of the bed, sit to stand position, and chair to bed transfer, toilet transfer and tub/shower transfer. A review of Resident #2 ' s Care Plan, dated on 12/26/2023, revealed the resident had an Activities of Daily Living (ADL) self-performance deficit. Statement in Resident #2 ' s care plan: assistance needed for self-care performance fluctuates and Resident #2 may require more or less assistance, therefore staff will provide the needed assistance at the time based on the circumstances. Interventions include being able to feed self after setting up, and extensive assistance with oral care, personal hygiene, dressing, bed mobility, and transfers. A review of Resident #2 ' s MDS [NAME] Report printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. A review of an intervention/task, in the Documentation Survey Report, titled, bed mobility, revealed Resident #2 required partial to moderate assistance 3 out of 7 days and substantial to maximal assistance on 3 out of 7 days and total dependency on 1 out of 7 days. For the task of toileting, Resident #2 required substantial to maximal assistance 4 out of 7 days, 2 out of 7 days of total dependence and 2 out of 7 days for partial to moderate assistance. The task of transferring, 4 out of 7 days required substantial or maximal assistance, 3 out of 7 days required partial to moderate assistance and 1 day Resident #2 was independent with transfer. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2 ' s room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch, and a large coffee stain around the neck of the shirt. When asked, Resident #2 stated a preference to be clean and did not want to be dirty when asked. During an observation on 10/30/2024, Certified Nursing Assistant (CNA) #4 and CNA #5 transferred Resident #2 to bed after breakfast. A gait belt was placed around Resident #2 ' s waist, the wheelchair was placed beside the resident ' s bed on the left side. The resident ' s jacket was removed. CNAs were on either side of Resident #2 and resident was asked to lean forward, with the gait belt, Resident #2 was brought to a standing position with body bent forward, scooted feet to pivot and was placed in a seated position on the side of the bed with CNA #4 and CNA #5 providing maximal support for Resident #2. Once on the side of the bed, both CNAs had to assist Resident #2 to scoot further up to the head of the bed, CNA #5 turned the top half of the body while CNA #4 brought Resident #2 ' s legs up and placed on the bed. During an interview on 10/30/2024 at 12:14 PM CNA #4 stated the closet care plan was used to determine what type of assistance was needed with care provided to Resident #2. CNA #4 confirmed Resident #2 needed assistance with cleaning up, shaving and changing clothing. Confirmation was given that Resident #2 was an extensive transfer of 2 staff members. 3. A review of Resident #14 ' s admission Record, indicated the facility admitted Resident #14 with diagnoses that included cerebral infarction, cerebellar stroke syndrome, dementia, pain, and seizures. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2024, revealed Resident #14 had BIMS score of 7 which indicated the resident had moderate cognitive impairment. Resident #14 required set up or clean up assistance with eating, supervision or touching assistance with oral care, upper and lower body dressing, required substantial or maximal assistance with showering/bathing and applying or removing footwear, partial to moderate assistance with bed mobility and personal hygiene. Resident #14 was dependent with toileting hygiene and transferring from one surface to another. A review of Resident #14 ' s Care Plan, initiated on 02/16/2018, indicated total dependence on staff for bathing and showering and transferring required 2 staff with the use of a mechanical lift. Resident #14 was able to feed self after setting up, and extensive assistance was required with bed mobility, personal hygiene and dressing. A review of Resident #14 ' s MDS [NAME] Report, printed 06/20/2024, indicated Resident #14 required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and total dependence for transferring. A review of an Activity of Daily living task in, the Documentation Survey Report, bed mobility for August 2024 revealed Resident #14 required total assistance with bed mobility 5 out of 7 days and partial to moderate assistance 2 out of 7 days. Toileting: 4 out of 7 days required total assistance, substantial to maximal assist for 1 out of 7 days and 2 days with partial to moderate assistance were required. During an observation on 10/28/2024 at 1:31 PM, Resident #14 was assisted to room by staff and 1 staff member was noted to be taking a mechanical lift into the room to assist the resident to bed. During an observation on 10/29/24 at 8:07 AM, Resident #14 was eating breakfast in the dining room without assistance. During an interview on 10/30/2024 at 4:10 PM, CNA #7 confirmed Resident #14 was unable to dress self, was transferred with a mechanical lift, and could not position self in bed. 4. A review of Resident 23 ' s admission Record, indicated the facility admitted Resident #23 with diagnoses that included encephalopathy (fluid on the brain), dependence on renal dialysis, chronic kidney disease, Stage 4 (severe), and acute metabolic acidosis. Review of 5-day Medicare Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/15/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. Resident #23 was not marked for taking a high-risk drug, a diuretic. A review of Resident #23 ' s Care Plan, initiated 12/09/2022 revealed Resident #23 was on diuretic therapy related to hypertension. Interventions included administering the diuretic medication and monitoring for side effects and effectiveness, monitoring dose; and to monitor, document and report as needed any adverse reactions to the diuretic therapy. A review of the Order Summary Report, revealed Resident #23 did not have an order for any type of diuretic. During an observation on 10/28/24 at 1:00 PM, Resident # 23 was lying in bed on right side eating lunch and watching television. During an observation on 10/29/24 at 8:11 AM, Resident #23 was lying in bed, watching television and voiced no concerns. MDS coordinator confirmed Resident #23 was no longer on a diuretic and the care plan was last updated on 12/09/2022. MDS Coordinator stated according to the discontinued physician orders, the diuretic had been discontinued on 04/12/2023. During an interview on 10/30/2024 at 12:09 PM, MDS Coordinator stated, the treatment nurse and dietary are responsible for, reviewing and updating care plans for their areas. MDS Coordinator confirmed the care plan was updated once the MDS has been completed. Stated Resident #2 must have had a significant change, and that resident would be reevaluated. Confirmation was given by MDS Coordinator that MDS and Care Plan did not match on either Resident #2, #14, or #23, and had not been updated when the MDS had been completed. During an interview on 10/30/2024 at 3:00 PM, the Director of Nursing (DON) stated the inaccuracy of MDS ' had been identified and were brought to the attention of the Quality Assessment and Assurance Committee in June 2024. An action plan was put into place which included 1) Interdisciplinary team members were in-serviced to make sure information was entered correctly on the MDS the first time, 2) MDS coordinator and DON/Assistant Director of Nursing (ADON) in-serviced to ensure accuracy prior to signing and/or submitting the MDS, 3) MDS coordinator will ensure the care plan is updated when completing the MDS, 4) MDS sections will be audited weekly to ensure all sections are being completed timely and accurately by the DON or designee, 5) hire new MDS coordinator, and 6) sign MDS coordinator up for training. DON stated the issue of MDS ' was discussed in the morning meetings and that Administrator would have the minutes. When asked how the staff would know what plan to follow when caring for the residents, since care plan, closet care plan and MDS did not match, DON stated staff had a fall binder which would tell what interventions had been put into place and what assistance would be required. During an interview on 10/30/24 at 3:10 PM, the Administrator was asked to review the morning meeting minutes to see if there was any information regarding the MDS inaccuracy issues. From June 2024 to October 2024, the Administrator confirmed there was no mention of MDS inaccuracy or care plan issues. The Administrator confirmed there was a mention of the MDS inaccuracy in the July 2024 Quality Assurance meeting, but no further follow-up was documented in the following months. The Administrator stated the DON had sent an email, titled Corrections/Plans from Mock Survey, dated 09/11/24 at 3:55 pm, which stated five care plans would be reviewed in the morning start up. During an interview on 10/30/24 at 3:52 PM, the DON provided paperwork showing care plan reviews, but no issues were described and no details on how those issues would have been corrected. Most of the pages had no dates, no last names of residents and only 100 hall was provided. No other forms were provided to support any evidence that ongoing reviews for the MDS and care plan inaccuracies were being completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure resident was shaved, failed to clean resident ' s face and hands after meals and failed to assist resident with changing clothing after being soiled during meals for 1 (Resident #2) of 1 resident reviewed for activities of daily living. Findings include: A review of a facility policy titled, Activities of Daily Living (ADLs), Supporting, revised in March 2018, indicated, residents who were unable to independently carry out ADLs would receive services to maintain good nutrition, grooming and personal and oral hygiene. A review of Resident #2 ' s admission Record, indicated the facility admitted Resident #2 with diagnoses that included Parkinsonism, dementia, chronic pain, and muscle weakness. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/18/2024, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact; needed supervision or touching assistance with personal hygiene; and partial to moderate assistance with upper body dressing. A review of Resident #2's Care Plan, initiated on 12/26/2023, revealed Resident #2 had an ADL deficit. Interventions included extensive assistance by one staff for personal hygiene and oral care and extensive assistance by one staff for dressing. A review of an intervention/task on the Documentation Survey Report, revealed Resident #2 had personal hygiene every shift, and staff were to layer clothing instead of applying loose articles such as a lap blanket to accommodate feeling cold while up to wheelchair related to mental awareness. A review of Resident #2 ' s MDS [NAME] Report , printed on 06/21/2024, indicated Resident #2 needed extensive assistance with personal hygiene and dressing. A review of an In-service Education Report, dated 08/02/2024, indicated staff were in-serviced on ADLs, baths, wheelchairs, transfers, and gait belts. During an observation on 10/28/2024 at 1:28 PM, Resident #2 returned to room after noon meal in the dining room, the area around the mouth, chin and hands were covered in orangish-red sauce from meal and the tee shirt that was worn was stained with droppings from the noon meal. Resident #2 had the appearance of not being shaved for several days as indicated by the hair growth on the cheeks and chin. During an observation on 10/29/2024 at 8:14 AM, Resident #2's room was darkened due to the light being off. Resident #2 was sitting in wheelchair waiting to go to bed. Resident #2 was in need of a shave due to facial hair growth on chin and cheeks. Droppings of food were noted on the shirt being worn at that time. During an observation on 10/29/2024 at 12:30 PM, Resident #2 was sitting at the dining room table eating lunch and was noted with long facial hair on chin and cheeks and the same shirt that Resident #2 was wearing at breakfast was still being worn with the same stains visible. During a concurrent interview and observation on 10/29/2024 at 1:47 PM, Resident #2 was made aware of the facial hair growth and the stains of food on the face and beard and that the shirt had not been changed since breakfast and was still soiled with droppings of food from breakfast and lunch, and a large coffee stain around the neck of the shirt. When asked, Resident #2 stated a preference to be clean and did not want to be dirty. During an interview on 10/30/2024 at 8:55 AM, Certified Nursing Assistant (CNA) #4 stated Resident #2 did like to be shaved and that with dressing, it was extensive assistance that was needed. CNA #4 confirmed CNAs provide showers and sometimes Resident #2 will refuse to be shaved, only when not feeling good, but most of the time will allow staff to shave when needed. CNA #4 confirmed Resident #2's face and hands should have been cleaned prior to leaving the dining room, and shirt should have been changed if Resident #2 agreed and that it should have been offered. During an interview on 10/30/2024 at 12:39 PM, Director of Nursing (DON) confirmed Resident #2 should have had his face and hands cleaned prior to leaving the dining room and staff should have offered to change the soiled shirt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, it was determined that the facility failed to ensure that residents had a clean, safe, homelike environment by not repairing water damaged ceiling, walls, light fixtures, and not keeping furniture and linens clean. The findings are: 1. On 10/28/2024 at 11:55AM, Resident #11's bedsheets were observed to have a brown, wet substance on them. Resident #11 confirmed she had an accident and needed assistance. A Certified Nursing Assistant (CNA) was called into the room to assist resident. a. On 10/29/2024 at 8:27AM, observed Resident #11 having the same bedsheets as the day before, and brown substance appeared to be dried on the sheets. 2. On 10/29/2024 at 8:31AM, in the hall of the secure unit, two ceiling tiles and a light covering appeared to have been wet by the appearance of brown ring stains, and a spot in the light covering that looked like liquid. 3. On 10/29/2024 at 8:48AM, rubber stripping that connects the floor with the wall in the dining room was peeled back and a hole was exposed in the wall. a. On 10/29/2024 at 8:49AM, in the dining room, above the exit sign, the ceiling tile was brown, as though it had been wet. b. On 10/29/2024 at 8:49AM, in the dining room, the wall had a lump in it and was spongy to touch. The rubber stripping that attaches the wall to the floor was not attached to the floor. The stripping was pulled up, and what appeared to be a wooden or cement wall was exposed, that looked like it had been wet. The wooden or cement surface had black and gray substance, and the bottom looked to be eroding and crumbling. 4. On 10/29/2024 at 8:59Am, in the secure unit of the facility, there was a chair in the dayroom that was observed to have several stains. The chair was a greenish gray color, and the stains were darker in color, as though there had been spills on it. 5. On 10/29/2024 at 11:44AM, an air conditioner was observed in a resident's room, that had a metal casing that attached it to the wall along with a puffy yellow substance around the edges where the air unit met the wall. 6. On 10/30/2024 at 8:45AM, a picture of the chair with stains, from the unit in the facility, was shown to the Administrator. The Administrator was asked if he would sit in the chair or have it in his home. The Administrator confirmed that the chair should not have been in the building, and it would be removed promptly. a. On 10/30/2024 at 8:47AM, a picture of Resident #11's bedsheets was shown to Administrator. Administrator was asked if the bedsheets needed to be changed. Administrator confirmed the bedsheets should not have been left on resident's bed in that condition. 7. On 10/30/2024 at 2:11PM, the surveyor observed in the secure unit of the facility, that the dirty chair with stains had been removed from the unit. Surveyor asked CNA #1 where the chair went and CNA #1 stated the chair was not even supposed to be in there, somebody came and took it out. 8. On 10/30/2024 at 2:13PM, Resident #11's bedsheets had been changed and resident was in bed taking a nap. 9. On 10/30/2024 at 2:15PM, Licensed Practical Nurse (LPN) #9 confirmed that resident's sheets are changed on bath day. LPN #9 confirmed CNAs are to change the bedsheets if needed or resident gets a bath. LPN #9 stated CNAs are assigned to residents, and it changes daily. There are no housekeeping chore assignments for the CNA's. 10. On 10/30/2024 at 2:45PM, the Administrator provided a copy of the Quality of Life-Homelike Environment Policy for the facility. The policy indicates that the residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 11. On 10/31/2024 at 7:30AM, upon entering facility the surveyor noticed several places in the dining room ceiling leaking a liquid onto the floor. Housekeeper #2 confirmed this happens often. Housekeeper #8 confirmed it happens every time it rains. a. On 10/31/2024 at 7:59AM, the Administrator confirmed the facility's roof leaks when it rains, and they have quotes to have the roof fixed and waiting for approval from owners. b. On 10/31/2024 at 9:52AM, the Maintenance Director (MD) confirmed the floors, walls, and rubber stripping were worn badly and needing repair. The MD said that new tile is on its way and when the new floor was laid, the walls and rubber stripping would be replaced. The MD also confirmed the roof leaks when it rains, and it was hard to seal the leaks when the roof was flat and stays wet from holding water. 12. On 10/28/2024 at 12:11PM, the air conditioning unit in room [ROOM NUMBER] had a yellowish tinge to the upper section where the cold air was dispersed. The same vent area showed a blackish brown substance adhered to the inside of the upper section and the vent fins. The vent joints contained a greyish-white, fuzzy substance. The wall directly to the left side of the window, behind the headboard and the wall to the right, where a resident ' s bed was pushed up against it, had gouges of paint missing. 13. On 10/28/2024 at 12:14PM, the 300-hall dayroom air conditioning unit, showed an approximate two-inch vertical accumulation of a dark brown, fuzzy-like unknown substance that clogged the right vent screen. The bottom screen near first vertical plastic stabilizer on the left side was approximately one and a half inches. The bottom screen, near the first vertical plastic stabilizer on the right side, had approximately one-third of the middle section clogged with a similar unknown dark brown, fuzzy-like substance. 14. On 10/28/2024 at 12:25PM, in room [ROOM NUMBER] the ceiling air vent near the window, directly above a resident's bed, contained several brown fuzzy objects hanging from the grating of the air vent. The wall air vent located by the door, where another resident ' s bed was pushed directly underneath the vent, contained a black grimy substance adhered to the air vent grid. 15. On 10/30/2024 at 7:33AM, a hallway 300 ceiling light cover contained what appeared to be various insect and spider carcasses, along with various black or brown specks. 16. On 10/31/2024 at 9:50AM, Maintenance Director, stated the air conditioning units were unable to be cleaned, but the facility was in the process of replacing them. The wall and ceiling air vents were maintenance responsibility to clean. The ceiling light covers were maintenance responsibility to clean. 17. On 10/31/2024 at 10:17AM, during an interview the Director of Nursing (DON) stated air filtration was a problem. Residents should not be exposed to the air coming out of dirty vents. It can exacerbate a lung diagnosis or increase a need for O2. All departments should be involved in observing and notifying maintenance or housekeeping to help keep air vents clean. 18. On 10/31/2024 at 10:23AM, during an interview Administrator stated, I need to get the housekeepers on deep cleaning ceiling vents and cleaning the air conditioning unit vent areas. The facility has been trying to replace the air conditioning units. 19. On 10/31/2024 at 10:30AM, the Nurse Consultant stated the facility does not have a housekeeping policy. 20. Review of a facility document, October 2024 housekeeping deep clean schedule showed October 1, 2024, room [ROOM NUMBER] and October 11, 2024, room [ROOM NUMBER] had been deep cleaned.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure medications were not pre-popped prior to administering medications to residents for 7 (Resident #5, #11, #15, #16, #26, #28, and #49) of 7 residents reviewed for preparation of medication administration. Findings include: A review of facility policy titled, Pharmacy Services Overview, revised in April 2007, stated pharmacy services were to provide feedback about performance and practices related to medication administration and medication errors. Services will collaborate with staff and practitioners to address and resolve medication problems. A review of facility policy titled, Administering Medications, revised April 2019, stated that medications will be administered in a safe, timely manner and as prescribed. Medications administered are to be verified with the resident ' s identity before administering medication and the person administering the medication must check the medication label three times to verify the correct resident, correct medication, correct dose, the right time and the right method. The person administering the medication was to sign the Medication Administration Record (MAR) after administering the medication and before administering any other resident ' s medication. During an observation on 10/30/2024 at 4:15 PM, Licensed Practical Nurse (LPN) #3 was noted to be placing empty medication cups on top of the medication cart. Some of the medication cups were noted to have initials on the outside of the cup and LPN #3 was holding a black marker. On 10/30/2024 at 4:24 PM, LPN #3 was observed taking a stack of cups that had medications in them and placed the cups in the top drawer of the medication cart. When LPN #3 was asked what was put in the medication cart, LPN #3 stated I was getting my medications together for the residents. LPN #3 confirmed medications were not to be pre-popped prior to giving and that medications were not supposed to be prepared that way. When asked why the medications had been pre-popped, LPN #3 stated, I thought you were gone. LPN #3 stated the Director of Nursing (DON) would not be happy about it. The DON walked out of the medication room behind the nurse ' s station, at that time and stopped at the medication cart. The DON was asked if it was known that LPN #3 was pre-popping medications and DON stated, No, and I am not happy about it. During an observation on 10/30/2024 at 4:33 PM, the DON went down the hall stating education was being provided for the rest of the nursing staff on duty. During an interview on 10/30/2024 4:34 PM, LPN #3 revealed staff had been educated on medication pass with lots of in-services. Confirmation was given that medications that had been pre-popped had been destroyed by crushing and putting the medications in the sharps container. LPN #3 described the proper way to prepare for medication administration was to confirm the right resident, look at the MAR, look at the medication card, make sure it was the right day scheduled, then pop the medication, go administer the medication and then come back and sign the medication off on the MAR. LPN #3 was asked what the importance was of not pre-popping medications and she stated, I know it is wrong, it is a bad habit. LPN #3 confirmed she had previously pre-popped medications and by stating, I know I did it yesterday too. LPN #3 stated the resident could die if they got the wrong medications. On 10/30/2024 at 4:46 PM, the DON informed the surveyor the facility was going to replace medications that had to be wasted at the facility ' s expense and that LPN #3 had been in-serviced and the Assistant Director of Nursing (DON) was observing medication administration with LPN #3. On 10/31/2024 at 11:04 AM, the DON stated she had no competencies on medication administration for LPN #3. The DON provided a list of the residents whose medications were observed being pre-popped on 10/30/2024, a list of what had been done to prevent recurrence of the same event and a copy of the Medication Administration Observation that had been completed on 10/30/2024 by the ADON. Two in-service records were provided by the DON titled, Preventing Medication Errors, dated 08/02/2024 and the in-service dated 10/30/2024 which stated, it is not best practice to pre-pop medications. Follow all steps for safe medication administration by preparing one resident at a time.

Based on observation, record review, and interview, the facility failed to ensure hot foods were served hot and cold dairy products were served cold to maintain palatability and encourage adequate nutritional intake for 1 of 1 meal observed. The findings are: 1. On 10/28/24 at 11:48 AM, Resident #30 stated the food was cold when served in the dining room and even colder if served in the resident's room. 2. On 10/30/24 at 12:38 PM, an unheated food cart was in the main dining room by the kitchen window. The first lunch tray for the unit was placed on a shelf in the unheated food cart by the Certified Nursing Assistant (CNA) #3. While CNA #3 was loading food trays in the unheated food cart, she left the door open. At 12:29 PM, as CNA #3 finished loading food trays onto the left side shelf of the food cart, she closed the door. The right side of the door remained open while she continued loading food cart. Once the right side was filled, she closed that door and delivered the food cart to the unit. The door was left open as the CNA #3 removed food trays from the food cart and served them to the residents in the unit dining room. At 1:13 PM, immediately after the last resident was served on the unit, the temperature of the food items on the test tray were taken and read by CNA #3 with the following results: a. Milk - 54.8 degrees Fahrenheit. b. Mashed potatoes - 108.1 degrees Fahrenheit. c. Pepper steak - 113 degrees Fahrenheit. d. Pureed pepper steaks with gravy - 111.7 degrees Fahrenheit. e. Sausage 107.4 degrees Fahrenheit. f. Ground sausage 98.7 degrees Fahrenheit. g. Fried potatoes - 109 degrees Fahrenheit. h. Fried Okra - 101.1 degrees Fahrenheit. i. Macaroni and Cheese - 110.1 degrees Fahrenheit. j. Vegetable blend - 110 degrees Fahrenheit. k. Pureed macaroni and Cheese - 95.9 degrees Fahrenheit. l. Pureed corn bread with milk - 97 degrees Fahrenheit. m. Pureed vegetable blend - 93 degrees Fahrenheit. n. Pureed ham and bean - 96.5 degrees Fahrenheit. 3. On 10/30/24 at 1:25 PM, CNA#3, was asked whether an unheated food cart should be left open when loading meal trays for lunch and when passing meal trays to the residents receiving their meal trays in dining room on the 100- hall (unit). CNA #3 mentioned that she had left the food cart open when passing the meal trays but had considered closing it. CNA#3 later confirmed she should have closed one side of the door.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure dish washing machine air vent was cleaned; floors, base boards, dish washer and kitchen walls were free of dirt; chipped floor tiles were replaced; a sanitary environment for food preparation was provided, and expired spices and leftover fruit items were promptly removed from stock for 1 meal observed. The findings are: 1. On 10/30/24 at 8:06 AM, the scoop holder on a wall by the ice machine in the kitchen had a gray, wet residue at the bottom of it. The scoop was directly touching the residue. The Lead Dietary [NAME] (LDC) was asked to wipe the gray residue at the bottom of the scoop holder. He did so, and the substance easily transferred to the paper towel. The LDC, when interviewed, stated, it [the residue] was gray in color. They use it [the ice machine] to fill beverages served to the residents at mealtimes, the CNAs (certified nursing assistants) use the ice for the water pitchers in the residents' rooms, and it is cleaned once a week. 2. On 10/30/24 at 8:07 AM, one container of leftover diced peaches, dated 8/21/24, was on a shelf in the refrigerator. The LDC stated it had been there too long. 3 On 10/30/24 at 8:09 AM, the wall around the water hose sink, on the dirty side of the dish machine, had discoloration of sage color. 4. On 10/30/24 at 8:13 AM, the base board, below the rack where clean pans were stored, was loose, the area that was exposed had sage color. 5. On 10/30/24 at 8:26 AM, the ceiling air vent, in the dish washing machine room, was rusty. 6. On 10/30/24 at 8:27 AM, the container of red pepper, on a shelf below the counter, had an expiration date of 9/24/2024. 7. On 10/30/24 at 11:27 AM, Dietary Aide (DA) removed crackers from a box under the counter for the residents. Without washing her hands, she picked up glasses by the rims and placed them on the tray to be used in serving beverages to the residents for lunch. 8. On 10/30/24 at 11:55 AM, the following observations were made in the kitchen. a. Dietary Aide, turned on the food preparation sink faucet, and filled a pitcher with water. Without washing her hands, she picked up glasses by the rims and placed them on the trays and poured beverages into each glass, to be served to the residents for lunch. b. The floor in front of the steamtable was chipped, exposing the concrete. c. There was a gap on the floor in front of the food preparation sink, exposing the cement. d. The floor, between the ice machine and the rack, where canned goods were stored in the storage room, was chipped, exposing the cement. e. 10/30/24 at 11:58 AM, the Dietary Aide removed a pitcher of tea from the refrigerator and placed it on the counter. Without washing her hands, she picked up glasses by the rims and poured beverages in them to be served to the residents for lunch. The Dietary Aide, when interviewed, stated she should have washed her hands. 9. A review of facility policy titled, Preventing Foodborne Illness -Employee Hygiene and Sanitary Practices, initiated October 2017, provided by the Administrator on 10/30/2024 indicated, employees should wash their hands after engaging in other activities that contaminate the hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the environment was free of potential hazards as possible, as evidenced by failure to ensure medications were stored and contained for 1 (Resident #41) of 1 sampled resident; and failed to ensure mattress's fit the bed frame to prevent potential accidental injury for 1 (Resident#53) of 1 sampled resident. The findings are: 1. Resident #41 had a diagnosis of diabetes mellitus and chronic kidney disease. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The resident required limited to extensive assistance with activities of daily living (ADL's). A review of Resident #41 electronic health record revealed no order to self-administer medications and was not care planned to self-administer medications. On 10/30/23 11:55 AM Resident #41 lying in bed watching tv. A bottle of rubbing alcohol (green) observed in the wheelchair next to the bed. A pink pill and a white pill were observed on the floor. Resident #41 was asked, what do you use the alcohol for? Resident #41 stated, astringent. On 10/31/23 10:07 AM Resident #41 was sitting in wheelchair in room. A bottle of rubbing alcohol was observed sitting on the bedside table. On 11/01/23 10:06 AM Resident #41 was observed lying in bed. A bottle of green alcohol was observed sitting on the bedside table. Certified Nursing Assistant (CNA) #1 was asked, what does Resident #41 use the alcohol for? CNA #1 stated, not sure, that's the first time I have seen it. CNA #1 was asked, why should alcohol not be left out in the resident ' s rooms? CNA #1 stated, usually if it says, keep out of reach we keep it out of the resident ' s rooms and if it's used as a medication, it should be put up for the resident's safety. CNA #1 was asked, why should pills not be left in the floor? CNA #1 stated, in case a resident comes by and takes it. On 11/02/23 10:42 AM Licensed Practical Nurse (LPN) #1 was asked, why does Resident #41 have a bottle of alcohol at the bedside? LPN #1 stated, I have no idea, it has been removed and placed in the cart. LPN #1 was asked, why should resident ' s pills not be left on the floor in their room? LPN #1 stated, because whoever medication it is, won't get scheduled dose, and any resident could wander in and take it and have an adverse reaction. 2. Resident #53 had a diagnosis of dementia, falls, and low back pain. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The resident required partial/moderate supervision and set up assistance for activities of daily living (ADL's). On 10/30/23 02:24 PM Resident #53 was observed sitting on the edge of the bed. There is a space approximately one foot between the foot of the mattress and the foot of the bed with the bed frame exposed. Resident was asked, is this your bed. Resident stated, yes. Resident was asked, how long have you been sleeping on this bed? Resident stated, a couple of months. On 10/31/23 09:47 AM A space approximately one foot between the mattress and the foot of Resident #53 bed was observed with the bed frame exposed. On 11/01/23 10:19 AM Resident # 53 was observed sitting on the edge of the bed. There is a space approximately one foot between the foot of the mattress and the foot of the bed with the bed frame exposed. On 11/02/23 11:05 AM Maintenance #1 was asked, why is there a space between the mattress and the foot board on R#53 bed? Maintenance #1 stated, I really don't know why, but I can find out and let you know.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior and improve the quality of life for 2 (Resident #18 and #40) of 2 sample residents. The findings are: 1. Resident #40 had a diagnosis of dementia and chronic obstructive pulmonary disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe impairment. The resident required extensive to dependent assistance for activities of daily living (ADL's). On 10/30/23 12:13 PM, Resident #40 in bed an area behind Resident #40 bed is an area peeling. A hole in the wall approximately 2 centimeters (cm) in diameter was observed on the wall behind Resident #40 bed. On 10/31/23 10:05 AM, Resident #40 observed in bed. The wall area behind the resident's bed was torn and peeling. A hole in the wall approximately 2 cm in diameter was observed on the wall behind Resident #40 bed. On 11/01/23 09:30 AM, the Administrator was asked, if something needs to be fixed, where is this documented? The Administrator stated, in the maintenance book at the nurses station. On 11/01/23 10:02 AM, Resident #40 observed in bed. Certified Nursing Assistant (CNA) #1 was asked, why is the wall behind Resident #40 bed torn and peeling, and a hole in the wall? CNA #1 stated, the bed is usually pushed against the wall, it's happened before, and it was fixed. On 11/02/23 10:48 AM, Maintenance #1 was asked about the peeling wall and hole behind Resident #40 bed and stated, I replaced it as soon as I found out about it yesterday. Maintenance #1 was asked, did you know about the wall and hole on 10/30/23? Maintenance #1 stated, no. Maintenance #1 was asked who was responsible for ensuring that things that need fixed are reported? Maintenance #1 stated, everyone. 2. Resident #18 had a diagnosis of dementia and chronic kidney disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 6, which indicated severe impairment. The resident required extensive assistance for activities of daily living (ADL's). On 10/30/23 12:05 PM, Resident #18 assisted out of bed with staff assistance. Resident #18 mattress is torn and peeling with shreds of plastic hanging down. A picture was taken. On 10/31/23 09:56 AM, Resident # 18 was observed in bed. The mattress has strips of plastic pieces torn and shredded and hanging from the mattress. On 11/01/23 10:00 AM, Resident #18 was observed in bed. The plastic mattress cover is torn and peeling and has strips of plastic hanging from the mattress. Certified Nursing Assistant (CNA) #1 was asked to describe Resident #18 mattress. CNA #1 stated, it's a standard mattress and the plastic cover of the mattress is torn and peeling. CNA #1 was asked, has this been reported and to whom? CNA #1 stated, I have not reported it, but it would be reported to maintenance. On 11/02/23 10:57 AM, Maintenance #1 was asked about the mattress on R#18 bed. Maintenance #1 stated, it was torn, peeling and could cause skin tears. I replaced it yesterday.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed and deemed safe to self-administer updraft treatments using a nebulizer for 1 (Resident #4) of 4 (#1, #2, #3, and #4) sample mix residents, to prevent the potential of accidental overdose and/or other respiratory complications. The findings are: 1. Resident #4 had diagnoses of Respiratory Failure, Pneumonitis, and Quadriplegia. The 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/06/23 documented the resident scored 12 (8-12 moderately impaired) on the Brief Interview for Mental Status (BIMS), required extensive assist of one person for bed mobility, dressing, and eating; and required extensive assist of two persons for transfers, toilet use, and personal hygiene; had an impairment to both sides of upper and lower extremities and was always incontinent of bowel and bladder. a. The Physician Order with a start date of 01/22/23 documented, .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 3 mg [milligrams]/3ml [milliliters] Ipratropium-Albuterol 3 ml inhale orally six times a day for shortness of breath . b. The Care Plan with an initiated date of 01/27/23 documented, .the resident has Pneumonia r/t [related to] CVA (Cerebrovascular Accident) .give medications as ordered. Monitor/document for side effects and effectiveness . c. On 03/30/23 at 12:32 p.m., Resident #4 was lying in bed in his room. The nebulizer mask covered his mouth and nose, and it was turned on and running. There were no staff in the room with him. d. On 03/30/23 at 12:35 p.m., Licensed Practical Nurse (LPN) #1 entered Resident #4's room. She turned the nebulizer off and removed the nebulizer mask from his face. e. On 03/30/23 at 12:36 p.m., the Surveyor asked LPN #1, Does Resident #4 self-administer updraft treatments? LPN #1 replied, No, I ran off to take the phone call. The Surveyor asked, Who is responsible for staying with the resident when administering an updraft treatment? LPN #1 replied, Me, I usually stay with them. The Surveyor asked, Why should the nurse stay with the resident when administering an updraft treatment? LPN #1 replied, Because they can't take it off when it's done, and to make sure it's administered right. f. On 03/30/23 at 2:21 p.m., the Surveyor asked LPN #2, Do you have anyone who self-administers updrafts? LPN #2 replied, I'm not sure. The Surveyor asked, Who is responsible for staying with the resident when they receive an updraft treatment? LPN #2 replied, The nurse. The Surveyor asked, Why should the nurse stay with the resident when receiving an updraft treatment? LPN #2 replied, Because it's medication, and to monitor for effectiveness. g. On 03/30/23 at 2:23 p.m., the Surveyor asked the Director of Nursing (DON), Do you have anyone who self-administers updrafts? The DON replied, No. The Surveyor asked, Who is responsible for staying with the resident while receiving an updraft treatment? The DON replied, The nurse. The Surveyor asked, Why should the nurse stay with the resident during an updraft treatment? The DON replied, It's administration of a medication. The Surveyor asked What are your expectations from your staff regarding following the facilities policy and procedures and following the Centers for Medicare and Medicaid Services (CMS) guidelines? The DON replied, That they will follow them. h. On 03/30/23 at 3:29 p.m., the Surveyor asked the Administrator, Who is responsible for staying with the resident while receiving an updraft treatment? The Administrator replied, The nurse. The Surveyor asked, Why should the nurse stay with the resident while receiving an updraft treatment? The Administrator replied, In case anything goes wrong. The Surveyor asked, What are your expectations from your staff regarding following the facilities policy and procedures and following the CMS guidelines? The Administrator replied, It's a must. i. The facility policy titled, Self-Administration of Medication, provided by the DON on 03/30/23 at 2:54 p.m. documented, .residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so . j. The facility policy titled, Administering Medications through a Small Volume Handheld Nebulizer, provided by the DON on 03/30/23 at 2:54 p.m. documented, .the purpose of this procedure is to safely and septically administer aerosolized particles of medications into the resident's airway .obtain a physician's order as needed .review the resident's care plan .remain with the resident for the treatment .

Based on record review and interview, the facility failed to ensure each resident was assessed using the standardized Quarterly Review Assessment Tool no less than once every 3 months between comprehensive assessments for 1 (R #1) of 31 (R #21, 19, 53, 43, 51, 20, 13, 49, 12, 18, 16, 53, 4, 32, 39, 30, 23, 22, 24, 34, 9, 40, 7, 11, 37, 15, 1, 31, 8, 33, 38, and 29) sampled residents who had a Minimum Data Set (MDS) due in the last 120 days according to a list provided by the Assistant Director of Nursing (ADON) on 7/29/22 at 09:26 AM. The failed practice had the potential to affect 31 residents who had a MDS due in the last 120 days. The findings are: 1. On 07/26/22 at 07:21 PM, Resident #1's Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/14/2022 was completed on 3/21/2022 but no MDS has been completed since. a. On 07/28/22 at 10:00 AM, the MDS Coordinator was asked, What checks are in place to make sure MDS's are completed in a timely manner? She said, We don't have checks. She was then asked, Do you know why the quarterly for [R1] has not been completed and it has been greater than 120 days? She said, No. We don't let things get that late. She then proceeded to look up in Point Click Care on the computer and said, She had an annual on 3/14/22. She was then asked, Should she have had one since then? She said, Yes. A quarterly 3 months later. She then continued to look in Point Click Care and said, The scheduler is not showing anything for her. I will have to contact someone. She was asked, So is that what you use to know what MDS to do? She said, Yes. She was then asked, What could be the negative outcomes for missing an MDS? She said, Money. And we do the quarterly to see how the resident is being cared for so I would have missed that.

Based on record review and interview the facility failed to ensure a comprehensive plan of care was developed for a resident who was on anticoagulant therapy to assure that the resident's individual needs were met and maintained for 1 (Resident #15) of 8 (Resident #15, #25, #19, #51, #4, #35, #11 and #38) of the sampled case mix residents who were receiving anticoagulants. The failed practice had the potential to affect 8 (Resident #15, #25, #19, #51, #4, #35, #11 and #38) who required anticoagulant therapy per the list provided by the Assistant Director of Nursing (ADON) on 7/29/22. The findings are: 1. Resident #36 had Diagnoses of Chronic Embolism and Thrombosis of unspecified Deep Veins of the Right Lower Extremity, Tachycardia, and Cerebral Infarction Due to Unspecified Occlusion of Stenosis of Unspecified Cerebral Artery. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/11/22 documented the resident scored 11 (8-12 indicates moderately impaired) on the Brief Interview for Mental Status (BIMS) and required ADL [Activities of Daily Living] extensive assistance of 1 to 2 staff members and with Transfers. a. A current physician's orders documented, Xarelto Tablet 20 MG [milligrams] (Rivaroxaban) Classification: Anticoagulants Give 20 mg by mouth in the evening for A-fib (Atrial Fibrillation) . start date 1/14/22 . b. On 7/27/22 at 12:38 PM, a review of R15's current Care Plan did not have interventions in place for anticoagulation therapy. 2. The Quarterly MDS with an ARD of 5/11/22 documented, N0410 Medication Received E. Anticoagulation Indicate the number of days the resident received the .medication .7 days. 3. On 7/27/22 at 4:48 PM, MDS Coordinator was asked, Who is responsible for completing the MDS's? She stated, Me. She was asked who is responsible for submitting the Care Plans? She stated, Me. The MDS Coordinator was asked, What is the last MDS ARD for [R15]? She stated, May 11th. [5/11/22] She was asked, Did you code him as being on an anticoagulant? she looked at her computer screen and stated, Yes, seven days. She was asked, What medication was the resident receiving those seven days? She stated, Xarelto The MDS Coordinator was asked, What are the anticoagulation care plan interventions do you have in place for him? She looked at her computer screen and stated, He does not have any. The MDS Coordinator was asked, What are the potential complications of him not having any care plan interventions in place for the anticoagulation? She stated, I don't understand your question. They are nurses . The question was asked again and the MDS Coordinator stated again, I do not understand your question.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure residents were regularly assisted with shaving or grooming of facial hair to ensure good grooming and hygiene for 1 (Resident #30) of 17 (R #64, 43, 20, 13, 47, 12, 4, 22, 34, 9, 44, 37, 31, 30, 21, 42, and 11) and failed to ensure hair was regularly shampooed to ensure good personal hygiene for 1 (Resident #30) of 41 (Residents #25, 157, 42, 21, 19, 53, 17, 14, 43, 20, 13, 49, 47, 12, 18, 55, 52, 4, 32, 39, 30, 23, 50, 22, 156, 34, 35, 9, 44, 40, 7, 11, 37, 15, 26, 1, 31, 8, 33, 38, and 29) sampled residents who required assistance with personal hygiene and shaving. The failed practices had the potential to affect 41 residents who required assistance with personal hygiene and 17 who required assistance with shaving according to a list provided by ADON (Assistant Director of Nursing) on 7/29/22 at 7:25 AM. The findings are: 1. R #30 had diagnoses of Cerebral Infarction, Unspecified, Weakness, Cerebrovascular Disease, Unspecified, and Vascular Dementia with Behavioral Disturbance. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/1/22 showed, a Brief Interview of Mental Status (BIMS) of 15 (13-15 indicates cognitively intact) cognitive impairment. The MDS showed, .Bathing .Supervision .Setup a. R #30's Care plan with a last review date of 6/11/21 showed, .Focus: The resident has limited physical mobility r/t [related to] Disease Process- Hx [history] CVA (Cerebral Vascular Accident), Weakness .Interventions: Requires supervision and set up with bathing. Provide resident with needed supplies for bathing and give resident privacy by pulling curtain .Use male Certified Nursing Assistants (C.N.A.)'s as needed for personal care r/t resident will make sexually inappropriate movements with himself .Requires limited assist with Toileting and personal hygiene. Requires supervision and set up with bathing. Provide resident with needed supplies for bathing and give resident privacy by pulling curtain . b. On 07/25/22 at 09:45 AM, Resident #30 was sitting up in a w/c [wheelchair] in his room. The Resident had shiny, greasy hair. His clothes had dried food on them. Resident was wearing blue sweatshirt and grey sweatpants. The Resident was asked, if he was showered as often as he wanted? and he stated, I would like to be showered more often. When asked how the meals tasted, the Resident stated, Never really good. c. On 07/26/22 at 07:54 AM, Resident #30 was observed in the dining room sitting up in a w/c eating breakfast. The Resident was wearing a green [NAME] shirt and orange sweatpants that were clean. The Resident's face still had facial hair, his hair was still shiny and greasy. d. On 07/27/22 at 08:02 AM, Resident #30 mobilized in the hallway via w/c, remained in green [NAME] shirt and orange sweatpants, food on clothing, hair was shiny and greasy. Facial hair approximately 1/4 inch long on upper lip and chin. 2. The Policy for Activities of Daily Living [ADLs], Supporting received by the ADON [Assistant Director of Nursing] on 7/29/22 at 7:25 AM showed, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a Hygiene (bathing, dressing, grooming, and oral care) .

Based on observation, record review, and interview, the facility failed to ensure that an oral surgeon's referral was made per the Doctor's recommendation on 2/10/22, for a severely cognitively impaired resident, without documentation of the resident's family and/or representative being informed about risks, benefits and treatment options and involved in the decision-making process for 1 (Resident #37) resident. This failed practice had the potential to affect 6 sample residents (R #37, #49, #17, #55, #9, and #7) who had dental issues according to the list provided by the Assistant Director of Nursing [ADON] on 7/29/22. The findings are: 1. Resident #37 had diagnoses of Alzheimer's Disease, Dementia, Cognitive Communication Deficit, Unspecified Protein-Calorie Malnutrition Muscle Wasting and Atrophy, Bipolar Disorder, Centrilobular Emphysema, and Dysphagia, Oropharyngeal Phase. The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 6/14/22 showed a Staff Assessment for Mental Status score of 3 (Severely impaired), required limited to extensive assistance for activities of daily living self-performance skills with one-to-two-person physical assist, and a weight gain of two pounds in the last month. 2. A Care Plan with a revision date of 5/10/21 documented . the resident exhibits dental/mouth problem as evidenced by broken/loose/missing, cavities, refuses dental appointment r/t [related to] impaired cognitive skills, resist mouth care, poor oral hygiene, personal preference Date Initiated: 03/05/21 . Assist in arranging referral, resource for payment and transportation as needed for dental evaluation and treatment. Date Initiated: 05/10/21 Discuss oral health concerns with resident/responsible party. Date Initiated: 03/05/21 . 3. On 07/25/22 at 01:51 PM, R #37 was sitting in her room with several teeth missing and dental caries. 4. On 07/27/22 at 09:08 AM, the SW [Social Worker] was asked, What is your process for assessing the dental needs of the resident? She stated that upon admission she assesses their basic dental needs if they have upper and lower dentures, or if they are natural and if they have any issues with them. If it happens after admission, she will notify the nurse who notifies the physician, that Mobile Dental comes to facility every 3 months, and she is responsible for setting up their appointments. The Surveyor asked, How are R #37's teeth? She stated, She does have missing teeth., and that she would look at her paperwork and let me know. 5. On 07/27/22 at 9:54 AM, the SW provided documentation dated 2/10/22 Pt seen on mobile clinic, .cooperative at time of visit .Dr. Notes: Pt [patient] needs to be seen by an oral surgeon to extract all remaining upper teeth. All remaining teeth are broken and decayed 6. On 7/28/22 at 9:07 AM, the SW was asked to provide any documentation regarding the oral surgeon referral recommendation. She provided me with a photocopy of a handwritten note, and she stated, These are the notes from the IDT [Inter Disciplinary Team] meeting that we had in March .we decided to wait until she was willing to see the Dentist .she had had a decline then and we were discussing placing her on comfort care. The note had been dated 3/17/22. The Surveyor asked if R #37's family was involved. She read the note, Family seems like things are going okay with care-no issues .Happy with everything. 7. On 7/29/22 at 7:25 AM, a policy provided by the ADON titled Routine Dental Care documented, Each resident will receive routine dental care, as appropriate .The Attending Physician will be notified of a resident's need for dental care/treatment and ordered dental consultation as appropriate. The ADON also provided a policy titled Dental Services that documented, Routine and emergency dental services are available to meet the resident's oral health needs in accordance with the resident's assessment and plan of care .5. Social services representatives will assist residents with appointments, transportation arrangements . 8. On 7/29/22 at 8:42 AM, the Nurse Consultant/Interim DON was asked, Are you familiar with R #37? She stated, Yes. The Surveyor asked, In February when the Doctor recommended that the resident was referred to an oral surgeon to extract all remaining teeth due to all of them being broken and decayed, was that referral followed up on? She stated, I am not sure I will get with ADON.

Deficiency Text Not Available

Based on record review and interview, the facility failed to notify the Resident and/or Resident Representative in writing of the reason for transfer to hospital in a language they understand for 3 (Resident #8, 34 and 156) of 8 (Resident #34, 8, 56, 38, 5, 42, 156 and 16) sampled residents who were transferred/discharged to the hospital in the last 120 days. This failed practice had the potential to affect 11 residents who were transferred/discharged to the hospital in the last 120 days as documented on a list provided by the Administrator on 7/27/22 at 8:07 AM. The findings are: 1. R #8 had diagnoses of VASCULAR DEMENTIA WITH BEHAVIORAL DISTURBANCE, ANXIETY DISORDER, UNSPECIFIED, OTHER RECURRENT DEPRESSIVE DISORDERS, and RESTLESSNESS AND AGITATION. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/22 showed a Staff Assessment of Mental Status (SAMS) score of 3 (a score of 3 indicates severe cognitive impairment). a. The Progress Note dated 6/11/2022 at 11:26 AM showed, Orders Administration Note Text: resident sent to hospital on 6/10/2022 b. The Progress Note dated 6/15/2022 at 09:58 AM showed, Nsg-General Note Text: This nurse spoke with Registered Nurse (RN) at facility concerning an anticipated DC 6/10/22 date from the hospital. RN states resident is being discharged to (Hospital) States she has been medically cleared for discharge and they are awaiting clearance from Hospital to admit . c. The Progress Note dated 6/23/2022 at 10:42 PM showed, Nsg-General Note Note Text: Resident arrived at approximately 2030 [10:30 PM] via Northwest Transport on a stretcher. She is positive for COVID-19, but asymptomatic and is on isolation. She is AO [Alert and Oriented] x1 and mostly nonverbal. She is incontinent of bowel and bladder and requires limited assistance x1. Her bowel sounds are present in all four quadrants. Her skin is warm, dry, and normal in color with a turgor of less than three seconds. She does not have any teeth. PERRLA [Pupils equal round, reactive to light and accommodation]. Peripheral pulses are palpable. Lung sounds are clear. Resident denied any pain. Medication administered and tolerated well. Resident is resting quietly in her room with her eyes closed at this time. WCTM [will continue to monitor]. d. The Notice of Transfer/discharge date d 6/13/2022 provided by the Business Office Manager on 7/26/2022 at 3:20 PM showed, A. Facility Initiated Transfer: Complete this form when a resident is temporarily transferred to an acute care hospital, emergency room or other location. A copy of this notice must be provided to the resident and resident representative at the time of transfer unless it is an emergency. If an emergency the facility will issue as soon as practicable. 1. Date of Notice: 6/13/22 2. Date of transfer or discharge 6/10/22 3. Reason for the transfer: a. (checked) The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs .4. Resident was transferred or discharged : (checked) 1. Hospital .C. Method of Delivery: 1. The resident and the resident's representative must receive a copy of this notice. Please indicate below the method in which this notice was delivered. (checked) 1. Notice was hand delivered to the resident .(checked) 4. Notice was mailed to the resident's representative . 2. R #156 had Diagnoses of ENCOUNTER FOR OTHER ORTHOPEDIC AFTERCARE, FRACTURE OF UNSPECIFIED PART OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING, AGE-RELATED OSTEOPOROSIS WITH CURRENT PATHOLOGICAL FRACTURE, OTHER SITE, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING, REPEATED FALLS. The Annual MDS with an ARD of 6/25/22 documented a Brief Interview of Mental Status (BIMS) score of 1 (a score of 0 - 7 indicates severe cognitive impairment). a. The Progress Note dated 7/17/2022 04:04 PM showed, Nsg-I&A Note Physician Contact (Who/When): On [APN] notified @ 0105 [1:05 AM]. Family Contact (Who/When): R #156 Responsible Party, notified @ 0135 [1:35 AM]. Incident Description: Called to unit per Certified Nursing Assistant (CNA). Resident on the floor in her room lying on her right side. Resident denies hitting her head. No visible injuries observed. Resident stated she got up and her leg gave away and she fell. Resident was rubbing the outer area of her left upper thigh and stated it was hurting. ROM [Range of Motion] to extremity WNL. [Within Normal Limits] After getting resident up into a semi-sitting position and onto her bedside she was rubbing the outer area of her right upper thigh and stated it was hurting. Upon checking ROM resident would place her hand on the right outer area of her upper thigh. Resident moving upper and LLE [left lower extremity] without difficulty, PEARL [Pupils equal round and reactive to light]. Immediate Intervention: Sent to [Emergency Room]. Vitals: 97.4, 68, 14, 120/100 . b. The Progress Note dated 7/19/2022 at 3:15 PM showed, Nsg-admission Summary Note Text: Resident transferred to this facility from Hospital and arrived via stretcher to Rm #103B. Transferred to her bed x4 staff. MD/APN [Medical Doctor/Advanced Practical Nurse] notified that resident returned. Daughter and son aware that she has returned. admission orders updated and pharmacy faxed orders. All departments made aware of her return. c. The Facility Initiated Transfer Form dated 7/17/2022 provided by the Business Office Manager on 7/26/2022 at 3:20 PM showed, A. Facility Initiated Transfer: Complete this form when a resident is temporarily transferred to an acute care hospital, emergency room or other location. A copy of this notice must be provided to the resident and resident representative at the time of transfer unless it is an emergency. If an emergency the facility will issue as soon as practicable. 1. Date of Notice: 7/18/2022 2. Date of transfer or discharge 7/17/2022 3. Reason for the transfer: a. (checked) The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs .4. Resident was transferred or discharged : (checked) 1. Hospital .C. Method of Delivery: 1. The resident and the resident's representative must receive a copy of this notice. Please indicate below the method in which this notice was delivered. (checked) 1. Notice was hand delivered to the resident .(checked) 4. Notice was mailed to the resident's representative . 3. R #34 has diagnosis of Other Sequela Following Unspecified Cerebrovascular Disease. The Quarterly MDS with an ARD of 6/6/2022 did not document a BIMS or a Staff Assessment of Mental Status (SAMS). The MDS showed, .Feeding tube .While a Resident .Proportion of total calories the resident received through parenteral or tube feeding .51% or more . a. R #34 Physician Order dated 5/21/2022 showed, .May send to ER for PEG (Percutaneous Endoscopic Gastrostomy) tube replacement . b. R #34 Care Plan last reviewed 12/2/2017 showed, .Focus: The resident requires tube feeding r/t [related to] late effects of CVA [Cerebrovascular accident] .Interventions: The resident needs total assistance with tube feeding and water flushes. See MD orders for current feeding orders . c. Progress noted dated 5/20/2022 10:52 PM showed, .CNA reported to this nurse that PEG tube fell out of abdomen when changing patient. PEG tube appears intact and completely out of abdomen with deflated balloon. Skin appears intact. No signs of distress seen. Non emergent northwest transport notified. PEG tube and face sheet with patient upon transport . d. Progress note dated 5/21/2022 01:45 PM showed, .MD at NWMC ER notified this reporter that they will be admitting resident at this time due to ER unable to replace peg tube and it will have to replaced later this morning/today . e. Progress note dated 5/21/2022 at 1:57 PM showed, .Resident returned from hospital, having had PEG tube replaced. No s/sx [signs and symptoms] of pain or distress noted at this time, VSS [vital signs stable], feeding started at this time. WCTM [will continue to monitor] . f. R #34 The Notice of Transfer/discharge date d 5/21/2022 provided by the Nurse Consultant on 7/27/2022 at 11:30 AM showed, A. Facility Initiated Transfer: Complete this form when a resident is temporarily transferred to an acute care hospital, emergency room or other location. A copy of this notice must be provided to the resident and resident representative at the time of transfer unless it is an emergency. If an emergency the facility will issue as soon as practicable. 1. Date of Notice: 5/21/2022 2. Date of transfer or discharge 5/20/2022 3. Reason for the transfer: a. (checked) The discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs .4. Resident was transferred or discharged : (checked) 1. Hospital .C. Method of Delivery: 1. The resident and the resident's representative must receive a copy of this notice. Please indicate below the method in which this notice was delivered. (checked) 1. Notice was hand delivered to the resident .(checked) 4. Notice was mailed to the resident's representative . 4. On 7/27/2022 at 3:40 PM, the Surveyor asked the Business Office Manager, Who is responsible for the Hospital Transfer/Discharge Notices sent to the Resident's and/or their Responsible Parties? She stated, I am. The Surveyor asked, Where on these forms you have provided for R #8, #34 and #156 is the reason for transfer/discharge in a language they can understand documented? She stated, It's not, just documented that their discharge/transfer was necessary for wellbeing and the facility cannot meet the resident's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that the Resident Assessment Instrument (RAI) was used and coded correctly, to comprehensively assess the resident's physical, mental and psychosocial needs to ensure the residents received their necessary care and services for 1 (R #31) of 2 (R#31, R#46) sampled residents according to a list provided by the Assistant Director of Nursing (ADON) on 7/29/22 at 7:25 AM. The failed practices had the potential to affect 2 residents who wander, and the facility also failed to ensure the Minimum Data Set (MDS) assessment accurately reflected medication use based upon pharmaceutical category for 1 (Resident #50) of sampled residents who had a Physician Order for Plavix an antiplatelet. This failed practice had the potential to affect 3 (Resident #50, #9 and #15) sampled residents who had Physician orders for antiplatelets per list provided by the ADON on 7/29/22. The findings are: 1. R #31 has Diagnoses of Unspecified Dementia with Behavioral Disturbance, Restlessness and Agitation, Generalized Anxiety Disorder and Unsteadiness on Feet. The annual MDS with an Assessment Reference Date (ARD) of 9/21/21 and the Quarterly MDS with and ARD of 6/1/22 documented a Staff Assessment of Mental Status as severely impaired. The MDS documented, .Has the Resident Wandered .Behavior Not Exhibited . a. R #31's Care Plan last reviewed on 5/5/21 showed, Focus: The resident is wanderer r/t [related to] disease process, she does wander into other residents rooms .Interventions: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes .Re-direct this resident if trying to go into the room of any other resident .Staff in-serviced to do a 1:1 activity with resident or offer snack/redirection when it is observed that she is anxious or otherwise moving things around in the facility .Distract resident from wandering into other rooms by offering pleasant diversions, fast paced activities, food, conversation, television . b. On 7/25/22 at 09:34 AM, Resident #31 observed in lobby of hallway sitting in chair. Resident also ambulated in hallway independently and entering other resident rooms. c. On 7/25/22 at 12:34 PM, Resident #31 ambulated down slope from 300 hall towards nurses' station independently. d. On 7/25/22 at 1:10 PM, Resident #31 sitting in chair with bedside table in lobby in on 300 hall eating lunch. Resident #31 had vegetables, ground meat and mashed potatoes. There was a spoon on resident's plate, Resident #31 was eating with fingers. Tea and water on tray. Tea almost gone. Resident #31 ate 100% of food. Staff performed hand hygiene to resident after meal. e. On 7/26/22 at 08:00 AM, Resident #31 in bed in room laying on left side asleep. Call light and water in reach. f. On 7/26/22 at 1:30 PM, Resident #31 sitting in recliner in front of vending machine in dayroom on 300 hall. Resident appears calm at this time and is holding a baby doll. g. On 7/27/22 at 4:56 PM, Resident #31 ambulated independently around corner of dining area to front lobby by gate to lower level. Resident made it within 5 feet of front door before staff redirected her by walking with the resident back down hallway. h. On 7/26/22 at 1:31 PM, The Surveyor asked CNA [Certified Nursing Assistant] #1, How long has R #31 had wandering behaviors? She said, I have been here two years and she has been like that. The Surveyor asked, How often are the behaviors monitored? CNA answered, I don't know. The Surveyor asked, What interventions are in place to address these behaviors? She said, I don't know. I don't usually work the floor. I rarely work this hall when I do. There probably are. The Surveyor asked, Do you know if there were any interventions put into place prior to using medications? She said, I don't. The Surveyor asked, Do you know if she is care planned for being a wanderer? She said, I'm pretty sure it is in her care plan. i. On 7/26/22 at 01:38 PM, The Surveyor asked Licensed Practical Nurse (LPN)#4, How long has R #31 had wandering behaviors? She said, I have been here for 3 years, and some months and she has been like this. They have tried her in the unit, and it doesn't work. Her family even took her out of this facility for a little while and brought her back because nothing seems to work. The Surveyor asked, How often are the behaviors monitored? She said, All day long. The Surveyor asked, What interventions are in place to address the wandering? She stated, We redirect her out of other residents' rooms. We have put up nets on other resident rooms that don't like for her to come in that choose to have that. We try to keep her occupied with snacks or baby dolls. We have staff walk one on one with her. The Surveyor asked, Were there any interventions put into place prior to using medications? She stated, Even with med changes she is still the same. The Surveyor asked, Is she care planned for wandering? She said, I'm not really sure I would have to look it up. j. On 7/26/22 at 1:43 PM, the Surveyor asked ADON, How long has R #31 had wandering behaviors? She said, As long as she has been here and as long as I have known her. The Surveyor asked, How often are the behaviors monitored? She said, Monitored hourly, during bathroom checks, and mealtimes. She honestly spends a lot of time with department heads. We walk with her. She likes our male staff better than female staff, so she is with a male employee, and he does one on one activities with her. She is closely monitored throughout the day as needed. The Surveyor asked, What interventions are in place to address the wandering? She stated, I wouldn't know without looking at the care plan. She then printed off the care plan and read it .reorientation .redirect out of other rooms .one on one walking .snacks .monitor The Surveyor asked, Were there any interventions in place prior to using medications? She said, Most definitely. k. On 7/28/22 at 08:39 AM, The Surveyor asked the MDS Coordinator, R #31 was not coded on the MDS dated [DATE] as a wanderer. Are you the one responsible for coding the MDS? She said, Yes. The Surveyor asked, Do you know why she was not coded as a wanderer? She said, The MDS triggers that. The Surveyor asked, Do you know who is responsible for triggering it? She said, Social services codes that section but I am ultimately responsible to double check the MDS. l. On 7/28/22 at 09:05 AM, the Surveyor asked the Social Services Director, Are you responsible for coding the behavior section of the MDS? She said, Yes. The Surveyor asked, Do you know why R #31 was not coded as a wanderer on the quarterly MDS dated [DATE]? She said, Well, we would have gone by the look back period. I am not sure I am the one that coded that one because I was out some that month, but I would have used the look back period. 2.R #50 had diagnoses of NON-ST Elevation (NSTEMI) Myocardial Infarction, Atherosclerotic Heart Disease of Native Coronary Artery, Dementia, and Coronary Artery Aneurysm. The Significant Change MDS with an ARD of 6/22/22 showed the resident scored 3 (indicates severely impaired) on a Staff Assessment for Mental Status. a. On 7/06/22 R #50's physician's order showed, Clopidogrel Bisulfate Tablet 75mg [milligrams] Give 75 mg by mouth in evening related to NON-ST Elevation (NSTEMI) Myocardial Infarction .start date 11/21/2021 . b. The Significant Change MDS with an ARD of 6/22/22 documented .N. 0410. Medication Received. Indicate the number of days the resident received the following medications by pharmacological classification . Enter 0 if medication was not received by the resident during the last 7 days . E. Anticoagulant was marked 7 [days received] . c. The MAR (Medication Administration Record) dated 6/1/22-6/30/22 showed R #50 received Clopidogrel Bisulfate Tablet 75mg (Plavix) an antiplatelet every day of the month of June. d. On 7/27/22 at 04:48 PM, the Surveyor asked the MDS Coordinator, Who was responsible for completing the MDS's? She stated, Me. The Surveyor asked who was responsible for submitting the Care Plans? She stated, Me. e. On 7/27/22 at 4:54 PM, The Surveyor asked the MDS Coordinator, What is the last MDS ARD for R #50? She stated, A Significant change was done on 6/22/22 The Surveyor asked, Did you code her as receiving an anticoagulant on that MDS? she looked at her computer screen and stated, Yes, seven days. The Surveyor asked, What medication was the resident receiving those seven days? She stated, Clopidogrel. The Surveyor asked MDS Coordinator, How is Clopidogrel classified? She looked at her computer screen and stated, Hematological. The Surveyor asked, Should that medication have been coded as an anticoagulant? She stated, Yes, it is a blood thinner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, The facility failed to ensure the Minimum Data Set accurately documented weight loss of 5% or more in 1 mo. and 10% or more in 6 months for 1 (Resident #8) of 20 (#25, 21, 43, 49, 47, 18, 16, 39, 23, 22, 24, 156, 34, 35, 40, 7, 37, 1, 8 and 3) Sampled Selected residents who had weight loss in last 6 months. This failed practice had the potential to affect 22 Residents with weight loss in the last 6 months according to a list provided by the Assistant Director of Nurses on 7/29/22 at 8:49 AM and failed to ensure the Minimum Data Set (MDS) assessment accurately reflected medication use based upon pharmaceutical category for 1 (Resident #50) of sampled residents who had a Physician order for Plavix antiplatelet. This failed practice had the potential to affect 3(Resident #50, #9 and #15) sampled residents who had Physician orders for antiplatelets per list provided by the ADON on 7/29/22 and failed to ensure MDS (Minimum Data Set) was accurately coded to reflect resident's status for 1of 2 (R #31) (R#31, R#46) sampled residents according to a list provided by the ADON (Assistant Director of Nursing) on 7/29/22 at 7:25 AM. The failed practices had the potential to affect 2 residents who wandered. The findings are: 1.R #8 DISTURBANCE, ANXIETY DISORDER, UNSPECIFIED, OTHER RECURRENT DEPRESSIVE DISORDERS, and RESTLESSNESS AND AGITATION. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/22 documented a Staff Assessment of Mental Status (SAMS) score of 3 (a score of 3 indicates severe cognitively impairment) and had no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. a. The weight record for March and April 2022 documented, 4/4/2022 118.5 Lbs. [pounds]; 3/11/22 145.9 Lbs. a weight loss of 18.7% for one month. b. On 07/26/22 at 10:32 AM, On 01/19/22, the resident weighed 147 lbs. On 07/21/22, the resident weighed 125.6 pounds which is a -14.56 % Loss.; On 06/24/22, the resident weighed 123.6 lbs. On 07/21/22, the resident weighed 125.6 pounds which is a 1.62 % Gain. c. The Quarterly MDS with ARD of 4/29/22 documented, no weight loss greater than 5 % last month; however, the Physician Progress Note, Plan of Care and Physician Orders documented interventions to put in place for the significant weight loss and is now back up to 125.4 and weight loss has stabilized. d. On 7/28/22 at 2:45 PM, informed the Administrator, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator and Nurse Consultant that R8 had a weight loss of 18.7% in one month from 3/11/22 to 4/4/22 but the MDS dated [DATE] documented no weight loss of 5% or greater in one month or 10% or greater in six months. They were asked, What should the MDS document regarding weight loss? The Administrator said, Should have documented a weight loss of greater than 5 % or more in one month. 2. R #31 has diagnosis of Unspecified Dementia with Behavioral Disturbance, Restlessness and Agitation, Generalized Anxiety Disorder and Unsteadiness on Feet. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/21/21 and the Quarterly MDS with and ARD of 6/1/22 documented a Staff Assessment of Mental Status as severely impaired. The MDS documented, .Has the Resident Wandered .Behavior Not Exhibited . a. R 31 care plan last reviewed on 5/5/21 documented, Focus: The resident is wanderer r/t [related to] disease process, she does wander into other residents rooms .Interventions: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes .Re-direct this resident if trying to go into the room of any other resident .Staff in-serviced to do a 1:1 activity with resident or offer snack/redirection when it is observed that she is anxious or otherwise moving things around in the facility .Distract resident from wandering into other rooms by offering pleasant diversions, fast paced activities, food, conversation, television . b. On 07/25/22 at 09:34 AM, Resident # 31 is in lobby of hallway sitting in chair. Resident ambulating also in hallway independently and observed entering other resident rooms. c. On 07/25/22 at 12:34 PM, Resident ambulating down slope from 300 hall towards nurses station independently. d. On 07/25/22 at 13:10 PM, Resident sitting in chair with bedside table in lobby in hallway on 300 hall eating lunch. Resident had vegetables, ground meat and mashed potatoes. There was a spoon on resident's plate, but resident was eating with fingers. Tea and water on tray. Tea almost gone. Resident ate 100% of food. Staff performed hand hygiene to resident after meal. e. On 07/26/22 at 08:00 AM, Resident in bed in room laying on left side asleep. Call light and water in reach. f. On 07/26/22 at 01:30 PM, Resident sitting in recliner in front of vending machine in dayroom on 300 halls. Resident appears calm at this time and is holding a baby doll. g. On 07/27/22 at 4:56 PM, Resident ambulating independently around corner of dining area to front lobby by gate to lower level. Resident made it within 5 feet of front door before staff redirected her by walking with resident back down hallway. h. On 07/26/22 at 01:31 PM, Certified Nursing Assistant (CNA) #1 was asked, How long has R31 had wandering behaviors? She said, I have been here two years and she has been like that. She was then asked, How often are the behaviors monitored? CNA answered, I don't know. She was then asked, What interventions are in place to address these behaviors? She said, I don't know. I don't usually work the floor. I rarely work this hall when I do. There probably are. CNA was then asked, Do you know if there were any interventions put into place prior to using medications? She said, I don't. She was asked, Do you know if she is care planned for being a wanderer? She said, I'm pretty sure it is in her care plan. i. On 07/26/22 at 01:38 PM, LPN [Licensed Practical Nurse] #4 was asked, How long has R31 had wandering behaviors? She said, I have been here for 3 years, and some months and she has been like this. They have tried her in the unit, and it doesn't work. Her family even took her out of this facility for a little while and brought her back because nothing seems to work. She was then asked, How often are the behaviors monitored? She said, All day long. She was also asked, What interventions are in place to address the wandering? She stated, We redirect out of other rooms. We have put up nets on other resident rooms that don't like for her to come in that choose to have that. We try to keep her occupied with snacks or baby dolls. We have staff walk one on one with her. She was then asked, Were there any interventions put into place prior to using medications? She stated, Even with med changes she is still the same. She was also asked, Is she care planned for wandering? She said, I'm not really sure I would have to look it up. j. On 07/26/22 at 01:43 PM, ADON [Assistant Director of Nursing] was asked, How long has R31 had wandering behaviors? She said, As long as she has been here and as long as I have known her. She was then asked, How often are the behaviors monitored? She said, Monitored hourly, during bathroom checks, and mealtimes. She honestly spends a lot of time with department heads. We walk with her. She likes our male staff better than female staff, so she is with [Activities Director] and he does one on one activities with her. She is closely monitored throughout the day as needed. She was then asked, What interventions are in place to address the wandering? She stated, I wouldn't know without looking at the care plan. She then printed off the care plan and read it .reorientation .redirect out of other rooms .one on one walking .snacks .monitor She was then asked, Were there any interventions in place prior to using medications? She said, Most definitely. k. On 07/28/22 at 08:39 AM, MDS Coordinator was asked, [R31] was not coded on the MDS dated [DATE] as a wanderer. Are you the one responsible for coding the MDS? She said, Yes. She was asked, Do you know why she was not coded as a wanderer? She said, The MDS triggers that. She was then asked, Do you know who is responsible for triggering it? She said, Social services codes that section but I am ultimately responsible to double check the MDS. l. On 07/28/22 at 09:05 AM, Social Services Director was asked, Are you responsible for coding the behavior section of the MDS? She said, Yes. She was then asked, Do you know why [R31] was not coded as a wanderer on the quarterly MDS dated [DATE]? She said, Well, we would have gone by the look back period. I am not sure I am the one that coded that one because I was out some that month, but I would have used the look back period. 3. R8 had diagnoses of VASCULAR DEMENTIA WITH BEHAVIORAL DISTURBANCE, ANXIETY DISORDER, UNSPECIFIED, OTHER RECURRENT DEPRESSIVE DISORDERS, and RESTLESSNESS AND AGITATION. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/29/22 documented a Staff Assessment of Mental Status (SAMS) score of 3 (a score of 3 indicates severe cognitively impairment) and had no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. a. The weight record for March and April 2022 documented, 4/4/2022 118.5 Lbs. [pounds]; 3/11/22 145.9 Lbs. a weight loss of 18.7% for one month. b. On 07/26/22 at 10:32 AM, On 01/19/22, the resident weighed 147 lbs. On 07/21/22, the resident weighed 125.6 pounds which is a -14.56 % Loss.; On 06/24/22, the resident weighed 123.6 lbs. On 07/21/22, the resident weighed 125.6 pounds which is a 1.62 % Gain. c. The Quarterly MDS with ARD of 4/29/22 documented, no weight loss greater than 5 % last month; however, the Physician Progress Note, Plan of Care and Physician Orders documented interventions to put in place for the significant weight loss and is now back up to 125.4 and weight loss has stabilized. d. On 7/28/22 at 2:45 PM, informed the Administrator, Assistant Director of Nursing (ADON), Minimum Data Set (MDS) Coordinator and Nurse Consultant that R8 had a weight loss of 18.7% in one month from 3/11/22 to 4/4/22 but the MDS dated [DATE] documented no weight loss of 5% or greater in one month or 10% or greater in six months. They were asked, What should the MDS document regarding weight loss? The Administrator said, Should have documented a weight loss of greater than 5 % or more in one month. 4. Resident(R) #50 had diagnoses of NON-ST Elevation (NSTEMI) Myocardial Infarction, Atherosclerotic Heart Disease of Native Coronary Artery, Dementia, and Coronary Artery Aneurysm. The Significant Change MDS with an Assessment Reference Date of 6/22/22 documented the resident scored 3 indicates severely impaired) on a Staff Assessment for Mental Status. a. On 07/06/22 R#50's physician's order documented, Clopidogrel Bisulfate Tablet 75mg (milligrams) Give 75 mg by mouth in evening related to NON-ST Elevation (NSTEMI) Myocardial Infarction .start date 11/21/21 . b. The Significant Change MDS with an Assessment Reference Date of 6/22/22 documented .N. 0410. Medication Received. Indicate the number of days the resident received the following medications by pharmacological classification . Enter 0 if medication was not received by the resident during the last 7 days . E. Anticoagulant was marked 7 [days received] . c. The MAR (Medication Administration Record) dated 6/1/22-6/30/22 documented R50 received Clopidogrel Bisulfate Tablet 75mg (Plavix) an antiplatelet every day of the month of June. d. On 7/27/22 at 4:48 PM, the MDS Coordinator was asked, Who is responsible for completing the MDS's? She stated, Me. She was asked who is responsible for submitting the Care Plans? She stated, Me. e. On 7/27/22 at 4:54 PM, The MDS Coordinator was asked, What is the last MDS ARD for [R50]? She stated, A Significant change was done on June twenty second (6/22/22) She was asked, Did you code her as receiving an anticoagulant on that MDS? she looked at her computer screen and stated, Yes, seven days. She was asked, What medication was the resident receiving those seven days? She stated, Clopidogrel. The MDS Coordinator was asked, How is Clopidogrel classified? She looked at her computer screen and stated, Hematological. She was asked, Should that medication been coded as an anticoagulant? She stated, Yes, it is a blood thinner.

Based on record review and interview, the facility failed to ensure person centered comprehensive care plans were updated to address specific, identified care needs to prevent potential inadequate care for 1(#34) of 3 (Residents #34, #38, and #49) sample selected residents. The failed practice had the potential to affect 58 residents according to the Resident Census and Condition of Resident's provided by Nurse Consultant on 7/25/22 at 11:02am, and failed to ensure the Resident Plan of Care was updated with Aftercare Instructions post Hip Surgery and fall interventions for 1 (Resident #156) of the Sampled Selected Residents with falls with major injury for the last 6 months according to a list provided by the Assistant Director of Nurses (ADON) on 7/29/22 at 8:49 AM. The findings are: 1. R #34 had Diagnosis of Other Sequela Following Unspecified Cerebrovascular Disease and Dysphagia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/6/22 documented a Staff Assessment of Mental Status (SAMS) of .Not Assessed .MDS with an ARD of 3/6/22 documented a SAMS of .severely impaired . The MDS documented, .Feeding tube .While a Resident .Proportion of total calories the resident received through parenteral or tube feeding .51% or more . a. The Physician Order dated 7/18/22 documented, .Feeding rate increased on 7/18/22 r/t [related to] weight loss MONITOR resident for fluid volume overload (auscultate lungs) NOTIFY provider immediately for intolerance (vomiting etc. [et cetera]) . b. The Physician Order dated 7/18/22 documented, .Enteral Feed every shift Osmolyte 1.2 @55 ml[milliliters]/hr. [hour] continuous (440 ml per shift). May use Glucerna 1.2 if Osmolyte 1.2 not available . c. R #34 care plan last reviewed 12/2/17 documented, .Focus: The resident requires tube feeding r/t [related t] late effects of CVA [cerebrovascular accident] .Interventions: The resident needs total assistance with tube feeding and water flushes. See MD [medical doctor] orders for current feeding orders . d. On 07/28/22 at 08:33 AM, MDS Coordinator was asked, [R #34] Tube Feeding was changed on 7/18. Are you the one responsible for updating the POC [Plan of Care]? She said, Yes. She was asked, When should the POC be updated? She said, With changes that I'm made aware of. She was asked, How are you made aware of changes? She said, Usually in stand-up meetings. She was then asked, Were you not aware of this change? She said, No. She was asked, What could the negative outcome be not updating his care plan? She did not respond. e. On 07/28/22 at 1:40 PM, MDS Coordinator and Director (ADON) entered room and stated, [R #34] is care planned for tube feeding to be administered as ordered. It is not feasible to update the care plan with each change in his tube feeding because it changes so frequently. In fact, he has recently had multiple ileus, multiple feeding changes and weight loss and that is why it cannot be resident specific . 2. R #38 had a diagnosis Diabetes Mellitus. MDS with an ARD of 6/20/22 documented a Brief Interview of Mental Status (BIMS) of 13 (13-15 indicates cognitively intact) cognitive status. The MDS documented, .Insulin Injections .7 days . a. The Physician Order dated 6/17/22 showed, .Insulin Glargine Solution 100 UNIT/ML Inject 10 unit subcutaneously at bedtime for diabetes related to DIABETES MELLITUS DUE TO UNDERLYING CONDITION WITH DIABETIC NEUROPATHY, UNSPECIFIED (E08.40) . b. R #35 care plan last reviewed on 10/14/21 documented, .Focus: The resident has Diabetes Mellitus .Interventions: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness . c. On 07/28/22 at 08:35 AM, MDS Coordinator was asked, [R38] Insulin was changed on 7/13. Are you the one responsible for updating the POC? She said, Yes. She was asked, When should the POC be updated? She said, With changes that I'm made aware of. She was asked, How are you made aware of changes? She said, Usually in stand-up meetings. She was then asked, Were you not aware of this change? She said, No. She was asked, What could the negative outcome be not updating his care plan? She did not respond. d. On 07/28/22 at 1:40 PM, MDS Coordinator and Assistant Director of Nursing (ADON) entered room and stated, The care plan for [R38] was not updated when the Novolog was discontinued because we have an intervention that states diabetic medications as ordered. There is no way for us to keep up with the changes on the care plan when all the changes for diabetic medications get changed frequently. 3. R156 had diagnoses of ENCOUNTER FOR OTHER ORTHOPEDIC AFTERCARE, FRACTURE OF UNSPECIFIED PART OF NECK OF RIGHT FEMUR, SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALING, AGE-RELATED OSTEOPOROSIS WITH CURRENT PATHOLOGICAL FRACTURE, OTHER SITE, SUBSEQUENT ENCOUNTER FOR FRACTURE WITH ROUTINE HEALING, REPEATED FALLS. The Annual Minimum Data Set with an Assessment Reference Date of 6/25/22 documented a Brief Interview of Mental Status (BIMS) score of 1 (a score of 0 - 7 indicates severe cognitive impairment) and had no falls since last assessment. a. The Incident and Accident Report dated 7/17/22 documented, .at 12:50 AM resident on floor in her room lying on her right side. Resident stated she got up and her leg gave away and she fell. Resident rubbing the outer area of her left upper thigh and stated it was hurting. rom [range of motion] wnl [within normal limits] orders received to send resident to [emergency room] via 911 for tx/evaluation due to suspected hip fx [fracture]. res [resident] has dx [diagnoses] of age-related osteoporosis and vit [vitamin] d deficiency idt [interdisciplinary] will eval [evaluation] res upon return from [hospital] as intervention will depend on resident's condition at that time . b. The Resident Plan of Care printed on 7/26/22 at 2:55 PM did not update R156 fall with major injury on 7/17/22 with fall interventions or aftercare instructions post hip fracture surgery. c. On 7/29/22 at 2:45 PM, the Administrator, Assistant Director of Nursing (ADON), MDS (Minimum Data Set) Coordinator and Nurse Consultant were asked, Should [R156] Plan of Care been updated with fall interventions and aftercare instructions post hip fracture surgery? They all said or indicated, Yes. They were asked, What could the complications be when the care plan is not updated? The ADON stated, The staff may not know how to provide care for her without possible complications. 4. R49 had diagnoses of UNSPECIFIED DEMENTIA WITH BEHAVIORAL DISTURBANCE and COGNITIVE COMMUNICATION DEFICIT. The Significant Change in Status (SCIS) Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/3/22 documented a Staff Assessment of Mental Status (SAMS) score of 3 (a score of 3 indicates severe cognitive impairment) and required limited assistance of one staff member for bed mobility and transfers. a. The Quarterly MDS with an ARD of 1/26/22 and 4/2/22 documented she required supervision with set up only for bed mobility and transfer and the SCIS MDS with an ARD of 7/3/22 documented she required limited assistance of one staff for bed mobility and transfer. b. The Resident Plan of Care documented, Bed mobility = independent; Transfer = independent with supervision. c. The decline in bed mobility and transfer from 1/26 and 4/2/22 Quarterly MDS to 7/3/22 SCIS MDS was not updated on the Plan of Care and no recent orders for therapy; last therapy notes in March. d. On 7/27/22 informed [MDS Coordinator] R49 bed mobility and transfer went from a 1/1 to 2/2 from the Qtr. 1/26/22 and 4/2/22 to the SCIS 7/3/22. Before questioned why the care plan was not updated, she said, The care plan was not updated, I noticed it last night. She was then asked, what could the negative outcome be when not updating the care plan she stated in this case she could develop pressure sores? 5. On 07/28/22 at 2:45 PM, Administrator, ADON, MDS Coordinator and Nurse Consultant entered room with surveyors and was asked, When should the care plan be updated? They all answered, With any changes. They were asked, Should the care plan be resident centered? They said, Yes. They were asked, Why should it be resident centered? They said, So we can provide the care to each residents specific needs. They were then asked, What would the complication be to not having the specific resident centered approach on a care plan? They said, The care plan is the way the care is directed for the resident. 6. The Policy for Care Plans, Comprehensive Person-Centered received from ADON (Assistant Director of Nursing) on 7/29/22 at 7:25 AM documented, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; d. At least quarterly, in conjunction with the required quarterly MDS assessment .

Based on interview and record review, facility failed to ensure residents and resident representatives were asked about their interest in receiving information about returning to the community for 2 of 2 (Resident #48 & R #106) sample selected closed record review residents. This failed practice had the potential to affect 59 residents not admitted to the facility since the facility's last annual recertification on 05/7/21 per the list of admissions provided by the Assistant Director of Nursing (ADON) on 07/29/22. The findings are: 1. Resident #48 had a Diagnosis of Acute Respiratory Failure, Chronic Obstructive Pulmonary Disorder (COPD), and Cognitive Communication Deficit. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/1/22 showed, the resident scored 11 (8-12 indicates moderate cognitive impairment) on a Brief Interview for Mental Status (BIMS). 2. Resident #106 had diagnoses of Aftercare for Joint Replacement, Diabetes Mellitus, and Cognitive Communication Deficit. The Quarterly MDS with an ARD of 02/16/22 showed, the resident scored 15 (13-15 indicates cognitively intact) on a BIMS. 3. On 07/26/22 During record review of R #48 and R #106 electronic records, the surveyor found no documentation regarding receiving information about returning to community. a. On 07/26/22 at 03:30 PM, the Surveyor requested Options Counseling documents from Administrator for R #48 & R #106. 4. On 07/27/22 at 12:20 PM, Administrator came to the kitchen where the Surveyor was observing and requested surveyor come to his office when the kitchen observation was completed. a. On 07/27/22 at 01:10 PM, the Surveyor went to Administrator's office as requested. The Administrator stated, We don't have that options counseling form for R #48 and R #106. The Surveyor asked, To clarify, do you just not have it for those two gentlemen or not for anyone? The Administrator stated, We don't have it for anyone. The Surveyor asked, So have you not been completing them? The Administrator stated, No we have not. The Surveyor asked, Who completes section Q of the MDS? The Administrator stated, I am not sure, but I can look it up. The Administrator turned and typed in his computer. The Administrator turned around and stated, The Social Service Director (SSD). 5. On 07/28/22 at 08:48 AM, The Surveyor interviewed the SSD in the conference room. The Surveyor asked, Do you complete section Q of the MDS? The SSD stated, Yes. The Surveyor asked, Where do you obtain the information if they wish to receive options counseling and return to the community? The SSD stated, It depends on the resident, if they are competent. The Surveyor asked, Who determines if they are competent? The SSD stated, I visit with the resident and the family to determine. The Surveyor showed the SSD the DHS-9571 Notice of admission form from the admission packet obtained from the 'Survey Readiness Binder' and asked, Have you been completing this form for new admissions? The SSD stated, None of those have been processed since I have been in my position. The Surveyor asked, Were you aware the information on this form gets submitted to OLTC [Office of Long-Term Care]. The SSD stated, I was unaware it was completed and entered for OLTC. 6. On 07/28/22 at 08:59 AM, The Surveyor interviewed the Administrator in the conference room. The Surveyor asked the Administrator, Who determines if a resident is competent to return to the community? The Administrator stated, The IDT team, family and doctor. The Surveyor asked, Were you aware that this page (Notice of Admission) of the admission packet was not being completed and submitted before the surveyor requested documents? The Administrator stated, No, I assumed all was being completed. The Surveyor asked, Who should have been completing this form and entering the information into the system? The Administrator stated, SSD and she was in-serviced and trained yesterday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to ensure residents were supervised when smoking for 2 of 2 (Resident #1, #5) sample selected residents that were assessed, and care planned for supervision while smoking and failed to ensure environment was free of hazards for 12 self-mobile residents that had moderate to severe cognitive impairment per list provided by Administrator 7/27/22 and for 9 residents that smoke per list provided by Administrator 7/25/22. The findings are: 1. Resident #1 had a diagnosis of Acute on Chronic Diastolic (Congestive Heart Failure), Chronic Obstructive Pulmonary Disease with (Acute Exacerbation), and Respiratory Failure. Annual Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 3/14/22 scored a 15 (13-15 intact cognition). 2. R #5 had a diagnosis of Metabolic Encephalopathy, Other Specified Disorders Due to Known Physiologic Condition, Alcohol Dependence with Alcohol-Induced Persisting Dementia, and Post Traumatic Seizure. The admission (MDS) with (ARD) of 4/26/2022 documented a Brief Interview of Mental Status (BIMS) of 11 (8-12 which indicates moderately cognitively impairment) cognitive status. The MDS documented, .Current Tobacco Use .No . a. R #5 care plan last reviewed 5/11/2022 showed, .Focus: The resident is a smoker .Interventions: .The resident's smoking supplies are stored by the facility .The resident requires SUPERVISION while smoking . b. On 07/25/22 at 09:55 AM, Resident #5 Resident was sitting on edge of bed. Resident stated that breakfast was good. Cigarettes and lighter noted on bedside table. Resident stated he had no complaints related to smoking or the smoking policy. c. On 07/26/22 at 08:02 AM, Resident #5 in restroom. Breakfast tray on bedside table. Cigarettes on bedside table. c. On 07/25/22 at 4:43 PM the Surveyor was entering 300 hall and the door by vending machine was standing open and two residents (Resident #1, #5) were sitting outside with lit cigarettes, aprons on, and no staff with them. As surveyor passed the door a CNA [certified nursing assistant] #1 went to the courtyard with residents. a. On 07/25/22 at 4:53 PM, after bringing in residents from courtyard, the Surveyor asked CNA #1 Had you been out there with the smokers when I saw you go back out? She said, Yes, I brought one in, they want to come in one at a time because they get too hot. The Surveyor asked CNA #1, Had the residents been out there alone while you brought in the other resident? She said, Yes. What could happen if they are left alone while smoking? She answered, They could get burned. 3. R #31 has diagnosis of Unspecified Dementia with Behavioral Disturbance, Restlessness and Agitation, Generalized Anxiety Disorder and Unsteadiness on Feet. The annual (MDS) with an (ARD) of 9/21/21 and the Quarterly MDS with and ARD of 6/1/22 showed, a Staff Assessment of Mental Status as severely impaired. a. R #31 care plan last reviewed on 5/5/21 showed, Focus: The resident is wanderer r/t [related to] disease process, she does wander into other residents rooms .Interventions: Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes .Re-direct this resident if trying to go into the room of any other resident .Staff in-serviced to do a 1:1 activity with resident or offer snack/redirection when it is observed that she is anxious or otherwise moving things around in the facility .Distract resident from wandering into other rooms by offering pleasant diversions, fast paced activities, food, conversation, television . b. On 07/25/22 at 09:34 AM, Resident #31 is in lobby of hallway sitting in chair. Resident ambulating also in hallway independently and observed entering other resident rooms. c. On 07/25/22 at 12:34 PM, Resident #31 ambulating down slope from 300 hall towards nurses station independently. d. On 07/25/22 at 1310 PM, Resident #31 sitting in chair with bedside table in lobby in hallway on 300 hall eating lunch near open door to smoking area. e. On 07/26/22 at 01:30 PM, Resident #31 sitting in recliner in front of vending machine in dayroom on 300 hall near open door to smoking area. f. On 07/27/22 at 04:56 PM, Resident #31 ambulating independently around corner of dining area to front lobby by gate to lower level. Resident made it within 5 feet of front door before staff redirected her by walking with resident back down hallway. g. On 07/26/22 at 01:31 PM, The Surveyor asked, CNA #1 How long has R #31 had wandering behaviors? She said, I have been here two years and she has been like that. h. On 07/26/22 at 01:38 PM, The Surveyor asked Licensed Practical Nurse (LPN) #4, How long has R #31 had wandering behaviors? She said, I have been here for 3 years, and some months and she has been like this. The Surveyor asked, What interventions are in place to address the wandering? She stated, We redirect out of other's rooms. We have put up nets on other resident rooms that don't like for her to come in that choose to have that. We try to keep her occupied with snacks or baby dolls. i. On 07/26/22 at 01:43 PM, the Surveyor asked the ADON (Assistant Director of Nursing), How long has R #31 had wandering behaviors? She said, As long as she has been here and as long as I have known her. She was then asked, How often are the behaviors monitored? She said, Monitored hourly, during bathroom checks, and mealtimes. j. On 07/28/22 at 08:39 AM, The Surveyor asked the MDS Coordinator, R #31 was not coded on the MDS dated [DATE] as a wanderer. Are you the one responsible for coding the MDS? She said, Yes. The Surveyor asked Do you know why she was not coded as a wanderer? She said, The MDS triggers that. The Surveyor asked, Do you know who is responsible for triggering it? She said, Social services codes that section but I am ultimately responsible to double check the MDS. 4. On 07/25/22 at 01:12 PM, the door by vending machine in day room on 300 hall open to the outside. The following hazards & concerns were observed: - [NAME] plastic snow shovel - Yellow wooden broom - Two broken chairs - Two metal ashtrays on ground, one overflowing with cigarette butts and over 58 butts on ground throughout area (surveyor stopped counting at 58) - Metal L-shaped bar approx. 4 feet long - Thick long tree branches on ground - [NAME] broken basket on ground - Jagged broken solar light on ground - 6 nails protruding from fence 1/4 to 1 inch - 3 nails protruding from fence 1/8 to 1/4 inch - 1 screw protruding from fence ¼ to ½ inch - Two pieces of blinds metal trim lying on ground - 24-inch fluorescent utility single bulb light fixture attached to material fraying gazebo with extension cord plugged into wall, wrapped around metal flowerpot holder, with slack hanging in reach of residents - Metal and wood pulley system on ground - Cup with coffee left on bedside table under fraying gazebo - Plastic bucket of dried black paint sitting on hose support on wall of building - Black metal u-shaped handle or support to fence/gate lying on ground - 3-foot metal rod handing over fence wedged in between slats - Dry white substance around drain and on concrete as you enter area - Garbage items (two KN95 masks, choc chip cookie bag, glucose meter strips, cigarette pack, and numerous clear plastic pieces) - Stagnant water 1/2 way covering half of drainage ditch length of entire area - Approximately 3-foot round mud puddle with green substance on surface of green colored water 5. On 07/25/22 at 1:34 PM, The life safety surveyor asked the Maintenance Staff, Who comes out here? Maintenance said, The residents. 6. On 07/25/22 at 02:13 PM, the Surveyor went to Director of Nursing's (DON) office to speak to the Registered Nurse (RN) Consultant about discharges. The Surveyor stood outside door and noted the RN Consultant walking toward the office. The Surveyor accompanied the RN Consultant inside and noted a pack of cigarettes and a lighter sitting on a small table in front of DON's desk. The Surveyor asked the RN Consultant, Are these yours? (Pointing to pack and lighter) the RN Consultant stated, yes they are. Did someone have them? The Surveyor asked, Did you notice the door open to the office when we walked in? The RN Consultant stated, Yes, was there a problem? The Surveyor asked, Should the door be shut, so a resident could not get ahold of them? The RN Consultant stated, Oh, they wouldn't. I usually keep them in my purse. 7. On 07/27/22 at 09:49 AM, The Administrator was interviewed in his office. The Surveyor asked, Should residents have their cigarettes and lighter on their bedside table? The Administrator stated, No. It should be in the container behind the nurse's station or in that same container out in the smoking area when on smoke breaks. The Surveyor asked, Should staff have their cigarettes and lighter in reach and visible from open door to their office? The Administrator stated, There is no policy, but I'm going to say no. The Surveyor asked what could happen? The Administrator stated, A resident could go in and grab them. The Surveyor asked, Should door to smoking area on 300 hall be open? The Administrator stated, No, unless they are transferring residents out in a wheelchair. The Surveyor asked, Should the door to the smoking area be propped open? Admin stated, No, unless they are transferring a resident in or out. It makes it easier when they are in a wheelchair. The Surveyor asked, Should the residents be left unsupervised while smoking? The Administrator stated, No, but they can if they don't have their cigarettes. The Surveyor asked, should the smoking area be free of garbage and hazards such as broken chairs, metal bars, snow shovel, broom, nails sticking out of the fencing, drooping electrical extension cords, broken sharp solar lights, and trash? The Administrator stated, Yes, the broom can be out there, but a resident could hurt themselves on the nails. The Surveyor asked, What about any of the other items? The Administrator stated, A resident could trip over those items if they were on the ground. The Surveyor asked, When was the last time you were out in the smoking area off the 300 hall? The Administrator stated, I went out there Tuesday. The Surveyor asked, Did you see any issues? The Administrator stated, No ma'am. a. On 07/27/22 at 10:07 AM, The Surveyor was accompanied by the Administrator to smoking area. The Surveyor asked, What could happen if a resident sat on these broken chairs? The Administrator stated, They could fall through and get hurt. The Surveyor pointed out broken solar lights, large wood sticks, metal pulley, trash (cigarette packs, glucose test strips, chocolate chip cookie bag) and electrical cord and asked if he noticed these things. The Administrator stated, Not really. What should we do about the extension cord? The life safety person mentioned it too. The Surveyor stated she could not tell him what to do but it needed to be safe for the residents to be in this area. The Surveyor asked, What is the concern with standing water?(pointing to the standing, green-colored water). The Administrator stated, I don't know. 8. On 07/28/22 at 11:30 AM, the Laundry room door was open and not locked with no worker/staff inside and two washers running and one dryer running. a. On 07/28/22 at 11:34 AM, a worker arrived - did not speak English, so Surveyor went to Administrator's office and asked for Laundry Supervisor. The Administrator stated that the facility did not have one right now and he was filling in that role. b. On 07/28/22 at 11:36 AM, a laundry tour was conducted with the Administrator. The Surveyor asked if doors should be left open if no worker was inside. The Administrator stated, No and the dryers should not be running if no staff is in here.

Based on record review, and interview, the facility failed to ensure the Pharmacist's documented Monthly Medication Reviews were placed in Resident Medical Records of Sampled Mix Residents (R#15, R#52, R#22, R#8, R#38). This failed practice had the potential to affect the 58 Residents who resided in the facility as documented on the Resident Census and Condition of Residents provided by the ADON [Assistant Director of Nursing] on 7/28/22 at 11:20 AM. The findings are: 1. On 7/28/22, a review of the resident's electronic charts showed, the Pharmacist's Monthly Medication Reviews were not found. 2. On 7/28/22 at 11:20 AM, The Surveyor asked the ADON, Where are the Pharmacist's Monthly Medication Reviews kept? She stated that they were kept in a binder behind the Director of Nursing (DON)'s desk. 3. On 7/29/22 a policy titled Medication Regimen Reviews showed .The Consultant Pharmacist shall review the medication regimen of each resident at least monthly .10. Copies of drug/medication regimen review reports, including physician responses, will be maintained as part of the permanent medical record .

In accordance with State and Federal laws, the facility failed to ensure all drugs were stored under proper temperature controls. This failed practice had the potential to affect 58 residents per census and conditions provided by the Nurse Consultant on 7/25/22. The findings are: 1. On 7/27/22 at 8:22 AM, the Assistant Director of Nursing (ADON) was asked to accompany the surveyors to review the facility's medication storage room. 2. On 7/27/22 at 8:25 AM, a small black refrigerator sitting on the floor on the left side of the room that contained medications and there was no thermometer in the refrigerator. The Surveyor asked the ADON if she saw a thermometer in the medication refrigerator. The ADON looked in the refrigerator and stated, I actually don't see one. The Surveyor asked who is responsible for monitoring this refrigerator temperatures? The ADON stated, The night shift nurses. The Surveyor asked, Where is this monitoring log? The ADON stated, I think in the DON's (Director of Nursing) office. I'm (I am) not sure. The Surveyor asked, How often is this refrigerator's temperature checked? The ADON stated, I would assume daily. The Surveyor asked if there was a thermometer available and she placed the thermometer from another refrigerator in the storage room and placed it the refrigerator where the medications were stored. The ADON waited approximately 5 minutes and the Surveyor asked her to read the temperature of the thermometer in the medication storage refrigerator. She opened the medication refrigerator door and stated, 50 degrees [Fahrenheit], was confirmed. The Surveyor asked, What is this refrigerator temperature supposed to be? she stated, I believe below 42 (forty-two) degrees. The Surveyor asked, What are the potential complications of medications not being stored at the correct temperatures? She stated, Possibly undesired adverse reaction, or the medication being spoiled and its ineffectiveness like insulin not working properly. The following medications were stored in the refrigerator; 3 unopened vials of Levemir Insulin, 2 Glargine Insulin vials, 12 Hydrocortisone Acetate 25 mg. (milligrams) suppositories, 3 unopened pneumovax ampules, 1 vial of Novolog Insulin, 2 Risperdal Consta 25 milligrams IV/IM (intravenous/intramuscular) vials, 1 Tubersol TB Purified Protein Derivative (Mantoux) vial, 32 Dronabinol 5 mg, (Marinol) tablets, 22 Dronabinol 2.5 mg tablets. ER (Emergency Stock) Narcotic kit with 2 vials of Lorazepam visible in the kit, 2 boxes of 50 Acetaminophen suppositories that were 3/4ths full, 12 Bisacodyl 10 mg suppositories, and a 150 ml (milliliter) bottle of Lansoprazole powder that was half full. 3. On 7/27/22 at 8:53 AM, The Surveyor asked the ADON if she would like to try another thermometer to check the medication refrigerator's temperature. The ADON placed another thermometer that was reading 40 degrees Fahrenheit in the nutritional storage refrigerator and placed it in the medication storage refrigerator. She waited eight minutes and stated, It has had enough time to read it now. The ADON open the refrigerator door and stated, It's (it is) at 55 [degrees Fahrenheit] now. The Surveyor confirmed the temperature. 4. On 7/27/22 at 9:27 AM, The Surveyor asked the ADON, the RN Consultant, and the Weekend RN Supervisor who were in the DON's office, Have you found the refrigeration temperature logs? The ADON stated, I've (I have) been working on replacing those medications that were in the refrigerator and I haven't (have not) gotten to look for the logs yet . The RN Consultant and the RN weekend Supervisor did not respond to the question. 5. On 7/27/22 at 9:37 AM, the ADON stated, I can't (cannot) find the refrigerator logs for the medication room refrigerator. 6. On 7/27/22 at 9:52 AM, the RN Consultant provided a facility policy titled, Storage of Medications that documented, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 1 of 1 meal observed. The failed practice had the potential to affect 7 residents who received pureed diets documented on the Diet Order Report provided by the Registered Nurse (RN) Consultant 7/27/22. The findings are: 1. On 07/27/22 at 10:45 AM, the Surveyor entered kitchen to watch puree and line service. The Surveyor obtained plastic spoons from the Dietary Manager (DM). Dietary Staff (DS)#1 asked the to check the puree. The Surveyor informed DS#1 that the Surveyor would check the puree once he was completed and was ready to cover the containers for service. DS#1 began puree process stating he had 8 puree and 20 mechanical soft but he typically made enough for 10 and 24 respectively. DS#1 pureed spaghetti noodles from colander resting on edges of sink, with cold water running over it. When the Spaghetti puree was completed, it was put in pan and left next to food processor uncovered. The Meat sauce, garlic bread, and vegetable mix were pureed and placed in containers next to the food processor. a. On 07/27/22 at 11:01 AM, DS#1 moved the 4 containers of puree to the center prep table in the middle of the kitchen and was about to place lids on them. The Surveyor dipped a plastic spoon into each puree and then felt texture. The Surveyor noted round balls of pasta in the spaghetti puree. The Surveyor asked The DM to feel the puree texture and asked the DM to describe it. The DM stated, Oh, it has balls. Spaghetti is difficult to puree. The DM stated to DS#1, We need to redo the spaghetti. It had lumps; not big lumps, but big enough that we have to get them out. 2. On 07/27/22 at 11:06 AM, The Surveyor asked the DM, what could happen if food with balls of ingredients was served to residents with orders for puree diet? The DM stated, Well those lumps were not big enough to choke on, but they [residents] could choke with larger ones.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure foods stored in the refrigerators, freezers, and dry storage were consistently dated & labeled of when received, opened and/or prepared, failed to ensure foods stored in refrigerators, freezers, and shelves were sealed/closed completely, failed to ensure left-over food products were used or discarded within 3 days, failed to ensure foods being prepared were kept free of contamination by insects to ensure foods were distributed in sanitary conditions, and failed to ensure dish washer sanitizer level was checked with test strips each shift to ensure dishes were washed in sanitary conditions to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen in facility. These failed practices had the potential to affect 57 residents who received meals from the kitchen, as documented by list of 1 resident NPO (nothing by mouth) 7/29/22 received from Assistant Director of Nursing. The findings are: 1. On 07/25/22 at 10:04 AM, During initial tour of kitchen with Dietary Manager (DM), the following was observed: a. On 07/25/22 at 10:05 AM, Dry storage room contained the following: - a Ziploc bag of cereal [cheerios] not dated of when opened. The DM was asked about open date and DM stated, Oh, I thought only perishable foods needed to have more than a received date. That is new to me. - a Ziploc bag of spaghetti noodles (uncooked) not dated when opened - a Ziploc bag of elbow noodles (uncooked) not dated when opened b. On 07/25/22 at 10:11 AM, Three door stainless freezer contained the following: - Ziploc bag of chicken tenders not dated when opened - Ziploc bag of oriental blend vegetables not dated when opened - Ziploc bag of tater tots not dated when opened - Ziploc bag of cookie dough not dated when opened - Ziploc bag of pancakes not dated when opened - Ziploc bag of dinner rolls not dated when opened - Ziploc bag of hash brown triangles not dated when opened - Ziploc bag of beef tips not dated when opened - Ziploc bag of diced chicken not dated when opened - Ziploc bag of pork rib patties not dated when opened - pork roasts (2) wrapped in plastic wrap and then aluminum foil not dated when opened c. Under prep counter in middle of kitchen contained a box dated 7/12/22 with a cantaloupe covered in black sunken in patches and white fuzzy patches. DM stated, That needs to be thrown out. They don't last long. d. On 07/25/22 at 10:18 AM, Three door stainless refrigerator contained the following: - plastic square storage container of strawberries in red liquid dated 7/8/22. Surveyor asked if the date was the received date, open date, or thaw date. DM stated, either the received date or thaw date. I'm not sure. - Ziploc bag of capri veggie blend with brown liquid at bottom of bag dated '7/21/22' and written 'use by 7/21/22'. The DM was asked, How long are left-overs good for? DM stated, 3 days. I'll throw that out. - Ziploc of shredded lettuce with brown discoloration on approximately 1/2 of the lettuce in the bag not dated received or opened - bag of broccoli dated 7/21/22. DM stated, Those both [lettuce and broccoli] need to be thrown out. - 3 bags of pork patties dated 7/19/22. The DM was asked what that date was. DM stated, Probably thaw date. e. On 07/25/22 at 10:23 AM, the DM was asked if dish washer was high or low temp machine. DM stated, It's a low temp machine with sanitizer and we add chlorine too. the DM was asked to check ppm level. DM stated, I need to get them from my office. The DM was asked, How often do you check the ppm levels? DM stated, We don't test the chlorine or sanitizer levels. We just have them [EcoLab] come out regularly. The last time was about 2 weeks ago. The DM was asked, How do you know it is accurately working? DM stated, They [EcoLab] check it when they come. DM checked ppm. Surveyor asked what it registered. DM stated about 40 or so. Just below 50. The DM was asked what it needed to be at. DM stated, it does not say on the bottle. Sticker on dish washer stated, 'wash min[imum] 155 degrees' and 'rinse min[imum] 180 degrees'. The DM was asked, Would you test the sanitizer solution in the bucket staff are using for the counter tops? DM tested the solution and it turned dark purple. DM stated, Oh, that is way too high. DM stated to kitchen staff You need to make new solution. The chlorine is way too strong. 2. On 07/25/22 at 10:45 AM, Surveyor entered kitchen to watch puree and line service. Surveyor obtained plastic spoons from DM. DS#1 asked when surveyor wished to check puree. DS#1 was informed that puree would be checked once he was completed and was ready to cover the containers. DS#1 began puree process stating he had 8 puree and 20 mechanical soft but he typically made enough for 10 and 24 respectively. DS#1 pureed spaghetti noodles from colander resting on edges of sink, with cold water running over it. Surveyor noted ants on prep counter and windowsill. Surveyor noted ants crawling on edge of colander with pasta and in and out of holes in colander containing pasta. Spaghetti completed and put in pan and left next to food processor. Meat sauce, garlic bread, and vegetable mix pureed. DS#1 wiped counter and food processor with sanitizer solution in between each food being processed; wiping ants from prep counter. a. On 07/25/22 at 11:01 AM, DS#1 moved the 4 containers of puree to the center prep table in middle of kitchen and was about to place lids on them. Surveyor dipped a plastic spoon into each puree and then felt texture. Surveyor noted round balls of pasta in the spaghetti puree. Surveyor asked DM to feel the puree texture and asked to describe it. DM stated, Oh, it has balls. Spaghetti is difficult to puree. DM stated to [NAME], We need to redo the spaghetti. It had lumps; not big lumps, but big enough that we have to get them out. b. On 07/25/22 at 11:04 AM, The DS#1 was asked if he noted the presence of ants. DS#1 stated, Yes a few and he again wiped off prep counter. The DS#1 was asked, Anywhere else? DS#1 stated, No. DS#1 began to scoop noodles out of colander to put in pan. The DM was asked if she noted the presence of ants. DM stated, we just had them [pest control] come out last week. Surveyor pointed to colander. DM stated, Good thing we are redoing the puree. DM informed DS#1 to get water to make new spaghetti. DM threw out spaghetti. c. On 07/25/22 at 11:24 AM DS#1 scooped spaghetti puree from pan back into food processor. Surveyor asked, What are you starting now? DS#1 stated, I need to puree this more to remove the lumps. The DS#1 was asked, Where did the pureed noodles come from? DS#1 stated, Ah [explicative], I didn't even think of that. d. On 07/25/22 at 11:26 AM Surveyor received Pest control receipt from 7/26/22 stated Kitchen .spot treatment .Ants from DM. 3. On 07/25/22 at 11:13 AM Received Chlorine PPM guidelines with general guidelines that health inspectors look for from Human Resources. 4. On 07/29/22 at 07:25 AM, Food Storage policy received from Assistant Director of Nursing (ADON) stated, .8. All foods stored in refrigerator or freezer will be covered, labeled, and dated (use by date) . a. On 07/29/22 at 12:41 PM, Surveyor went to DM office and asked for manufacturer guidelines for the PPM test strips used, as the ones previously given was for another brand and type of test strip. DM stated, Oh, yes that was for the other type of test strips. We changed companies. Let me get a hold of them and see if they can send me one. Surveyor stated, So to clarify, you do not have a reference in order to know if the ppm level is correct or not. DM shook her head. b. On 07/29/22 at 01:20 PM, Test strip manufacturer instructions received from DM stated, .recommended ppm .the level is 50-100 ppm .

Based on observation, record review and interview, the facility failed to follow and implement an appropriate plan of action to correct an identified quality deficiency cited on the 2021 Annual Survey to monitor, track, and evaluate the effectiveness of accurately coding the Minimum Data Set (MDS) Plan for their Quality Assurance Corrective Action/Performance Improvement Activities/Plan (QACAPIAP). This failed practice had the potential to affect 58 Residents residing in the facility according to the Resident Census and Condition of Residents provided by the Nurse Consultant on 7/25/22 at 11:02 AM. The findings are: a. The 2567 dated 5/7/21 showed, Based on observation, interview and record review the facility failed to ensure the Minimum Data Set was coded correctly for 1 (Resident #36) of 5 (Residents #10, 32, 35, 36 and 43) final sampled residents who wandered in the facility. b. On 7/29/22: Based on observation, record review and interview the facility failed to ensure the MDS was completed in a timely manner for 1 (Resident #1). The facility failed to ensure the MDS was accurately coded to reflect Resident status for 1 resident (Resident #31). The facility failed to ensure the MDS assessment accurately reflected medication use based upon pharmaceutical category for 1 (Resident #50) who had a physician order for Plavix; antiplatelet. The facility failed to ensure the MDS accurately coded a weight loss of 5% or more in a month for 1 (Resident #8) sampled selected residents. c. On 7/29/22 at 10:50 AM, during the QAA/QAPI Facility Task, the Surveyor asked the Administrator, Were you aware you had a MDS accuracy deficiency in 2021? He said, I was aware of the deficiency in 2021 when I started in December 2021 after I looked over their last Annual Survey. The Surveyor asked, Have you developed a QAPI plan to address the MDS accuracy deficiency? He said, No. d. The Quality Assurance and Performance Improvement (QAPI) Plan received by the Administrator on 7/29/22 at 12:31 PM showed, Policy Statement: The facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality and resolve identified problems. Policy Interpretation and Implementation: The objectives of the QAPI Plan are to: 1. Provide a means to identify and resolve present and potential negative outcomes related to resident care and services; 2. Reinforce and build upon effective systems and processes related to the delivery of quality care and services; 3. Provide structure and processes to correct identified quality and/or safety deficiencies; 4. Establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcome; 5. Help departments, consultants, and ancillary services that provide direct or indirect care to residents to communicate effectively and to delineate lines of authority, responsibility and accountability; 6. Provide a means to centralize and coordinate comprehensive QAPI activities in order to meet the needs of the residents and the facility; and 7. Establish systems and processes to maintain documentation relative to the QAPI Program, as a basis for demonstrating that there is an effective ongoing program.