**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure there was consistently enough linen (specifically towels and washcloths) available for incontinent residents (those unable to control their bowels and/or bladders) during night shifts. This failure resulted in the facility's incontinent residents, approximately over half of the facility's census of 64, to receive incontinent care with non-linen items such as toilet paper, which has the potential to increase discomfort, decrease cleaning, and increase chance of skin issues. (Linens, such as washcloths, provide better to provide care to incontinent residents with because they can retain moisture better, are gentler on skin, reduce the risk of skin breakdown, clean better, and are more comfortable, especially when pre-moistened with warm water). Findings: During an interview on 4/11/25, at 1:50 p.m., with Laundry Worker (LW) 1, LW 1 stated she normally begins her shift at 5 a.m., and is responsible for washing, drying, folding, sorting, and delivering clean and sanitized linen throughout the facility. LW 1 stated the facility has three clean linen closets in resident care areas to store the clean linens, such as resident gowns, towels, washcloths, bed sheets and pillow cases. LW 1 stated there are times when she arrives to work at 5 a.m., and finds the three linen closets without linens such as washcloths and towels. LW 1 stated she has to order five dozen new washcloths every week, and stated, I don't know where they go. LW 1 stated a low amount of linen could negatively impact resident care by not having enough clean linen to clean residents with. During a concurrent observation and interview on 4/11/25, at 1:55 p.m., with LW 1, the three linen closets in the facility were observed and photographed. LW 1 stated the facility has three hallways, with a locked linen closet on each hall, for a total of three linen closets. LW 1 stated there were no other storage areas for clean linen in the facility for staff to use. The first linen closet, by room [ROOM NUMBER], contained approximately one dozen washcloths and approximately one dozen towels. The second linen closet, by room [ROOM NUMBER], contained approximately one dozen washcloths and towels. The third linen closet, by room [ROOM NUMBER], contained approximately seven washcloths and approximately nine towels. During an interview on 4/11/25, at 2:03 p.m., with Housekeeper (HK) 1, HK 1 stated, she, on occasion, finds dirty washcloths in the resident trash cans. HK 1 says this should not be happening, and when she sees it, she reports it to her supervisor. During an interview on 4/11/25, at 2:03 p.m., with Staff 1, Staff 1 stated, they provide direct care to residents in the facility. Staff 1 stated they work day shifts and night shifts. Staff 1 stated there are no issues with linen shortages during the day, but there are linen shortages during the night while residents sleep. Staff 1 stated, If there are no washcloths for a resident, we have to use toilet paper to clean residents [after an incontinent episode, when a person cannot control their bowels and/or bladder and release these wastes while in bed]. During an interview on 4/11/25, at 2:14 p.m., with the Director of Staff Development (DSD), the DSD stated during the last staff meeting on 3/28/25, the topic of throwing away linen and not hoarding linen in resident rooms was discussed. During a review of the facility document titled, All Staff , dated 3/28/25, the All Staff indicated a meeting took place and among the items discussed was Hoarding of linen in room needs to stop. and Please do not throw away linen, it needs to be placed in proper laundry barrel for laundry. The All Staff was signed by 25 employees. During a concurrent observation and interview, on 4/11/25, at 2:25 p.m., with the Administrator and Director of Nursing (DON), the three photographs of the three linen closets were reviewed. The DON and Administrator stated the facility is licensed for 64 residents. Both the Administrator and DON stated the photographs of the linen closets did not contain enough linen, and appeared to be a low quantity, and were not enough to provide services to the facility residents throughout the evening and night shifts. During an interview on 4/11/25, at 2:35 p.m., with Central Supply Worker (CSW) 1, CSW 1 stated, We order five dozen washcloths every two weeks, but they are being thrown away, so the facility keeps ordering them. My suggestion would be to stock more linen. During an interview on 4/11/25, at 3:15 p.m., with Staff 2, Staff 2 stated they provide direct resident care, and stated, We run low [on linen] sometimes at the end of the shift. During a concurrent observation and interview on 4/16/25, at 3:45 a.m., with Staff 3, the facility's three linen closets were observed. Staff 3 stated they provide direct resident care and their linen inventory was very light. The linen closet located by room [ROOM NUMBER] contained zero washcloths and two towels. The linen closet located by room [ROOM NUMBER] contained zero washcloths and zero towels. The linen closet located by room [ROOM NUMBER] contained eight towels and 4 washcloths. Staff 3 stated, We have not started last rounds yet [a process where facility staff goes to each resident to determine if they have had an incontinent episode, and if so, provides incontinent care]. This is a problem, but only if they have had a bowel movement. We need more washcloths and towels to clean them properly. This is not enough to last us through last rounds. During an interview on 4/16/25, at 3:50 a.m., with Staff 4, Staff 4 stated they provide direct resident care. Staff 4 stated, We are usually short of linens on night shift. This is pretty typical. During an interview on 4/16/25, at 3:52 a.m., with Staff 5, Staff 5 stated they provide direct resident care. Staff 5 stated, the linen closet on their assigned area was empty of washcloths and towels since the beginning of their shift at 10:30 p.m. Staff 5 stated they have been using toilet paper and a cleaning spray to clean residents after an incontinent episode. Staff 5 stated, It gets annoying when you don't have the proper linen to care for residents. Duirng an interview on 4/17/25, at 4:54 p.m., with Staff 6, Staff 6 stated they provide direct resident care, and the facility's lack of washcloths during night shift is a real problem. Night after night I work with no washcloths. I have to buy my own. I arrive to work at 10:30 p.m., and already there are no washcloths. There's not enough at the start of the shift. We need those washcloths for pericare, to wipe the bottoms of the residents after an incontinent episode. There are no showers or baths at night, we only use them for incontinent care. The facility has 64 beds and there are usually over 60 residents there at any time. I'd say over half are incontinent, not everyone, but over half. [Not having enough linen] is not fair to the residents and it's not right.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat one of three residents (Resident 1) with dignity and respect when Resident 1 requested assistance from the Certified Nursing Assistant (CNA) to locate the footrest (a stationary hanger and footplate for the user's feet to rest on the wheelchair) to her wheelchair and the CNA told Resident 1 to shut up on 3/31/25. This failure resulted in Resident 1 to experience mental and emotional distress (anger and frustration) on 3/31/25. Findings: During a concurrent observation and interview on 4/3/25 at 9:47 a.m. with Resident 1 in Resident 1's room, Resident 1 was sitting in her wheelchair and Spanish speaking only. The Unit Manager (UM) interpreted. Resident 1 was alert and oriented to person, place, and time. Resident 1 stated on 3/31/25 at 3:30 a.m., the CNA came to assist her to get ready for dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys have failed). Resident 1 stated she requested the CNA to assist her with her shoes and the CNA said no. Resident 1 stated she asked the CNA to hurry because the dialysis transportation was waiting outside. Resident 1 stated the CNA replied by saying I don't know. Shut up. Resident 1 stated the CNA was on her phone. Resident 1 stated the CNA should not have treated her that way. Resident 1 stated staff were paid employees and were expected to treat residents with respect. During a review of Resident 1's admission Record (AR), dated 4/3/25, the AR indicated Resident 1 was admitted on [DATE] with a history of right femur fracture (broken upper leg bone) and End Stage Renal Disease (a medical condition where the kidneys have permanently lost the ability to function adequately, requiring dialysis or a kidney transplant to survive) During a review of Resident 1's Minimum Data Set (MDS- a federally mandated process for clinical assessment of all residents of long term care nursing facilities) , dated 3/3/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 12 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated Resident 1 required moderate assistance (Helper does less than half the effort) with transfer (unable to move without help from another person or persons) from bed to chair and required moderate assistance with dressing and personal hygiene (habits to maintain cleanliness). During a review of the facility's Interdisciplinary Team(a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Post Incident Meeting (IDT) , dated 3/31/25, the IDT indicated, . Unit Manager informed [Administrator]/[Director of Nursing] today at [3:00 p.m.] that Resident 1 reported to her that she feels like going home and does not like it here . Resident 1 informed the UM that the [night] shift Registry (an individual licensed or certified by a regulatory agency who receives compensation from a third party to work at a nursing care facility) [name of CNA] was using her phone and told her to shut up when asked to be changed . DON interviewed Registry CNA [name of CNA] via phone who denied the allegation . For safety reasons, this facility has blocked this CNA to defer from situations like this . IDT RECOMMENDATIONS: DON blocked CNA from picking up more shifts on [name of Registry's website] . During an interview on 4/3/25 at 10:10 a.m. with Resident 2, Resident 2 stated on 3/31/25 the CNA came into the room to assist Resident 1 go to dialysis, but their roommate, Resident 3 was soaked and wet with urine. Resident 2 stated the CNA instructed Resident 3 to take her clothes and sheets off. Resident 2 stated Resident 3 was unable to do that, and Resident 2 informed the CNA Resident 3 required assistance. Resident 2 stated Resident 1 asked the CNA for the footrest to her wheelchair and the CNA told Resident 1 to wait and shut up. Resident 2 stated Resident 1 was Spanish speaking only and Resident 2 told the CNA not to talk to Resident 1 like that. Resident 2 stated the CNA no longer provided care at the facility. During an interview on 4/3/25 at 12:35 p.m. with the CNA, the CNA stated on 3/31/25 at 3:30 a.m. she went to Resident 1's room to assist her to go to dialysis. The CNA stated she assisted Resident 1 to the bathroom and Resident 3 complained of being cold. The CNA went to check Resident 3 and Resident 3 was wet with urine, and Resident 3 had soiled her clothes and linen. The CNA stated she changed Resident 3 while Resident 1 was in the bathroom brushing her teeth and hair. The CNA stated Resident 1 requested the footrest for her wheelchair and the CNA was unable to find the footrest. The CNA stated Resident 2 stated the blue footrest was hers, and Resident 1 started saying callate callate callate over and over again (meaning shut up in Spanish). The CNA stated she asked Resident 1 who she was saying callate to and Resident 2 stated Resident 1 wanted to go to the front for dialysis. The CNA denied telling Resident 1 to shut up. The CNA stated it was not acceptable to tell any residents to shut up for any reason. The CNA stated staff were required to treat residents with respect and dignity. During an interview on 4/3/25 at 10:31 a.m. with the Director of Staff Development (DSD), the DSD stated the CNA assisted Resident 1 on 3/31/25 and was not kind to Resident 1. The DSD stated staff and Registry staff were required to treat residents with dignity and respect. The DSD stated staff and Registry staff were required to abide by the residents privacy and residents rights policy and procedure. The DSD stated the CNA's behavior on 3/31/25 was unacceptable and the CNA was no longer allowed to work at the facility. During an interview on 4/3/25 at 10:33 a.m. with the DON, the DON stated Resident 1 alleged that the CNA told her to shut up on 3/31/25. The DON stated the allegation was investigated and was substantiated (confirmed) with Resident 2 as a witness. The DON stated the CNA was no longer allowed to work at the facility and would be reported to the Board (the agency that provides oversight for Certified Nursing Assistants). The DON stated staff and Registry staff were required to treat residents with kindness and respect. The DON stated the facility was the resident's home and should be treated with dignity. During an interview on 4/3/25 at 11:35 a.m. with the Administrator (ADM), the ADM stated Resident 1 asked for assistance on 3/31/25 and was told to shut up. The ADM stated an investigation was conducted and the CNA's behavior was unacceptable. The ADM stated the CNA no longer provided care at the facility and would be reported to the Board. The ADM stated residents should be treated with dignity and respect by all staff. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 12/2021, the P&P indicated, Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation; .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #7) of 1 sampled resident reviewed for dialysis. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 08/2024, indicated, Enhanced barrier precautions (EBP's) are utilized to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. The policy revealed the section titled Policy Interpretation and Implementation, included, 5. EBPs are indicated (when contact precautions do not otherwise apply) for resident with wounds and/or indwelling medical devise regardless of MDRO colonization. Further review revealed, b. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies. The policy revealed, 6. EBP's remain in place for the duration of the resident's stay or until the resolution of the wound or discontinuation of the indwelling medical device that places them at risk. Per the policy, 11. Signs are posted in [sic] the door or wall outside the resident room indicating the type of precautions and PPE required. An admission Record revealed the facility admitted Resident #7 on 09/13/2024. According to the admission Record, the resident had a medical history that included diagnoses of dependence on renal dialysis and acquired arteriovenous fistula. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2025, revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated Resident #7 received hemodialysis. Resident #7's Care Plan Report included a focus area, revised 03/27/2025, that indicated the resident had an arteriovenous fistula to the left arm. Interventions directed staff to monitor for thrill and bruit every shift and notify the medical doctor of any complications. Resident #7's Order Summary Report, with active orders as of 04/01/2025, contained an order dated 11/08/2024, that instructed staff to monitor dialysis fistula every shift for potential complications and signs and symptoms of infection. The Order Summary Report contained an order dated 11/08/2024, that instructed staff to monitor dialysis fistula every shift for thrill and bruit. Further review of the resident's Order Summary Report did not reveal an order for EBP. On 03/31/2025 at 10:07 AM, Resident #7 stated that upon returning to dialysis, the nurse checked their dialysis access site, removed the dressing, and took vital signs. Resident #7 stated that the nurses did not wear gowns when checking the resident's arteriovenous fistula site. During a concurrent observation there were no EBP postings for Resident #7. Resident #7 stated that they did not think they were on precautions. A document titled Enhanced Barrier Precautions provided by the facility and dated 04/01/2025 revealed a list of residents at the facility on EBP. Further review revealed Resident #7 was not listed as being on EBP. On 04/01/2025 at 1:03 PM, Licensed Vocational Nurse (LVN) #1 stated that Resident #7 received dialysis but was not on EBP. LVN #1 said that nurses performed a post-assessment after dialysis, including checking vital signs, the dialysis access site for bruit and thrill, and disposing of the dialysis access site dressing. LVN #1 could not explain why the resident was not on EBP and recommended asking the Infection Preventionist (IP). LVN #7 stated that residents on dialysis had EBP signs posted on their door, but Resident #7 did not. On 04/01/2025 at 1:56 PM, the Unit Manager (UM) stated the facility posted EBP signage to alert staff when extra precautions were needed for residents with indwelling devices, like a fistula. She said Resident #7 had a fistula that required EBP. The UM stated the IP reviewed orders and the resident's condition to decide if EBP was needed. The UM stated the IP would tell the nurse to get an order from the medical doctor for EBP and that it was missed for Resident #7. On 04/02/2025 at 7:50 AM, the IP stated that the goal of EBP was to prevent the spread of MDROs between residents, especially those with indwelling devices or wounds. The IP said Resident #7 met the EBP requirements, but the precaution was not implemented, and the resident did not have an order for EBP. On 04/02/2025 at 1:14 PM, the Director of Nursing (DON) stated that the facility's expectation was for the IP to recognize when a resident required EBP and implement it immediately. According to the DON, EBP was intended for residents with a point of entry, with the goal of protecting them from infection. The DON stated Resident #7's condition met the criteria for EBP, but it was not implemented. On 04/03/2025 at 7:45 AM, the Executive Director stated residents needing EBP should be placed on the program to ensure safety protocols are followed. The Executive Director stated Resident #7, who was on dialysis, should have been on EBP but was not. The Executive Director stated he expected staff to follow the facility's EBP policy for residents' safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of three residents (Resident 1), when Resident 1 required two person assist for transfer but was transferred from wheelchair to bed by Certified Nursing Assistant (CNA) 1 without another person to assist on [DATE]. This failure resulted in Resident 1 falling out of bed and onto the floor on [DATE] and the potential for Resident 1 to be injured. Findings: During a concurrent observation and interview on [DATE] at 9:41 a.m. with Resident 1 in Resident 1's room, Resident 1 was sitting in a wheelchair. Resident 1's left arm and left leg was contracted (a medical condition where muscles, tendons, or other tissues become permanently shortened and tight, resulting in limited range of motion and joint stiffness). Resident 1 stated he fell off the bed a few days ago. Resident 1 was unable to recall the date. Resident 1 stated one staff member was transferring him from his wheelchair to his bed when he fell. Resident 1 stated he required assistance with transfers. During a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 was admitted on [DATE] with a history of Hemiplegia (paralysis of one side of the body) and Hemiparesis (weakness on one side of the body) affecting left non-dominant side and Contracture of the left knee, left ankle and left upper arm. During a review of Resident 1's Minimum Data Set (MDS; process for clinical assessment of all residents of long term care nursing facilities), dated [DATE], the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS; an assessment of a resident's cognitive status; the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 6 (a score of 0 to 7 indicated severe impairment, 8 to 12 indicated moderate impairment, and 13 to 15 indicated minimal to no impairment). The MDS indicated, Resident 1 was dependent (relying on others) on toileting hygiene (the ability to maintain cleanliness after voiding or bowel movement) and dependent on transfer to and from bed to chair. During a review of the Resident 1's IDT (Interdisciplinary Team; a group of staff members consisting of nursing, dietary, rehabilitation, social services, activities, and administration who meet regularly to discuss incidents that occurred involving the well-being of residents and staff) Post Incident Meeting (IDT), dated [DATE], the IDT indicated, Resident had an unwitnessed fall (on [DATE]) at 1:30 p.m., resident was found by CNA 1. Per CN (Charge Nurse) resident was found on the floor by the L (left) bedside floor fall mat, lying on his R (right) side. Per CN resident stated he wanted to get up, CN reports resident has discoloration with no drainage on the Right top parietal (side of head), Right posterior (the back or rear part of the body) ribcage, and right knee . During an interview on [DATE] at 9:46 a.m. with CNA 1, CNA 1 stated on [DATE], he transferred Resident 1 from the wheelchair to the bed. CNA 1 stated he sat Resident 1 down on the bed, and with CNA 1's left arm, CNA 1 moved the wheelchair away. CNA 1 stated while he moved the wheelchair, Resident 1 slipped off the bed and fell on to the floor and landed on Resident 1's right shoulder. CNA 1 stated Resident 1 had a bump on the right side of his head. CNA 1 stated he put a pillow under Resident 1's head and notified the Charge Nurse. CNA 1 stated Resident 1 required two staff members for transfer but stated he has been transferring Resident 1 without an assistant and thought it was safe. CNA 1 stated he was provided in-service (education) after the incident to transfer Resident 1 with an assistant to ensure safe transfer and was instructed to refer to Resident 1's [NAME] (a communication tool used to provide the type of care and assistance a resident required). During an interview on [DATE] at 1:37 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had left sided weakness and required two staff members to transfer to ensure safe transfer. LVN 1 stated CNA 1 should have had another staff member to assist when transferring Resident 1 from wheelchair to bed on [DATE] to avoid falling. During a review of Resident 1's Morse Fall Scale (MFS; a tool that assesses a patient's risk of falling), dated [DATE], the MFS indicated, Score: 45 (High Risk: Total Score greater than 45, Moderate Risk: Total Score 25-45 and Low Risk: Total Score less than 25). During a review of Resident 1's Care Plan Report (CPR), dated [DATE], the CPR indicated, [Resident 1] has an ADL (Activities of Daily Living; basic self-care tasks that are necessary for maintaining personal hygiene, health, and overall well-being) Self Care Performance Deficit r/t (related to) muscle weakness, hemiplegia left side . Interventions/Tasks: . Transfer: [Resident 1] requires total assistance of (2) staff for transferring . During an interview on [DATE] at 10:40 a.m. with the Director of Staff Development (DSD), the DSD stated CNA 1 was provided in-service on the use of the facility's [NAME] to identify Resident 1's care plan. The DSD stated instructing employees with the use of the [NAME] was completed during orientation (training) upon hire and as needed. The DSD stated the information on the [NAME] was needed to provide safe care to the residents. The DSD stated Resident 1's [NAME] indicated two staff members were required for transfer. During an interview on [DATE] at 10:45 a.m. with the Director of Nursing (DON), the DON stated Resident 1 had left sided weakness, had impaired mobility (a disability that limits a person's ability to move freely) and was a high fall risk. The DON stated Resident 1's care plan indicated two staff members were required to assist during transfer on [DATE]. The DON stated two staff members were required to ensure safe transfer and to avoid falling. During an interview on [DATE] at 10:52 a.m. with the Administrator (ADM), the ADM stated Resident 1 had left sided weakness and contracture in his left arm. The ADM stated Resident 1's care plan indicated two staff members were required to assist with transfer due to Resident 1's impaired mobility. The ADM stated two staff members were required to assist Resident 1 with transfer on [DATE] to ensure safe transfer. During a review of the facility's policy and procedure (P&P) titled, Fall Management and Neurological Check, dated 1/2025, the P&P indicated, Policy Statement: The center implements a fall management plan based on medical history review and resident evaluation . Procedure: . 5. The LN (Licensed Nurse) updates care plans reflecting individualized intervention in an attempt to reduce or prevent falls . During a review of the facility's P&P titled, Safety and Supervision of Residents, dated 11/2017, the P&P indicated, Policy Statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . Policy Interpretation and Implementation. Facility-Oriented Approach to Safety. 1. Our facility-oriented approach to safety addresses risks for groups of residents . 4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents . Individualized, Resident-Centered Approach to Safety. 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received supplemental oxygen (from a portable tank which delivers oxygen through a tube inserted into the nostrils), as ordered by her physician, when she left the facility to go to a medical appointment. This failure resulted in Resident 1 going approximately 7 hours without her physician-ordered supplemental oxygen, which has the potential to cause respiratory distress such as shortness of breath, elevated heart rate, anxiety, and confusion. Findings: During a review of Resident 1's admission Record (AR) dated 7/3/24, the AR indicated Resident 1 was a [AGE] year-old female admitted to the facility with diagnoses that included Acute and Chronic Respiratory Failure with Hypercapnia (a condition where there is too much carbon dioxide, a waste product, in the body), and Dependence on Supplemental Oxygen. During a review of Resident 1's Order Summary Report (OSR), dated 7/3/24, the OSR indicated Resident 1 had a physician's order for Oxygen administered continuous [at all times] at 2 Liters, every shift for oxygen, dated as beginning on 4/17/24. During a review of Resident 1's Care Plan (CP), dated 4/18/24, the CP indicated Resident 1 has oxygen therapy. Resident is on oxygen. During a review of Resident 1's Progress Notes (PN), dated 5/28/24, at 3:44 PM, the PN indicated that earlier that day, at 1:45 PM, Resident 1 had returned from a medical appointment outside the facility. A PN dated 5/28/24, at 3:50 PM, indicated Resident 1 was at the appointment for most of AM shift. Both Progress Notes were written by Licensed Vocational Nurse (LVN) 1. During an interview with the Administrator, on 7/3/24, at 10:50 AM, the Administrator stated Resident 1 had gone to this appointment without her ordered supplemental oxygen. The Administrator stated this incident was investigated by the facility, found it to be substantiated , and LVN 1 had been assigned to Resident 1's care when she left for her appointmen.t During an interview on 7/3/24, at 11:45 AM, with LVN 1, LVN 1 stated he recalled Resident 1 going to a medical appointment outside the facility that day. LVN 1 stated he was assigned to Resident 1's care and transportation had arrived early that morning at about 6:30 AM to take her to the appointment. LVN 1 stated he assigned Certified Nursing Assistants to get her up out of bed and ready for her appointment, and he did not notice she was to have oxygen, and subsequently Resident 1 left the facility with no supplemental oxygen. LVN 1 stated Resident 1 returned to the facility later that day about 1 or 1:30 PM in no respiratory distress but was notified by her accompanying family she was to be on supplemental oxygen. During a review of the facility document titled Verification of Investigation Report (VOIR), dated 6/20/24, the VOIR indicated .facility identified that the nurse was [LVN 1] and he admitted to forgetting to send [Resident 1] out with [oxygen] tank. Employee was in-serviced by the Director of Nursing and Director of Staff Development. During a review of the facility document titled Employee Correction Notice (ECR), dated 6/20/24, the ECR indicated that on 5/28/24, LVN 1 Failed to follow MD [Medical Doctor] order for Resident 1 on that date, and failed to ensure [Resident 1] was wearing and receiving oxygen via nasal cannula [flexible tubing that is inserted into the nostrils] prior to leaving for a doctor appointment as per MD order. The ECR was signed by LVN 1. During a review of the facility Policy and Procedure (P&P) titled, Oxygen Administration, dated 10/10, the P&P indicated, in part, Review the physician's orders or facility protocol for oxygen administration. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three residents (Resident 1) when Resident 1 was admitted with a stage 3 pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) to the sacral (tailbone) region on 4/17/24 and Resident 1 ' s stage 3 pressure ulcer assessment was not documented (a process used to learn about a patient's condition) until 5/14/24. This failure was not the standard of practice according to the facility ' s policy and procedure titled, Charting and Documentation, and Prevention of Pressure Injuries. Findings: During a review of Resident 1 ' s admission Record (AR), dated 6/19/24, the AR indicated Resident 1 had a stage 3 pressure ulcer to the sacral region. During a review of Resident 1 ' s Admission/readmission Evaluation (ARE), dated 4/17/24, the ARE indicated, 4a. Is a skin issue present? Yes. Site: Sacrum. Description: Stage III (3) pressure ulcer. During a review of Resident 1 ' s IDT Skin Meeting (ISM), dated 4/24/24, the ISM indicated, Reason for Meeting: Open area to coccyx (tailbone). During a review of Resident 1 ' s Progress Report (PR), dated 5/14/24, the PR indicated, Wound Details: Location: Center Midline Coccyx. Classification: Pressure Ulceration. Stage: Stage III. Width: 7.5 cm (centimeters; unit of measurement). Length: 6 cm. Depth: 0.1 cm. Area 4.5 cm2 (centimeter squared; unit of measurement). Volume: 4.5 cm2. During an interview on 6/19/24 at 12:11 p.m. with Registered Nurse (RN), RN stated she was the designated wound nurse on the weekend. RN stated she provided wound treatment and wound assessment weekly for residents with wounds. RN stated she provided wound care and wound assessment for Resident 1. RN stated she was unable to locate the wound assessment record with measurements of the wound she completed for Resident 1 from 4/17/24 through 5/13/24. RN stated wound assessments with measurements of the wounds were required to record the condition and progress of the wound. During an interview on 7/9/24 at 3:42 p.m. with Physician Assistant (PA), PA stated she visited residents with wounds at the facility once a week. PA stated Resident 1 was referred to her on 5/14/24 with an open area to her coccyx. PA stated Resident 1 ' s wound was fully covered in eschar (dead tissue that forms over healthy skin and then, over time) during the first assessment. PA stated weekly assessments of the wound was required as proof of care. PA stated wounds should be measured and photographed to determine the progress of the wound. PA stated medical records should be complete and accurate. During an interview on 7/11/24 3:14 p.m. with Director of Nursing (DON), DON stated the wound nurse was available only on the weekend. DON stated licensed nurses were required to assess and provide care for the wound when the wound nurse was not available. DON stated wound assessments were required to be completed weekly either by the licensed nurses or the wound nurse. DON stated wound assessment were to monitor the change of condition of the wound; if the wound is getting worse or better. DON stated untreated wounds can lead to sepsis (blood poisoning) and death. DON stated wounds should be assessed (including measurements) when providing treatment and should be assessed at minimum of once a week. DON stated documentation of the assessments were required to be kept in the resident ' s medical record to monitor trend. DON stated the medical record must be complete and accurate to reflect the quality of care provided at the facility. During an interview on 7/11/23 at 3:23 p.m. with Administrator (ADM), ADM stated the reason for wound assessment were to see if the wound was getting better or worse. ADM stated wounds should be assessed at minimum weekly and during each treatment to see if the treatment is effective. ADM stated assessments were required to be in medical records to reflect care provided. ADM stated the resident ' s medical record must be complete and accurate in case family request a copy of the resident ' s medical record. ADM stated if wound care was completed and documented and the assessments (with measurements) were not documented it was not completed. During a review of the facility ' s policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017, the P&P indicated, Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record . Policy Interpretation and Implementation: .2. The following information is to be documented in the resident medical record: .c. Treatments or services performed . 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . 7. Documentation of procedures and treatments will include care-specific details, including: .c. The assessment data and/or any unusual findings obtained during the procedure/treatment . During a review of the facility ' s P&P titled, Prevention of Pressure Injuries, dated 4/2020, the P&P indicated, Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation: Review of the resident ' s care plan identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Risk Assessment: 1. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition . Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident ' s risk factors, and prior to discharge .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide needed care according to professional standards of practice for one of four sampled residents (Resident 59) when facility did not notify physician of Resident 59's change of condition (COC) of hyperglycemia (high blood sugar). This failure had the potential to result in Resident 59's development of diabetic ketoacidosis (DKA- complication of diabetes, when the body can't make enough insulin to allow blood sugar into the cells for energy and the body breaks down fat). Findings: During a review of Resident 59's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 59 was admitted to the facility on [DATE] with diagnosis, . Influenza A with Pneumonia (lung inflammation caused by virus or bacteria) . Type 2 Diabetes Mellitus (DM-long term condition in which the body has trouble controlling blood sugar) . Muscle weakness . Dysphagia (difficulty swallowing) . cerebral infarction (disrupted blood flow in the brain) . hemiplegia (loss of ability to move one side of the body) . depression (constant feeling of sadness and loss of interest) . chronic kidney disease (progressive damage and loss of function to the kidneys) . pain . dependence of supplemental oxygen . hyperlipidemia (high fats or lipids in the blood). deficiency (lack of) of other specified B group vitamins (essential for normal growth and nutrition) . During a review of Resident 59's, Discharge Summary for expired residents, dated [DATE], indicated, . date and time of expiration: [DATE] at 12:24 p.m. final diagnosis/cause of death . cardiopulmonary arrest (sudden unexpected loss of heart function, breathing, and consciousness) . During a review of Resident 59's Physician Orders for Life Sustaining Treatment (POLST- a portable form with instructions for emergency medical care that travels with a resident), dated [DATE], indicated, . Do not attempt resuscitation (DNR) . Comfort-focused treatment . request transfer to hospital only if comfort needs cannot be met in current location . During a review of Resident 59's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 59's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 00 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 59 BIMS could not be completed. During a review of Resident 59's, Nursing Note, dated [DATE] at 9:53 p.m., indicated, . sent Dr . a fax to notify of blood sugar (BS), was 425 and 450 was documented for night (NOC) shift . During a record review of Resident 59's, Blood Sugar Summary, dated [DATE]-[DATE], the summary indicated Resident 59 had a blood sugar documented on:[DATE] at 5:38 a.m. of 440 milligram/deciliter (mg/dL- unit of measure) and a blood sugar documented at 3:34 p.m. of 425 mg/dL. The Summary also indicated blood sugar documented on [DATE] at 7:16 a.m. of 500 mg/dL, 7:21 a.m. of 500 mg/dL, 1:45 p.m. of 411 mg/dL, 3:55 p.m. of 496 mg/dL and 7:02 p.m. of 430 mg/dL. During a review of Resident 59's Order Summary, dated [DATE], indicated, . Check Blood glucose twice a day, notify medical doctor (MD) if BS is more than 400 or less than 60. Two times a day for DM . Linagliptin (medication used to treat DM) oral tablet 5 mg give 1 tablet by mouth in the morning for DM . metformin hydrochloride (medication used to treat DM) give 1 tablet by mouth two times a day for DM . During a review of Resident 59's, Situation, background, assessment and Recommendation (SBAR), dated [DATE] at 5:28 a.m., indicated, . hyperglycemia fasting blood glucose at 500 . recommendation new orders from physician/provider: pending answer. Report given to AM to follow up resident appears in no s/s of pain or discomfort at this time . During a review of Resident 59's, Nursing note, dated [DATE] at 5:28 a.m., indicated, Resident has episode of hyperglycemia, called MD but unable to be reached at this time, faxed home fax, report given to AM shift to follow up with MD, resident appears comfortable at this time, no distress noted, no s/s of pain or discomfort, no facial grimacing or body guarding, no change from level of consciousness(LOC), resident is DNR comfort care, Resident representative (RR) has been made aware . During a review of Resident 59's, Nursing note, dated [DATE] at 11:18 a.m., indicated, . rechecked BS and is 370. Resident only taking 10% of breakfast and refusing to eat more. No distress continue to monitor & assess . During a review of Resident 59's, Nursing note, dated [DATE] at 1:37 p.m., indicated, . insulin (medication used to lower blood sugar) given to right lower quadrant (RLQ) for one time order for blood sugar (BS) 411. Continue to monitor & assess . During a review of Resident 59's, Order Summary, dated [DATE], indicated, . Insulin Lispro subcutaneous solution cartridge 100 unit/mL inject as per sliding scale: if 401-450 = 12 units; 451+ greater than 450 call MD . one time only for DM for 1 day . order status completed . order date [DATE] . order end date [DATE] . During a review of Resident 59's, Nursing Note, dated [DATE] at 12:45 p.m., indicated, . Resident is on alert charting for s/p hyperglycemia episode, resident had a blood sugar of 496, notified MD who gave order to give an additional 14 units of Humalog, rechecked blood sugar was 430, MD notified with no new orders, residents last blood sugar reading at 197 with insulin given, resident has not had any intake of nutrition, resident refused medications x 3 unable to open mouth properly to take medicine, resident on alert charting for unlabored breathing and high respiration rate, resident's current oxygen (O2) level at 89% on 3 liters via nasal cannula . RP notified, RP wishes to not send resident to hospital, resident is DNR, notified MD. MD gave order to keep resident comfortable, increase oxygen level as needed, resident at this time is laying in bed, when asked if comfortable resident nodded his head, respirations continue to fluctuate between 38 to 42 breaths per minute (BPM) . During a review of Resident 59's, Nursing Note, dated [DATE] at 12:45 p.m., indicated, . resident passed. No respirations and no pulse. Notified Dr . and paperwork started. Notified RP but no response . During a review of Resident 59's, Diabetes Mellitus (DM) Care Plan, dated [DATE], indicated, . the resident has DM at risk for complications . resident will be free from any signs and symptoms (s/sx) of hyperglycemia through the review date . Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness . Dietary consult for nutritional regimen and ongoing monitoring . monitor/document/report PRN compliance with diet and document any problems . During an interview on [DATE] at 11:37 a.m. with Licensed vocational nurse (LVN 4), LVN 4 stated the facility process for a change in condition (COC), was for the charge nurse to complete an assessment, call the residents physician, Resident 59's physician could have been contacted by pager, cell phone, main office line, or fax. LVN 4 stated if there was another physician assigned to the facility, the nurses call them if Residents physician could not be reached. LVN 4 stated it was the expectation for the oncoming nurse to continue to monitor the resident, attempt to contact the physician and document in Resident #'s medical record. LVN 4 stated it was not an acceptable practice to wait two days to notify Resident # physician of the COC and it was the expectation for the charge nurse to continue to follow up with the RP and physician while documenting all interventions completed for the resident. During a concurrent interview and record review on [DATE] at 3:51 p.m. with the director of nurses (DON), Resident 59's, Nurses Note, dated [DATE] at 9:53 p.m., indicated, . sent Dr . a fax to notify of blood sugar glucose (BSG), was 425 and 450 was documented for night (NOC) shift . The DON stated the facility process for a identifying a change of condition (COC) included the assessment of resident symptoms of hyperglycemia including sweating, altered mental status and Resident 59's level of consciousness. The DON stated the nurse should have checked Resident 59's vital signs which include respirations, heart rate, blood pressure, temperature, oxygen levels, blood sugar level and then notify the physician. The DON stated the physician should have been notified first by pager, then by cell phone, physician's office number, lastly by fax and when there was no response from the physician, it was the expectation that the nurse would have called the DON and the resident representative (RR) to update on Resident 59's condition and inability to contact the physician. The DON stated there was a delay in care for Resident 59. The DON stated the nurses note indicated there was not an appropriate assessment completed and the expectation was for the nurse identifying the COC to document the assessment, attempts to notify the physician, RP notification and response understanding the potential outcomes. On [DATE] at 11:34 a.m. a record review of the fax sent to physician to notify of Resident 59's COC was requested. The DON stated the fax was not available in Resident 59's medical chart. During an interview on [DATE] at 11:23 a.m. with LVN 1, LVN 1 stated the facility process for a COC included completion of an SBAR, physician notification, alert charting, and RR notification. LVN 1 stated it was expected to call the physician and allow time to follow up, typically within 30 minutes, if the physician could not be reached, it was expected the charge nurse call the medical director. LVN 1 stated Resident 59's high blood sugar was not a notification that should have been faxed to the physician because it could have taken 8-10 hours for a response. LVN 1 stated it was the expectation for the charge nurse to call the physician when there was an abnormal result, document the COC and call for emergency services if the physician could not be contacted. LVN 1 stated it was the expectation to educate the RR of the potential of outcomes or death and document in the medical record. During a concurrent interview and record review on [DATE] at 11:24 a.m. with LVN 1, Resident 59's Order Summary, dated [DATE] was reviewed. The order summary indicated, . Insulin Lispro subcutaneous solution cartridge 100 unit/mL inject as per sliding scale: if 401-450 = 12 units; 451+ greater than 450 call MD . one time only for DM for 1 day . LVN 1 stated that on [DATE] at 3:57 p.m., Resident 59's was administered 12 units of insulin Humalog. LVN 1 stated it was expected to document a follow up completed of resident 59's condition. During a concurrent interview and record review on [DATE] at 11:46 a.m. with the DON, Resident 59's Order Summary, dated [DATE] was reviewed, the order summary indicated, . Check blood glucose twice a day, notify MD if BS is more than 400 or less than 60 . The DON stated it was expected that the charge nurse notify the physician by any means necessary but preferably by phone. During a concurrent interview and record review on [DATE] at 11:46 with the DON, the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021. The P&P indicated, . significant change in condition is a major decline or improvement in the resident's status . except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status . The DON stated Resident 59's elevated blood sugar was considered an emergency and it was expected the charge nurses would have identified the COC as a medical emergency. During a telephone interview on [DATE] at 12:05 p.m. with Resident 59's physician, the physician stated it was the expectation for the facility to have called and notified the physician immediately of Resident 59's significant COC. The physician stated there were protocols that are followed with a COC of high blood sugars and could not recall a fax received regarding Resident 59 from the facility. The physician stated the facility should have treated Resident 59's hyperglycemia even when the POLST stated DNR with comfort measures. The physician stated it was expected the facility explained and encouraged the RR to transfer Resident 59 to the hospital following the COC of elevated blood sugars if the physician was not available. The physician stated it was the expectation for the facility to identify a blood sugar reading of 400 or above as an emergency and should have notified the physician if the blood sugar readings were between 250-300 as it was expected to identify these readings as a warning sign, the physician further stated the order to notify physician should have read, call the physician. The physician stated the facility was familiar with the physician practices and should have transferred Resident 59 to the hospital when the COC occurred, as the weight loss and high blood sugars could have been a probable contributing factor in Resident 59's death. During a telephone interview on [DATE] at 12:32 p.m. with the resident representative (RR), the RR stated there were two phone calls received from the facility leading up to Resident 59 death. The phone calls were to notify of resident 59's oxygen levels with labored breathing and to inform of high blood sugars with unsuccessful outcome from the insulin administration to lower the blood sugar. The RR stated the facility communicated Resident # condition and upon Resident #'s wishes, resident was not transferred to the hospital. The RR stated Resident 59's death happened so fast following admission to During a telephone interview on [DATE] at 1:24 p.m. with the LVN 3, LVN 3 stated the facility process when a COC was identified was for the charge nurse to complete a resident assessment and notify the physician. The LVN 3 stated the physician was called for Resident 59 and when there was no response, the physician was then faxed. The LVN 3 stated Resident 59's high blood sugar would have been a significant change in condition. The LVN 3 stated there was a lack of documentation following the identified COC for Resident 59 and it was important to have documented the assessment as it would have provided more detail in Resident 59 condition. The LVN 3 stated there should have been more documentation and the COC should have been identified as an emergency requiring transfer to the hospital. During an interview on [DATE] at 1:31 p.m. with LVN 2, LVN 2 stated the facility process for identifying a COC was to notify the physician, RR, and complete an SBAR. LVN 2 stated it was the facility expectation to document an identified COC and resident assessment. LVN 2 stated a high blood sugar would be considered a COC and considered a medical emergency. LVN 2 stated when the physician was not reached by fax, it was the expectation to call the medical director and the DON. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2021, indicated, . our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .the nurse will notify the resident's attending physician or physician on call when there has been a (an) . significant change in the resident's physical/emotional/mental condition . significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff . impacts more than one area of the resident's heath status . prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the interact SBAR . the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . During a review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated 11/2020, indicated, . purpose to provide an overview of diabetes in the older adult, its symptoms and complications, and the principles of glucose monitoring . Diabetic ketoacidosis occurs when hyperglycemia is untreated . symptoms include . high blood sugar . weakness and fatigue . shortness of breath . confusion .establish provider notification protocols, for example . call as soon as possible when . blood glucose values are greater than 250 mg/dL more than once within a 24 hour period . blood glucose values are greater than 300 mg/dL more than once over two consecutive days . support optimal nutrition and protein intake for diabetic residents . monitor the resident for nutritional problems and unintended weight loss and notify the health care provider . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly . During a review of a professional reference titled, American Nurses Association: Principles of Nursing Documentation, dated 2010, page 8 indicated, .Patient documentation frequently is used by professionals who are not directly involved with the patient's care. If patient documentation is not timely, accurate, accessible, complete, legible, readable, and standardized, it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two of four sampled residents (Resident 361 and Resident 17) when 1. Resident 361's toenails were not cut or trimmed for a year and 3 months. 2. Resident 17's toenails were not cut or trimmed. These failures resulted in Resident 361's and Resident 17's toenails to become long and curled which had the potential to result in Resident 361's and Resident 17's toenails to become painful, ingrown or to break off the nail bed causing infection and limit resident's mobility during activities of daily living (ADL). Findings: 1. During an observation on 2/13/24 at 3:20 p.m. in Resident 361's room, Resident 361 was observed lying in bed with both feet exposed, observed to have long, yellow, hard thick toenails (all ten toes). During a review of Resident 361's admission Record (AR), the AR indicated, Resident 361 was admitted to the facility on [DATE]. The AR indicated Resident 361 had a diagnosis of Unspecified Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Muscle Weakness (Generalized) (a condition when the muscle becomes weak due to aging or disease such as diabetics), Unspecified Abnormalities of the Gait and mobility (an abnormal walking condition), Unspecified Symbolic Dysfunctions (language deficits related to an organic or medical condition), Unspecified hearing loss bilateral (medical condition when both hearing have lost the ability to hear normally), Dysphagia oropharyngeal phase (a term that describes difficulty in swallowing), Major Depressive Disorder Unspecified (medical condition for feeling of sadness), Hypertension (medical condition when the pressure in your blood vessels is too high (140/90 mmHg or higher). During a review of Resident 361's Minimum Data Set (MDS-a resident assessment tool used to identify cognitive (mental processes) and physical function level assessment dated [DATE], the MDS indicated, Resident 361's Brief interview for Mental Status (BIMS-screening tool used to assess resident cognitive level) the score was 3 out of 15 (0-7 indicated severe cognitive impairment-[memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact). Review of Resident 361's functional ability and Goals section GG under section I for personal hygiene the score was indicated at 2 (a score of 6 indicated resident is independent -no assistance needed, a of 5 indicated resident need help with setup or clean-up-assistance, a score of 3 indicated partial/moderate assistance [ helper does less than half the effort], a score of 2 indicated substantial/maximal assistance-[helper does more than half the effort], a score of 1 indicated resident is dependent where helper does all of the effect. During a review of Resident 361's Nursing Care Plan (CP), dated 3/11/2022 the CP indicated, Resident 361 has an ADL self-care performance deficit Activity Intolerance .muscle impairment. The CP goals indicate Resident 361 will improve with current level of function with target date of 2/29/2024. Resident 361's intervention included bathing and showering staff to provide personal hygiene routinely, CNAs to assist with dressing and grooming every shift as tolerated. During an interview on 2/13/24 at 3:22 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 361 had a diagnosis of diabetes (a medical condition in which the sugar level is high in the bloodstream). LVN 5 stated the podiatrist (foot doctor) was responsible for trimming Resident 361's toenails due to his diagnosis of diabetes. LVN 5 stated it was the facility process to refer resident's who had a diagnosis of diabetes to the podiatrist for further care. During a review of Resident 361's Order Summary, dated 1/11/24, the Order Summary indicated, .Ordered Date: 1/11/2024 at 4:44 p.m. Description: Podiatry as Needed for Mycotic/hypertrophic [an infection that affects your toenails and separates your nail from your nail bed, making it thick and fragile] and/or keratotic lesion [A bump or patch of thickened skin] . During a concurrent interview and record review on 2/14/24 at 9:26 a.m., with the Unit Manager Registered Nurse (UM-RN), Resident 361's Order Summary dated 1/11/24 was reviewed. The Order Summary indicated, .Ordered Date: 1/11/2024 at 4:44 p.m. Description: Podiatry as Needed for Mycotic/hypertrophic and/or keratotic lesion . The UM-RN stated on 2/14/24 Resident 361's toenail were observed long and proceeded to trim them. The UM-RN stated Resident 361 needed full assistance with ADL's including nail care. The UM-RN stated the Certified Nurse Assistants (CNA) were responsible for notifying the nurses when Resident 361 needed the toenails trimmed because the CNAs were not trained to cut or trim toenails for residents with a diagnosis of diabetes. The UM-RN stated she could not recall the last time Resident 361's toenails were trimmed/cut prior to 2/14/24. During an interview on 2/14/24 at 4:44 p.m. with the Social Services Director (SSD), the SSD stated it was the facility process expectation was to follow up after a grievance was received and obtain a physician order to refer Resident 361 to a podiatrist. The SSD stated after receiving the physician order for referral it was then communicated to the scheduler for transportation and scheduling of podiatry services per insurance. During an interview on 2/15/24 at 9:42 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was assigned to care for Resident 361 and was familiar with the resident's care needs. CNA 1 stated it was the facility process to allow CNAs to trim/cut fingernails, but they were not allowed to trim/cut toenails because they were not trained and could potentially cause skin breakdown with residents who were diagnosed with diabetes. CNA 1 stated it was the facility expectation for all scheduled CNAs to observe residents' toenails during ADL care and notify the charge nurse when the toenails needed to be trimmed or cut. During an interview on 2/15/24 at 10:02 a.m. with the SSD, the SSD stated Resident 361 did not have an appointment scheduled with the podiatrist. The SSD stated she was not aware Resident 361's toenails were long and needed to be trimmed. SSD stated it was the facility process to identify needed services such as a referral to a podiatrist and schedule appointments as needed. The SSD stated it was the expectation to follow a grievance from the resident or resident representative (RP) immediately to identify the issue and correct it. During an interview on 2/15/24 at 10:02 a.m., with the Business office Manager (BOM), the BOM stated Resident 361 did not have a referral to be seen by podiatry. The BOM stated there were no notification from facility staff reporting Resident 361's toenails being long and needing to be trimmed or cut. The BOM stated it was the facility process for the BOM to receive a referral from the SSD and provide transportation to the podiatry services. During a concurrent interview and record review on 2/25/24 at 10:14 a.m. with the infection preventionist (IP), a photograph taken on of Resident 361's toenails , was reviewed. The IP stated Resident 361's toenail appearance was a dignity issue and appeared to not have been trimmed or cut for a long period of time. The IP stated it was the facility process that the CNAs provided toenail care on Resident 361's assigned shower days and during ADL care. The IP stated, it was the facility process for the CNAs to notify the charge nurse when Resident 361 needed to have the toenails trimmed or cut, as the CNAs were not allowed to cut any resident's toenails when there was a diagnosis of diabetes. The IP stated it was the expectation for the charge nurse to notify the SSD to schedule an appointment with the podiatrist. The IP stated long toenails could have harmed Resident 361 because of the potential for infection or dislodgment (force out of a secure or settled position) of the toenails. During a concurrent interview and record review on 2/15/24 at 2:37 p.m., with the Director of Nursing (DON), a photograph taken of Resident 361's toenails, was reviewed. The DON stated based on the photograph it appeared the resident had not had nail care provided. The DON stated it was the facility process for the CNAs to provide toenail care during ADL's to resident's who did not have a diagnosis of diabetes and were responsible for notifying the charge nurse when a resident needed toenail care. The DON stated she expected the nurses to obtain a physician order for a referral to schedule an appointment with the podiatrist. The DON stated the SSD was responsible for making an appointment with the podiatrist and schedule the transportation for Resident 361. The DON stated personal hygiene was important due to the potential risk for infection and for a dignified existence. 2. During a concurrent observation and interview on 2/13/24 at 4:56 p.m., with Resident 17, in Resident 17's room, Resident 17 was observed lying in bed, slightly ungroomed in appearance and responsive to voice. Resident 17 stated he has been at the facility for three weeks and no one has asked him about his preferences. Resident 17 stated it is his preference to have his toenails clipped but doesn't bother telling staff because as an example he asked for a washcloth to wash his face about 1 o'clock and nothing, it's been 4 hours. During a review of Resident 17's admission Record (AR), the AR indicated, Resident 17 was admitted to the facility on [DATE]. The AR indicated Resident 17 had a diagnosis of dementia, muscle weakness, chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems) morbid obesity, difficulty in walking, meniscus derangement (describes disorders affecting the knee joint) right knee. During a review of Resident 17's MDS dated [DATE], the MDS indicated Resident 17's BIMS score was 12 out of 15 (moderate cognitive impairment). During a concurrent observation and interview on 2/13/24 at 5:00 p.m., with CNA 7, in Resident 17's room. CNA 7 responded to Resident 17's request for help by using the call light. CNA 7 came in and took Resident 17's vital signs (blood pressure, heart rate, etc.). CNA 7 stated her practice is to, normally, introduces self and tell them [residents] she will be their CNA for the shift. CNA 7 assisted resident to apply non-skid large size socks. CNA 7 stated Resident 17's toenails look like they could be trimmed. Resident 17 stated he would like his toenails clipped and had not been asked this before and they don't listen to me about my preferences. During a review of Resident 17's Order Summary Report dated 2/14/24, the report indicated, .May have dental, vision & eye health, hearing, and podiatry consults as needed .Order Date 12/8/23 . During a Review of Resident 17's Care Plan (CP), dated 2/16/23, CP indicated Focus Resident 17 .has an ADL self-care performance deficit r/t (related to) muscle weakness, torn right knee meniscus .Goal Resident 17 will improve current level of function through the review date .Interventions During Shower Days check fingernails and toenails if need to be trimmed. Notify Charge Nurse . During a concurrent interview and record review on 2/15/24 at 2:37 p.m., with the DON, a photograph taken of Resident 17's toenails, was reviewed. The DON stated based on the photograph it appeared resident had not had nail care provided. The DON stated it was the facility process for the CNAs to provide toenail care during ADL's to resident's who did not have a diagnosis of diabetes and were responsible for notifying the charge nurse when a resident needed toenail care. The DON stated she expected the nurses to obtain a physician order for a referral to schedule an appointment with the podiatrist. The DON stated personal hygiene was important due to the potential risk for infection and for a dignified existence. During a concurrent interview and record review on 2/16/24 at 10:19 a.m., with LVN 4, Resident 17's CP was reviewed. LVN 4 stated one of the goals is .improve current ADL's function . LVN 5 stated he would do toenail care for diabetics, if the nails were too thick the resident would be send out to podiatry. LVN 4 stated CNAs can do nail care for non-diabetics. LVN 5 stated it is hard to know when podiatry was here last due to days off and there are different vendors, the optometrist comes often. LVN 5 stated Resident 17's CP was not updated to reflect resident's current status, he is no longer max assist. LVN 5 stated the CP should be updated when it doesn't match his current level of ability. LVN 5 stated he does not know what the policy states about how often the CP should be updated. During a review of the facility's job description titled, Certified Nursing Assistant, dated 10/2020. The job description indicated, . the primary purpose of this position is to provide residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . assist residents in accordance with their needs ranging from minimal assistance to total dependent care on activities of daily living ADL's . assist residents with bathing functions . assist residents with personal grooming . assist non-diabetic residents with nail care . check each resident routinely to ensure that his/her personal care needs are being met . During a review of the facility's job description titled, Registered Nurse (RN), dated 10/2020. The job description indicated, . the primary purpose of this position is to provide skilled nursing care to residents under the medical direction of the residents attending physician . provide support and assistance with residents' personal care and activities of daily living as needed . During a review of the facility's policy and procedure (P&P) titled Foot Care, dated 3/2018, the P&P indicated, . residents will receive appropriate care and treatment in order to maintain mobility and foot health . residents will be provided with foot care and treatment in accordance with professional standards of practice . resident will be assisted in making transportation appointments to and from specialists podiatrist . as needed . trained staff may provide routine foot care . During a review of the facility's P&P titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated 11/2020, the P&P indicated, . skin and foot care .toenails should only be trimmed be personnel qualified to do so this can be regular associates, and does not have to be a podiatrist . During a review of the facility's P&P titled, Resident rights, dated 2/2021, the P&P indicated, . employees shall treat all residents with kindness, respect and dignity . the rights include the residents right to a dignified existence . exercise his or her rights . During a review of the Nursing Times article titled, Foot Assessment and Care for Older People dated 12/9/14, the article indicated, .Foot care can prevent mobility problems and social isolation; it is a crucial part of nursing care, particularly for older patients, who may be unable to care for their own feet . Toenail disorders including hardened or ingrown nails . Toenails can thicken and become hard and brittle with age, which makes it difficult to cut them. Continuous pressure from inappropriate footwear can also cause more extreme nail deformity. Nails that become too long or thickened can damage the skin on adjacent toes .Ingrown toenails occur when a nail grows into the skin, and can cause pain, swelling, redness and infection .Fungal infection of skin, such as athlete's foot - which causes peeling, redness, itching, burning .Fungal nail infections occur when microscopic fungi enter the nail through a break; they result in thick, discolored and brittle nails .Foot assessment .When older people can no longer manage their own foot care, an initial assessment is required to identify what help they need .Podiatrists assess all new nursing home residents . After an individual has been assessed, care may be provided by Podiatrists . Referrals should be made to podiatrists, GPs, or pharmacists (for medication review) if patients have .Medical complications that put feet at risk, such as diabetes .Painful foot lesions, including severe deformities and toenails that are excessively thickened and cause pain, prevent mobility or are a risk to surrounding skin .Loss of sensation .Patients with diabetes who have an increased risk must have an expert assessment carried out by health professionals with specialist experience in the management of the foot in diabetes. Registered nurses should know who to refer and should ensure a timely referral is made and response given .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure drug records to account for the receipt and accurate reconciliation (comparing medication received is being delivered) for controlled medications (medications that may be abused or cause addiction) for one of three sampled residents (Resident 13) when the pharmacy manifest (form that contains information about the type and quantity of medication delivered) was not signed upon delivery of a controlled medication. This failure had the potential for drug diversion (distribution or abuse of a prescription drug or it's use for purpose) of Resident 13's controlled medication. Findings: During a concurrent observation and record review on 2/14/24 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident 13's medication Acetaminophen-codeine (APAP/COD) #3 (controlled medication) tablet 300-30 mg (unit of measure) was observed during Medication cart 2's review of medications. During a review of Resident 13's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 13 was admitted to the facility on [DATE] with diagnosis, .Pain . polyneuropathy (A condition where many peripheral nerves are damages and is characterized by weakness, numbness and burning pain) . During a review of Resident 13's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 13's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 13 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 13 was cognitively intact. During a review of the facility's manifest titled, Consolidated delivery sheets for controlled substances, dated 2/7/24, indicated, . 90-tab APAP/COD 300/30 mg delivered . The manifest was not signed with signature of recipient, dated and time medication was received from the pharmacy. During a review of Resident 13's, Physician Order, dated 7/27/23, indicated, . Acetaminophen-codeine #3 tablet 300-30 mg-controlled drug give one tablet by mouth three times a day for pain . During a concurrent interview and record review on 2/14/24 at 11:48 a.m. with LVN 1, the manifest titled, Consolidated delivery sheets for controlled substances, dated 2/7/24, indicated, . 90-tab APAP/COD 300/30 mg delivered ., was reviewed. LVN 1 stated the manifest was not signed and dated with time of receipt by the charge nurse. LVN 1 stated it was the expectation for the nurse receiving the medication to sign the pharmacy manifest and confirm with another nurse the amount of medication being delivered. LVN 1 stated the manifest for Resident 13's medication should have been signed by the receiving nurse to ensure the medication being delivered was correct. During a concurrent interview and record review on 2/15/24 at 3:33 p.m. with the director of nurses (DON), the manifest titled, Consolidated delivery sheets for controlled substances, dated 2/7/24, indicated, . 90-tab APAP/COD 300/30 mg delivered ., was reviewed. The DON stated the manifest was not signed and dated with time of receipt by the charge nurse. The DON stated upon review of the manifest, the charge nurse did not reconcile the medication for Resident 13 upon delivery. The DON stated it was the facility expectation for the charge nurse receiving medications from the pharmacy, to reconcile, sign and date the manifest before receiving. The DON stated it was important to have an accurate account of medications being received in the facility to avoid medication diversion. During a telephone interview on 2/15/24 at 4:02 p.m. with the pharmacy manager (PM), the PM stated it was the expectation for the facility to sign the manifest of all medications being received in the facility to ensure reconciliation of medications. During a review of the facility's P&P titled, Accepting Delivery of Medications, dated 2/2021 was reviewed. The P&P indicated, . any errors noted in receiving medications shall be brought to the attention of the pharmacist and the director of nursing services . before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/order receipt . if an error is identified when receiving medications from the pharmacy, the nurse verifying the order shall inform the delivery agent of any discrepancies and note them on the delivery ticket return correct medications to the dispensing pharmacy and reorder the correct medication . a nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications were properly stored and labeled in accordance with professional standards when: 1. The facility's medication emergency kit (ekit) containing controlled medications (medications that may be abused or cause addiction) was observed missing a zip tie. 2. Medication for one of three sampled residents (Resident 14) was observed with expired date in Medication Cart two. These failures had the potential for medication diversion (distribution or abuse of a prescription drug or it's use for purpose) from the ekit and the potential for adverse effects (undesired harmful effect) and medication error for Resident 14 when the expired medication was left in the medication cart. Findings: 1. During a concurrent observation and interview on 2/14/24 at 10:48 a.m. with licensed vocational nurse (LVN) 1 in the medication room, the ekit for medications taken by mouth, was observed inside a file cabinet with one red zip tie on the right-side lock, the left side lock did not have a zip tie. LVN 1 stated once the e-kit was open it was easier to open and retrieve medications. LVN 1 stated the ekit was not properly secured because the zip tie on the left side was missing. LVN 1 stated there was a potential for medications to go missing and the ekit should not have been received by the charge nurse if there was a missing zip tie. During a review of the facility's, Oral Emergency Kit inventory, dated August 2022, indicated, . medication name and strength . Acetaminophen-codeine (controlled pain medication) 30 mg (unit of measure)/300 mg 4 tablets (tabs) . alprazolam (controlled medication used to treat anxiety) 0.5 mg 8 tabs . clonazepam (controlled medication used to treat anxiety) 0.5 mg 8 tabs . lorazepam (controlled medication used to treat anxiety) 0.5 mg 8 tabs . quetiapine(medication used to treat mental disorders) 25 mg 4 tabs . tramadol (controlled pain medication) 50 mg 8 tabs . zolpidem (controlled medication used to treat sleeping disorder) 5 mg 4 tabs . During a review of the facility's, Manifest, dated 2/13/24, the manifest indicated, . emergency PO e-kit new . quantity one delivered . The manifest indicated the facility received the delivery of the e-kit with confirmation of receiving nurse signature, date and time. During an interview on 2/15/24 at 3:28 p.m. with the director of nurses (DON), the DON stated the expectation was for the ekit's to be fully sealed with two zip ties when it arrives from the pharmacy. The DON stated if the ekit was missing a zip tie, it was the expectation for the receiving nurse to refuse acceptance of the ekit and call the pharmacy for a delivery of a sealed ekit. The DON stated there was a potential for drug diversion (illegal distribution or abuse of medications) when the ekit was not properly secure with two zip ties. During a telephone interview on 2/15/24 at 3:55 p.m. with the pharmacy manager (PC), the PC stated it was the expectation for the facility nurse receiving the ekit to sign the acceptance on the pharmacy delivery slip. The PC stated the ekit's delivered to the facility have two red zip ties for quality assurance. The PC stated it was expected that the facility used yellow zip ties to identify when the e-kit was opened and replacement was needed. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy, dated 8/2014 was reviewed. The P&P indicated, . when an emergency or stat dose of a medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply . before reporting off duty, the charge nurse indicates the opened status of the emergency kit at the shift change report . if exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening . During a review of the facility's P&P titled, Accepting Delivery of Medications, dated 2/2021 was reviewed. The P&P indicated, . any errors noted in receiving medications shall be brought to the attention of the pharmacist and the director of nursing services . before signing to accept the delivery, the nurse must reconcile the medications in the package with the delivery ticket/order receipt . if an error is identified when receiving medications from the pharmacy, the nurse verifying the order shall inform the delivery agent of any discrepancies and note them on the delivery ticket return correct medications to the dispensing pharmacy and reorder the correct medication . a nurse shall sign the delivery ticket, indicating review and acceptance of the delivery, and shall keep a copy of the delivery ticket. Both the receiving nurse and the delivery agent must sign any notations about errors . 2. During a concurrent observation and interview on 2/14/24 at 11:24 a.m. with licensed vocational nurse (LVN) 1, Resident 14 medication container for nitroglycerin (used to treat chest pain) 0.4 mg (unit of measure) expiration date 10/20/23 was observed in medication cart two. LVN 1 stated the medication for Resident 14 was expired and should not have been left in the medication cart. LVN 1 stated there was a potential for adverse reactions and medication ineffectiveness if the medication was administered. During a review of Resident 14's admission Record (a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 14 was admitted to the facility on [DATE] with diagnosis, .myocardial infarction (heart attack) . congestive heart failure (heart does not pump blood the way it should) . During a review of Resident 14's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 14's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 11 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, (13-15) cognitively intact) which indicated Resident 14 was moderately cognitively intact. During a review of Resident 14's, Physician order, dated 3/15/2022, indicated, . Nitroglycerin tablet sublingual 0.4 mg give one tablet sublingually (under the tongue) every 5 minutes as needed for chest pain x 3 doses. If no relief call MD . During an interview on 2/15/24 at 3:37 p.m. with the director of nurses (DON), the DON stated the facility expectation was for the expired medications to have been removed from the medication cart. The DON stated there was a potential for Resident 14 to experience adverse effects or medication ineffectiveness if medication was administered. The DON stated it was the expectation for the nurses to check the medication carts daily for expired medications. The DON stated it was the expectation to have an expiration date on all medications to avoid potentially administering expired medications to Resident 14. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated 4/2008, indicated, . medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . outdated, contaminated or deteriorated medications and those in containers that are . immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if current order exists . medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified . During a review of the facility's P&P titled, Labeling of Medication Containers, dated 2/2019 indicated, . all medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations . labels for individual resident medications include all necessary information, such as . the expiration date when applicable .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infections when: 1. Unit Manager-Registered Nurse (UM- RN) did not perform hand hygiene during a dressing change to Resident 28; 2. Three hand sanitizer dispensers in the hallway outside resident rooms did not work; These failures placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. During an observation on 2/14/24 at 3:35 p.m. in Resident 28's room, Unit Manager, RN (UM-RN) was observed performing a dressing change to Resident 28's right lower leg. UM-RN was observed removing soiled gloves after removing a soiled bandage and donning (putting on) new clean gloves without performing hand hygiene. During a review of Resident 28's admission Record (AR), dated 2/15/24, the AR indicated, Resident 28 was admitted to the facility on [DATE] with diagnoses of chronic combined systolic (congestive) and diastolic (congestive) hear failure, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/5/23, the MDS Section C indicated, Resident 28 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) of 14 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 28 was cognitively intact. During an interview on 2/15/24 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated if staff providing residents wound care, gloves should be worn and once the gloves were taken off the hands should be washed. g. LVN 1 stated if staff is not washing hands after removing and before placing a clean pair of gloves it can cause cross-contamination to the resident. During an interview on 2/15/24 at 3:37 p.m. with the Infection Preventionist (IP), the IP stated staff need to wash hands before putting on gloves and in-between removing and putting on new gloves when doing wound care. The IP stated her expectation is that staff needs to wash hands before putting on the next pair of gloves. The IP stated there is a risk of cross-contamination and the resident's wound could get infected if proper hand hygiene is not performed. During an interview on 2/16/24 at 4:19 p.m. with the Director of Staff Development (DSD), the DSD stated her expectation is for staff to wash hands prior to providing wound care and after providing wound care. The DSD stated her expectation is for staff to wash their hands anytime their gloves become soiled and after taking off gloves. During an interview on 2/20/24 at 12:24 p.m. with the Director of Nursing (DON), the DON stated prior to performing a dressing change staff should perform hand hygiene: before applying clean gloves, after the removal of a soiled dressing, and perform hand hygiene again before applying a clean dressing. After performing the dressing change, remove gloves and perform hand hygiene. The DON stated staff should perform hand washing each time after removing gloves. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, dated 2019, the P&P indicated, . all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . wash hands with soap . when hands are visibly soiled . before handling clean or soiled dressings . after contact with blood or bodily fluids . after handling used dressings . after removing gloves . hand hygiene is the final step after removing and disposing of personal protective equipment (PPE). During a review of the training and in-service logs titled, Enhanced Precaution Introduction . Washing Hands ., dated 3/29/23, indicated, UM-RN was not listed on the training log. During a review of the training and in-service logs titled, Hand hygiene/Peri hygiene, dated 4/28/23, indicated, UM-RN was not listed on the training log. 2. During an observation on 12/13/24 at 12:00 p.m. in the Unit B Hall, two sanitizer dispensers were observed to not dispense sanitizer solution. During an observation on 12/13/24 at 3:05 p.m. in the Unit C Hall, one sanitizer dispenser was observed to not dispense sanitizer solution. During a concurrent observation and interview on 2/15/24 at 9:55 a.m. with Housekeeper (HSK) 1 in the Unit B Hall, HSK checked the 2 sanitizer dispensers and was unable to get sanitizer solution to dispense. HSK stated if dispensers are not working, you could get germs, and everyone could get sick. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 2019, the P&P indicated, . Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff to use .

Based on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when a drawer holding clean utensils used for meal service was no longer on the drawer track (the mechanisms that allow drawers to open and close smoothly) and was difficult to open and close. This failure had the potential to result in contamination of the clean utensils because the drawer could not be completely closed and potential in bodily injury to dietary staff. Findings: During an initial kitchen tour on 2/13/24 at 10:58 a.m., an observation of a drawer holding clean utensils used for meal service was found to be difficult to open and close and it was kept ajar. The drawer was not on the track on one side and it make it difficult to open and close. During a concurrent observation and interview on 2/14/24 at 8:34 a.m. with the District Dietary Manager (DDM) in the kitchen, a drawer was difficult to open and close. The DDM stated, the DDM was not sure if the drawer could be fixed. During an interview on 2/15/24 at 10:41 a.m. with the Regional Maintenance Supervisor (RMS), the RMS stated he was unaware of a drawer in the kitchen that needed to be repaired. During a phone interview on 2/15/24 at 4:01 p.m. with the Registered Dietician (RD), the RD stated, the drawer was difficult to open and close and her expectation was for the drawer to be fixed. During a phone interview on 2/16/24 at 3:22 p.m. with the Maintenance Supervisor (MS), the MS stated, he was notified of the drawer in the kitchen that was difficult to open and close two weeks ago. The MS stated, he was not sure if there was a TELS (facility's electronic work order system) work order created. The MS stated, he had planned to fix the broken drawer but was focused on other projects. During a review of the professional reference titled, FDA Food Code, dated 2022, 4-501.11 indicated, .(B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications . In addition, Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a clean, safe, and sanitary homelike environment for six of 19 sampled residents (Residents 4, 8, 10, 15, 29 and 31) when: 1. There were missing floor tile in Residents 4 and Resident 10's bathroom with darkened areas in the tile grout. 2. There was a missing baseboard from the wall behind Resident 8's bed exposing chipped paint and grime. 3. The floor tile by Resident 15's bed was broken with missing pieces of tile. 4. There were trash and dirt on the floors and dirty (blackened) floor tiles in Resident 29's room. 5. The privacy curtain in Resident 31's room was torn. These failures placed Residents 4, 8, 10, 15, 31 and 29 in an unclean, unsafe, unsanitary and a non-homelike environment which could affect residents' well-being. Findings: 1. During a concurrent observation and interview on 2/13/24 at 11:50 a.m., with Resident 10 in Resident 10's room, Resident 10 was observed sitting up in a wheelchair. Resident 10 stated she needed help to move her wheelchair. Resident 10's bathroom was observed to be missing tile on the bathroom floor, with dark areas on the tile and on the surface of the missing tile areas. During a review of Resident 10's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/20/24, the AR indicated, Resident 10's admission date was 1/28/22 with diagnoses of epilepsy (a seizure a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), muscle weakness, and dysphagia (difficulty swallowing). During a review of Resident 10's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/11/24, the MDS indicated, Resident 10 had a Brief Interview for Mental Status (BIMS - a screening tool used to assess resident cognitive level) score of 10 out of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills], 8-12 moderate cognitive impairment, 13-15 cognitively intact) which suggested Resident 10 was moderately impaired. During an observation on 2/13/24 at 12:11 p.m. in Resident 4's room, Resident 4 was observed sleeping in bed. Resident 4 did not respond when spoken to. Observed tile missing from the bathroom floor with dark areas observed on the tile and on the surface of the missing tile areas. During a review of Resident 4's AR, dated 2/15/24, the AR indicated, Resident 4 was admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, dysphagia and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 4's MDS, dated 1/30/24, the MDS indicated Resident 4 had a BIMS of 0, which indicated Resident 4 was severely cognitively impaired. During an interview on 2/15/24 at 11:15 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the broken tile in Resident 4's shower could be a trip hazard. LVN 1 stated housekeeping would not be able to get into the cracks of the tile to properly clean. LVN 1 stated it could be an infection hazard. 2. During a concurrent observation and interview on 2/13/24 at 11:04 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 8's room, the baseboard behind Resident 8's bed was observed missing. The wall with missing baseboard was observed with chipped paint and a brown substance. LVN 2 stated the wall behind Resident 8's bed had peeled off paint that appeared to have been removed with the base board. LVN 2 stated the missing baseboard appearance did not provide a homelike environment for Resident 8. During a review of Resident 8's admission Record (AR- a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated, Resident 8 was admitted to the facility on [DATE] with diagnosis, . Neurocognitive Disorder with Lewy Bodies (disorder that leads to decline in thinking, reasoning and self-function . During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment dated [DATE], the MDS indicated Resident 8's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) score was 5 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact) which indicated Resident 8 BIMS indicated severe cognitive impairment. During a concurrent observation and interview on 2/15/24 at 10:59 a.m. with the Regional Maintenance Supervisor (RMS) in Resident 8's room, the area with the missing baseboard behind Resident 8's bed was observed. The RMS stated the baseboard should have been placed back on the wall as is, did not provide a homelike environment for Resident 8. During an interview on 2/16/24 at 5:17 p.m. with the Regional Infection Preventionist (RIP), the RIP stated there were concerns regarding the missing baseboard because of the potential for harm. The RIP stated the facility should have kept up with the issues to prevent residents from infection that could have been caused by growing organisms from not cleaning the surfaces thoroughly. 3. During an observation on 2/13/24 at 2:21 p.m. in Resident 15's room, the floor tile next to Resident 15's bed was observed broken with missing pieces, the area appeared to be the size of a tennis ball with tile pieces broken off that remained inside the open tile. During a review of Resident 15's admission Record (AR), indicated, Resident 15 was admitted to the facility on [DATE] with diagnosis, . Alzheimer's Disease (destroys memory and other mental functions . During a review of Resident 15's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/11/24, the MDS indicated, Resident 15's Brief Interview for Mental Status score was 6 out of 15 which indicated Resident 15's BIMS was severe cognitive impairment. During a concurrent observation and interview on 2/15/24 at 11:01 a.m. with the Regional Maintenance Supervisor (RMS) in Resident 15's room, the floor tile next to Resident 15's bed was observed broken with missing pieces. The RMS stated the tile needed to be replaced and there was a safety concern due to the potential of falls with the missing and broken tile. During a telephone interview on 2/16/24 at 3:22 p.m. with the Maintenance Supervisor (MS), the MS stated the broken tile in resident 15's room was on the list of maintenance issues to complete in the facility. The MS stated there were other projects in the facility that were currently being worked on, but the facility had not completed the task for the broken tiles. The MS stated the missing baseboard in resident 8's room was approved for replacement. The MS stated although the missing baseboard was not pleasant to look at, it was livable for resident 15. A Work Order List was requested on 2/16/24 from RMS for review, no records were provided. During an interview on 2/16/24 at 5:12 p.m. with the Administrator (ADM,) the ADM stated the expectation was to maintain the facility as homelike as possible. The ADM stated there was not a list of the current projects within the facility. The ADM stated the facility expectation was for resident safety to come first and expected the MS to make the determination of prioritizing the facility projects. During an interview on 2/16/24 at 5:17 p.m. with the Regional Infection Preventionist (RIP), the RIP stated there were concerns regarding the missing tile and base board because of the potential for harm. The RIP stated the facility should have unkempt the issues to prevent residents from infection that could have been caused by growing organisms from not cleaning the surfaces thoroughly. 4. During an observation on 2/13/24 at 2:44 p.m. in Resident 29's room, the floor behind and next to Resident 29's bed was observed to have dirt and crumpled paper next to the wall. The wall behind Resident 29's bed was observed to have missing paint. The floor in front of the bathroom door in Resident 29's room was observed to have black marks on the tile and black grime in the grout. During a review of Resident 29's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 2/15/24, the AR indicated, Resident 29 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, encounter for palliative (comfort) care and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 29's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment), dated 12/18/23, the MDS indicated, a Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level)score of 15 (0-7 indicated severe cognitive impairment [memory loss, poor decision making-skills] 8-12 indicated moderate cognitive impairment, 13-15 indicated cognitively intact), which suggested Resident 29 was cognitively intact. During a concurrent observation and interview on 2/14/24 at 8:50 a.m. with the Maintenance Supervisor (MS), in the first shower, the transition between the hallway and the shower room was observed to be missing tiles that created an uneven area between the two areas, exposed cement, dirt and yellow dried adhesive. The MS stated the transition on the floor under the door needed to be replaced. The MS stated it was unsanitary and unsafe. During an interview on 2/15/24 at 1:59 p.m. with the House Keeping Manager (HSK MGR), the HSK MGR stated the floor behind and next to Resident 29's bed was dirty. The HSK MGR stated his expectation was the floor would be clean and up to standards. The HSK MGR stated the black grime buildup between the tiles and black marks on the floor tiles by the bathroom in Resident 29's room was from the glue coming up from the tile. The HSK MGR stated dirty floors can be infectious to residents. The HSK MGR stated he was responsible for monitoring the cleaning of residents' rooms. During a review of the facility's policy and procedure (P&P) titled, Job Description . Light Housekeeper, dated (undated), the Job Description indicated . the light housekeeper . cleans floors in residents' rooms: Dry mops, wet mops, sweeps and disinfects; pulls dresser and moves furniture while dust mopping and damp mopping . ensures that established sanitation and safety standards are maintained . follows infection control and universal precautions policies and procedures to ensure that a sanitary environment is maintained at all times. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated 12/2009 was reviewed. The P&P indicated, . The maintenance department is responsible for maintaining the buildings . in safe and operable manner . maintaining the building in good repair . the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds . are maintained in safe operable manner .the maintenance director is responsible for maintaining the following records/reports. Inspection of building. Work order requests . records shall be maintained in the maintenance director's office . Review of professional reference titled, Why Is Cleanliness Critical For Nursing Home Resident Safety?, dated, 2024, available at: https://braswellmurphy.com/why-is-cleanliness-critical-for-nursing-home-resident-safety/. The professional reference Indicated, .Nursing residents often suffer from several conditions linked to their age. Their immune systems are often not adequately equipped to handle exposure to germs which may be linked to poor cleanliness in a facility . During a review of profession reference titled, CDC and ICAN. Best Practices for Environmental Cleaning in Healthcare Facilities in Resource-Limited Settings. Atlanta, GA: US Department of Health and Human Services, CDC; Cape Town, South [NAME]: Infection Control [NAME] Network, dated 2019, available at: https://www.cdc.gov/hai/prevent/resource-limited/index.html, and http://www.icanetwork.co.za/icanguideline2019/, indicated, It is well documented that environmental contamination in healthcare settings plays a role in the transmission of HAIs.2,3 Therefore, environmental cleaning is a fundamental intervention for infection prevention and control (IPC) . outbreak investigations have determined that the risk of patient colonization and infection increased significantly if the patient occupied a room that had been previously occupied by an infected or colonized patient. Therefore, the role of immediate patient care environment-particularly, environmental surfaces within the patient zone that are frequently touched by or in direct physical contact with the patient such as bed rails, bedside tables, and chairs-in facilitating survival and subsequent transfer of microorganisms was established . 5. During an observation on 2/13/24 at 11:16 a.m. in Resident 31's room, the privacy curtain was observed to have three rings that hold up the curtain to be torn off and hanging down. During a review of Resident 31's admission Record (AR), dated 2/15/24, the AR indicated Resident 31 was admitted on [DATE] with diagnoses of heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/9/23, the MDS Section C indicated Resident 31 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 31 was cognitively intact. During an interview on 2/14/24 at 4:00 p.m. with Resident 31, Resident 31 stated his curtain had been torn for a while. Resident 31 stated he did not remember when it happened. Resident 31 stated the cleaning lady knows about it. During an interview on 2/15/24 at 1:59 p.m. with the Housekeeping Manager (HSK MGR), the HSK MGR stated he was aware of Resident 31's torn curtain. The HSK MGR stated they were waiting for the curtain order to come in. During a review of the facility's policy and procedure (P&P) titled, Job Description . Light Housekeeper, dated (undated), the Job Description indicated . the light housekeeper . cleans floors in residents' rooms: Dry mops, wet mops, sweeps and disinfects; pulls dresser and moves furniture while dust mopping and damp mopping . ensures that established sanitation and safety standards are maintained . follows infection control and universal precautions policies and procedures to ensure that a sanitary environment is maintained at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered Care Plan (CP-the process by which healthcare professionals and patients discuss, agree, and review an action plan to achieve the goals or behavior change of most importance to the patient) to prevent falls and injuries, for four (4) of fifty-four (54) sampled residents (Resident 4, Resident 28, Resident 250, and Resident 410) when: 1. Resident 4's supervision CP during meals was not implemented. This failure put Resident 4 at an increased risk of choking and aspiration of food. 2. Resident 28's toenail clipping and/or podiatry care was not done and there was no CP to address repeated refusals to bathe or shower. This failure placed Resident 28 at risk for infection and other diabetic (high blood sugar disease) complications. 3. Resident 250 fell out of bed on 9/13/23 and the fall mat (a cushion made of high-density foam and covered with a non-slip material to minimize the risk of injury) was not put in place by staff members based on Resident 250's CP. This failure resulted in avoidable injuries when Resident 1 fell from bed and sustained a displaced nasal bone fracture (broken nose) and left periorbital (area surrounding the socket of the eye) soft tissue contusion (bruise), a laceration (cut) of the left eyebrow and experienced pain and discomfort. 4. Resident 410 was not turned or repositioned every two hours as indicated on her CP. This failure placed resident 410 at risk of developing a pressure injury and had the potential to cause delayed healing to a current pressure injury. Findings: 1. During an observation on 2/13/24 at 12:58 p.m. in Resident 4's room, Resident 4 was observed sitting up in bed eating her meal. Resident observed feeding herself with no staff in the room and the Resident's door was closed. Resident did not respond when spoken to. Observed Resident 4's call light hanging over the side of the bed behind her and no bell on Resident 4's bedside table. During a review of Resident 4's admission Record (AR), dated 2/15/24, the AR indicated, Resident 4 was admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, dysphagia (difficulty swallowing foods or liquids) and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 1/30/24, the MDS Section C indicated, Resident 4 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) of 0 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 4 was severely cognitively impaired. During an interview on 2/15/24 at 10:35 a.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 4 did not use the call light. CNA 4 stated Resident 4 was able to feed herself. CNA 4 stated we would just set up her food and check on her. During a concurrent interview and record review on 2/15/24 at 2:10 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 4's CP, dated 2/15/24 was reviewed. The CP indicated, Resident 4 was to eat only with supervision. LVN 1 stated Resident 4 needed a CNA in the room for meals. LVN 1 stated Resident 4 was unable to use her call light. During an interview on 2/16/24 at 4:19 p.m. with the Director of Staff Development (DSD), the DSD stated her expectation was for staff to follow physician's orders and CPs. During an interview on 2/20/24 at 12:24 with the Director of Nursing (DON), the DON stated staff should be following the CP. The DON stated if a resident has a diagnosis of dysphagia and has no supervision during meals, there is the potential for choking. 2. During an observation on 2/14/24 at 8:31 a.m. in Resident 28's room, Resident 28 was observed seated in bed, finishing breakfast. Resident observed to be alert, hair uncombed and a detectible mild sour body odor. Resident 28 agreed to allow LVN 2 to remove the socks to observe his feet. During a review of Resident 28's AR, dated 2/14/23, the AR indicated, Resident 28 was admitted on [DATE] with diagnoses of congestive heart failure (CHF- long-term condition that happens when your heart can't pump blood well enough), chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (high blood sugar), chronic ulcer of right and left lower leg (areas on the legs, ankles or feet where underlying tissue damage, or a trauma, has caused skin loss, leaving a raw wound that takes a long time to heal), retention of urine, chronic kidney disease, pain, use of anticoagulants (blood thinners), use of insulin (an animal-derived or synthetic form of insulin used to treat diabetes)and cerebral infarction (refers to damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 28's MDS, dated 12/28/23, the MDS Section C indicated, Resident 28 had a BIMS of 14 out of 15 which suggested Resident 28 was cognitively intact. During an interview on 2/14/24 at 8:35 AM, with LVN 2, LVN 2 stated that Resident 28's toenails were a problem. LVN 2 stated Resident 28 refuses a lot of care he has his favorite staff and sometimes they can get him to participate or cooperate with care. LVN 2 stated that CNA's do nail care for residents that are not diabetic. LVN 2 stated that [licensed] nurses (LNs) can clip/file diabetic resident toenails but if toenails are too thick or difficult to clip/file, the residents are referred to a podiatrist (foot doctor). LVN 2 stated if a resident needs podiatry, the LN reports to the Social Services Director (SSD) for coordination of a podiatry visit, either in-house or out-patient visit. LVN 2 stated, can't remember when they [podiatry] were last here. LVN 2 stated if a resident refuses care, the refusal is documented on either the Medication Administration Record (MAR) or Treatment Administration Record (TAR) depending on what care is refused. During an interview on 2/14/24 at 8:48 a.m., with the Social Services Director (SSD), SSD stated the podiatry group was scheduled to come next week. SSD stated the podiatrist usually does a round (visits residents), and request consent for services, if a resident refuses service she is made aware. SSD stated Resident 28 is his own RP (RP- Responsible Party) and able to give consent to treat. SSD stated that because of COVID (a disease caused by a virus named SARS-CoV-2) [podiatry doesn't come in] they send residents out to the office. SSD stated she does not have a list of residents that have been sent out [for podiatry services]. During a concurrent interview and record review on 2/14/24 at 10:19 a.m., with the facility Administrator (ADM), the facilities Podiatry Services Agreement, dated 2/6/23, was reviewed. ADM validated her signature on the new contract with Podiatry, as 2/9/24. ADM stated prior to this agreement, the facility was with a previous group. During an interview on 2/15/24 at 9:34 a.m., with CNA 6, CNA 6 stated that the resident fingernails and toenails care is done while bathing. CNA 6 stated this includes cleansing the nails on hands with a nail brush disposable or resident assigned. Then toenails and fingernails, if the resident is not diabetic, is done after the shower when the nails are softened a bit. CNA 6 stated nail care is documented in the CNA documentation in the computer under personal care area. CNA 6 stated she would not be able to tell me if Resident 28 was a diabetic. CNA 6 stated that Resident 28 had dressings to both legs, nurses do dressings. CNA 6 stated she has not visualized the resident's legs without dressings. CNA 6 stated she would not be able to tell if Resident 28's toenails have been clipped or filed, because he keeps his socks on. CNA 6 stated that if residents allow, the CNA should be looking at legs/feet to apply lotion and alert nurse to any concerns. During a concurrent interview and record review on 2/15/24 at 09:37 a.m., with CNA 6, Resident 28's Electronic Medical Record (EMR), dated ? CNA 6 stated Resident 28 likes to be independent. CNA 6 stated that Resident 28 is scheduled for a bath or shower each Monday and Thursday evening on the PM (2nd) shift. CNA 6 stated Resident refused a shower on Monday, 2/12/24. CNA 6 stated that if a resident refuses a shower the CNA is to alert LN, offer multiple times, may offer another CNA if preferred. CNA 6 stated once the nurse is notified about a refusal, then one can document refused and create a new alert. CNA 6 stated she would document a summary of what happened and chart that the assigned charge nurse LN was notified. CNA 6 stated according to the EMR, Resident 28 refused a shower/bath on 2/8/24 -Refused, 2/5/24 -Refused, 2/1- Refused 1/29 - Not in room/facility. CNA 6 stated, it does seem he needs a shower; body odor is strong. During a concurrent interview and record review on 2/15/24 at 10:34 a.m., with Unit Manager, Registered Nurse (UM-RN), Resident 28's Electronic Medical Record (EMR), was reviewed, UM-RN stated she was familiar with Resident 28. UM-RN stated Resident 28, was his own RP, able to tell staff what he wants and is independent with care and if he allows it, staff provide some assistance for ADL's (Activities of Daily Living- bathing, dressing, etc.). UM-RN stated she has not observed any podiatry visits for Resident 28. UM-RN stated there has been no attempts to cut Resident 28's toenails. UM-RN stated she has a good rapport with Resident 28, and she can get him to accept care. UM-RN stated that Resident 28 is a diabetic, but stable and would do his nail care herself. UM-RN stated she is not aware of a recent referral to podiatry. UM-RN stated she has not offered toenail care today and doesn't believe it has been offered. UM-RN stated Resident 28's toenails are manageable, they look fine, the nails could have been trimmed. UM-RN indicated Resident 28 has a standing order that is PRN (PRN- As Needed) but has not been referred. UM-RN stated that Resident 28's nails should have been addressed, the refusals are a challenge. UM-RN stated that refused care is documented in the MAR/TAR with a progress note. UM-RN stated that for residents with standing orders for podiatry, she will verbalize to SSD and ask them to start the referral process, if it is a resident/family request a note would be documented UM-RN stated that the LNs are expected to enter a note if the provider of (vision, dental or podiatry) comes to the facility to deliver care under a progress note. UM-RN stated that there is the potential of harm to a diabetic resident, if foot care is not being done , because it takes longer for a wound to heal as a diabetic and can lead to other complications such as risk for infection/amputation., foot care is important. UM-RN stated that if a resident refuses care, repeatedly, she would CP and follow planned interventions. If interventions are not working, they should be change and reassess the effectiveness. UM-RN stated LN's do the CP update revisions. CNA's can do nail care if the resident is non-diabetic, LN's can do the care of a trim and file if nails are tough/thick. UM-RN stated Resident 28 should have been placed on the podiatry list. During a concurrent interview and record review on 2/15/24 at 10:38 a.m., with UM-RN, Resident 28's CP dated 2/14/24 was reviewed. The CP indicated, .Focus Resident 28 has history of resistive to care, refuses finger and toenail care. Refuses to allow staff to clean, trim, cut or file . Goal [Resident 28's] preferences will continue to be met through the next review date with no negative outcomes due to his preference .Interventions Allow [Resident 28] to make decisions about treatment regime, to provide sense of control .Healthcare teaching provided .Notify MD of any complications . Staff to encourage compliance . UM-RN stated she thinks that the interventions could have added to offer a bed bath, or offer other alternatives. UM-RN stated, we should have incorporated a better hygiene plan and emphasized how important it is to his health. UM-RN stated they could have changed the approach to care, offer choices and allow him to be the driver of his care. Resident 28 liked to control everything, so approach is important, he likes to decide. UM-RN stated, There isn't documentation of his preferences or evidence of a meeting to address them. The UM-RN stated, the CNAs seem to think it is ok to not bathe/shower and that isn't OK. UM-RN stated LNs rely on CNA reports of any concerns to the LVN/RN or CN. UM-RN stated her expectation of the nurses is that assessments are done weekly, as assigned to each nurse to do in the A.M./ P.M. and notify the RN of any Change in Condition. UM-RN stated she does not routinely review the weekly assessments or attend Interdisciplinary Team (IDT) meetings. During a concurrent interview and record review on 2/15/24 at 10:34 a.m. with Unit Manager, RN (UM-RN), Resident 28's Electronic Medical Record (EMR), was reviewed. UM-RN stated Resident 28 is regularly refused bathing and showers, in the last 30 days in the computer. UM-RN stated she has not been made aware of this consistent refusing. UM-RN stated if repeatedly refusing as with Resident 28, she would offer a sponge bath, notify MD if he refuses a bed bath. UM-RN stated that as the UM-RN she should have been notified, to come up with another plan. Um-RN stated that the potential harm to the resident no showered/bathed, is infection, not good for skin/care, and poor hygiene which can lead to sickness During an interview on 2/15/24 at 2:37 p.m., with the facility Director of Nurses (DON), DON stated her expectation regarding resident nail care is nursing driven, staff should be performing nail care per the facility policy. DON stated if a resident is identified as needing podiatry care, the facility would coordinate foot care with an outside podiatry office. DON stated that the Social Services department handles referrals, with the Central Supply department coordinating the transportation. DON stated that with the prior podiatry contract, SSD coordinated the podiatrist visit to the facility. DON stated the last podiatry visit to the facility was on 11/2022. DON stated she was not sure what was done for the residents during that visit. DON stated that her care expectation is that the resident in need, if non-diabetic have their nails cleaned, trimmed and/or filed during personal hygiene care done every shift. DON stated that CNAs should provide nail care, and if they are not comfortable the charge nurse should be notified. DON stated that if a resident refuses care, the LN documents the resident refusal. DON stated if the resident refuses repeatedly, the LN is expected to notify the physician and RP/family. DON stated her expectation is that LNs document the refusal-of assessment and reason for the refusal. DON stated with diabetic residents their diagnosis causes slow healing, possible infections, and lesions (open skin) increase risks for infection or losing their toes. During an interview on 2/15/24 at 3:17 p.m., with DON and [NAME] President of Clinical Operations (VPCO), DON stated she expects staff to notify the physician and IDT of resident refusals of care. DON stated the IDT would speak with resident to determine the reason for refusals and recommend any alternative interventions be add to the CP along with resident preferences/wishes. DON stated then staff should follow through with the resident wishes. DON stated CNA's can escalate to DON or other Department Head for intervention if nurse does not respond to reports. DON stated the resident is entitled to a dignified existence and hygiene. DON stated she cannot recall any reports of repeated refusals of care; she would have responded herself to any chronic refusals of care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 2022, indicated . each resident's comprehensive person-centered CP is consistent with the resident's right to . receive the services and/or items included in the plan of care . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 3. During a concurrent observation and interview on 9/26/23 at 8:57 a.m. with Resident 250 in Resident 250's room, Resident 250 was sleeping in bed. Resident 250 had a healing wound to the upper left eyebrow, a bruised nose, and bruised right and left cheek. Resident 1 was easily arousable (awake) and did not respond to simple questions. During a review of Resident 250's admission Record (AR), dated 9/18/23, the AR indicated, Resident 250's diagnosis included contusion (bruise) of other part of head (left eye) and fracture of the nasal bone, Alzheimer (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities), Muscle Weakness, and Difficulty in Walking. During a review of Resident 250's Minimum Data Set (MDS - a federally mandated process for clinical assessment of all residents of long term care nursing facilities) dated 6/14/23, the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS - an assessment of a resident's cognitive status (the ability to remember, concentrate, learn new things, and/or make decisions that affect their everyday life) score was 0 (a score of 0 - 7 indicate severe cognitive impairment, a score of 8 - 12 indicate moderate cognitive impairment, and a score of 13 - 15 indicate the resident is cognitively intact). During a review of Resident 250's MDS for Functional Status (FS), dated 6/14/23, the FS indicated Resident 250 required one-person extensive to total assistance with activities of daily living (eating, dressing, bathing, etc.) and two-person physical assistance with transfers (how residents move between surfaces including to or from: bed, chair, wheelchair, standing position). During a review of Resident 250's Morse Fall Scale (MFS - a simple method of assessing a person's likelihood of falling), dated 9/15/23, the MFS indicated Resident 250 had a fall risk score of 55 (a score 0 - 24 was low risk; a score 25 - 44 was moderate risk and a score 45 or higher was high risk). During a review of Resident 250's Care Plan (CP), dated 5/1/18, the CP indicated, Resident 250 was at risk for falls related to gait (walking) balance problems, muscle weakness, difficulty walking, abnormalities of gait and mobility, history of falls, cognitive impairment, diagnoses of Alzheimer's Disease, and severe Dementia. The CP interventions indicated, Resident may have fall mats on each side of her bed. During a review of Resident 250's ED (Emergency Department) Provider (Physician) Notes (EPN), dated 9/13/23, the EPN indicated, CT Maxillofacial wo (without) Contrast (CT - Computed Tomography; a diagnostic imaging test that uses specialized X-ray equipment to create detailed cross-sectional images of the bones, tissues, and sinuses in the face and skull region. Contrast - a substance used to make specific organs, blood vessels, or types of tissue (such as tumors) more visible on X-rays). Final Result: Age-indeterminate (breaks in the bones where it's challenging to precisely determine the age of the injury) mildly displaced nasal bone fracture. Left periorbital soft tissue contusion. The EPN indicated, Resident 1 had a one cm (centimeter - unit of measurement) laceration to her left eyebrow and required a laceration repair with [brand name; a skin adhesive to close a wound] in the ED. During an interview on 9/26/23 at 9:04 a.m. with Resident 3, Resident 3 stated Resident 250 was lying in bed too close to the edge of the bed and fell on 9/13/23. Resident 3 stated the bed was not at its lowest position. Resident 3 stated Resident 250's bed was approximately hip high (the height of the average person's hip). Resident 3 stated staff was still moving Resident 250's personal belongings (clothes, etc.) into room [ROOM NUMBER] when Resident 250 fell. Resident 3 stated she called the nursing station to notify the nurse that Resident 250 fell. During an interview on 9/26/23 at 9:53 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 3 was moved to room [ROOM NUMBER] from room [ROOM NUMBER] since Resident 250's roommate in room [ROOM NUMBER] tested positive for COVID (an infectious disease caused by the SARS-CoV-2 virus) on 9/13/23. LVN 1 stated Resident 250's roommate in room [ROOM NUMBER] telephoned the nursing station and notified LVN 1 that Resident 250 fell out of bed and was on the floor. LVN 1 stated when LVN 1 went to the room [ROOM NUMBER], Resident 250 was on the floor on the right side of the bed. LVN 1 was unable to recall the height of Resident 250's bed but stated the bed was not at its lowest position and there was no fall mats on the floor next to Resident 250's bed. LVN 1 stated Resident 250 was bleeding from the nose. LVN 1 stated she gave Resident 250 [brand name - pain medication] and called the physician. Resident 250 was transferred to the hospital and had a hematoma (a solid swelling of clotted blood within the tissues) above the left eye and a broken nose. LVN 1 stated the fall was unavoidable, but the injuries could have been less severe (serious) had the fall mats been put in place to absorb the impact of the fall. During an interview on 9/26/23 at 10:21 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 9/13/23, CNA 1 moved Resident 250 to room [ROOM NUMBER] from room [ROOM NUMBER] due to Resident 250's roommate in room [ROOM NUMBER] tested positive for COVID. CNA 1 stated she put Resident 250 in bed in room [ROOM NUMBER] and went to retrieve the rest of Resident 250's personal belongings (clothes, etc.) from room [ROOM NUMBER]. CNA 1 stated LVN 1 informed CNA 1 that Resident 250 fell while CNA 1 was gathering Resident 1's belongings from the closet in room [ROOM NUMBER]. CNA 1 stated Resident 250's bed was low but not in its lowest position. CNA 1 was unable to recall the height of Resident 250's bed. CNA 1 stated Resident 250 required total care, was a high fall risk, and required fall mats. CNA 1 stated the fall mats were still in room [ROOM NUMBER] at the time of the fall. CNA 1 stated she should have placed the fall mats on the floor immediately after moving Resident 250 to room [ROOM NUMBER]. CNA 1 stated Resident 250's injuries could have been less severe (serious) if Resident 250 had fallen onto the fall mat. During an interview on 9/26/23 at 11:13 a.m. with Director of Nursing (DON), DON stated staff were required to follow each resident's care plan. DON stated Resident 250 had a history of falls and was high risk for falls. DON stated Resident 250's bed should always be in the lowest position when not providing care and the fall mats should be in place at all times. DON stated Resident 250's injuries could have been minimized if the fall mats were in place to absorb the impact of the fall. During a professional reference review retrieved from https://elderlyfallprevention.com/reducing-fall-injuries-with-fall-mats/titled, Reducing Fall Injuries with Fall Mats, dated 3/16/23, the professional reference indicated, .Falls are common events among nursing home residents with dementia or confusion (may be affected by medication) who forget or are unable to use the call bell. These residents often get out of bed without assistance or roll out of bed and hurt themselves . Fall mats are specially designed floor mats made from different materials. They are placed on the floor at the bed or chair to protect the elderly from serious physical trauma resulting from falls. A fall mat is useful for cushioning a fall and reducing the impact when the elderly accidentally rolls out of bed at night . The fall mat is placed at the side of the bed where the patient exits the bed from. Only place the mat on the floor when the patient rests in bed . During a review of the facility's Policy and Procedure (P&P), titled, Falls - Clinical Protocol, dated 3/2018, the P&P indicated, .Treatment/Management. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . 4. During a review of Resident 410's admission Record (AR), dated 2/15/24, the AR indicated, resident 410 was admitted on [DATE] with diagnoses of Diabetes Mellitus, Dementia, Psychotic disturbance, Mood disturbance and Anxiety. During a review of Resident 410's MDS, dated 11/1/23, the MDS indicated Resident 410 had a BIMS of 6, which suggested severe cognitive impairment. During an interview on 2/15/24 at 11:23 a.m. with CNA 5, CNA 5 stated Resident 410 had no pressure ulcers or new wounds. CNA 5 stated Resident 410 was to be turned every 2 hours. CNA 5 stated she checked on Resident 410 every so often. CNA 5 stated Resident 410 could not press her call light button. During a review of Resident 410's CP, dated (undated), the CP indicated . turn and reposition every 2 hours and as needed . for Resident 410's interventions. During a concurrent interview and record review on 2/16/24 at 4:19 p.m. with the DSD, Resident 410's Turn and Reposition Record was reviewed. The Turn and Reposition Record indicated, Resident 410 was not turned every 2 hours as ordered on Resident 410's CP. The DSD stated Resident 410 was not being turned every 2 hours. The DSD stated Resident 410 had orders to be turned every 2 hours or as needed. The DSD stated there were some breaks in time. The DSD stated her expectation was that staff follow the CPs and turned Resident 410 every 2 hours due to Resident 410 being more prone to skin breakdown. During a concurrent interview and record review on 2/20/22 at 12:24 p.m. with the DON, the facility's policy, and procedure (P&P) titled, Repositioning, dated 2013 was reviewed. The P&P indicated, . Residents who are in bed should be on at least an every two hour [q2 hour] repositioning schedule . for residents with a Stage I or above pressure ulcer, an every two hour [q2 hour] repositioning schedule is inadequate . The DON stated her expectation is the resident should be turned every 2 hours or as needed. The DON stated if the CP is not followed, there is the potential for skin breakdown.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for the dysphagia advanced (bite-sized foods that are moist) diet for five of 47 sampled residents (Residents 17, 22, 31, 35, and 36) when Residents 17, 22, 31, 35, and 36 received puree broccoli instead of chopped broccoli for lunch. This failure had the potential to result in Residents 17, 22, 31, 35, and 36 having a decrease in satisfaction with their meal because it was not the correct texture of food as prescribed by the physician. Findings: During an observation on 2/13/24 at 11:54 a.m. in the kitchen, [NAME] 1 plated the food for residents and served Resident 36 who was on a dysphagia advanced diet pureed broccoli. During a concurrent interview and record review on 2/15/24 at 10:29 a.m. with the Dietary Supervisor (DS), Resident 36's lunch meal tray ticket (document which indicates food items residents received for their meal), dated 2/13/24 was reviewed. The lunch meal tray ticket indicated, Resident 36 should receive half a cup of chopped roasted brussels sprouts (broccoli was substituted). The DS stated, the [NAME] should have prepared and served chopped broccoli. The DS stated, a dysphagia advanced diet should have a little more texture than a puree texture. During a review of the facility's document titled, Census List , dated 2/13/24, the document indicated five residents (Residents 17, 22, 31, 35 and 36) were on a dysphagia advanced diet. During a review of the facility's document titled, Production Counts, dated 2/13/24, the document indicated five servings of chopped roasted brussels sprouts (broccoli was substituted) should had been prepared and served for lunch. During a phone interview on 2/15/24 at 4:01 p.m. with the Registered Dietician (RD), the RD stated, her expectation for staff was to serve residents on a dysphagia advanced diet chopped vegetables. The RD stated her expectation was for staff to understand there were different versions of the dysphagia diet and should know how each diet should be served. During a review of the facility's Diet and Nutrition Care Manual, dated 2019, the Diet and Nutrition Care Manual indicated a dysphagia advanced diet would receive .cooked, tender, chopped, shredded . vegetables.

Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety when: 1. There was a build-up of food crumbs and debris under the dishwasher, this had the potential for microorganism growth and to attract pests. 2. The ceiling had a patch that was not smooth and easily cleanable, this had the potential for build-up of dust and microorganism growth. These failures had the potential for microorganism growth that could be inadvertently transferred to food and to attract pests in the kitchen that prepared food for 47 out of 47 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 2/13/24 at 10:47 a.m. with the Dietary Supervisory (DS) in the kitchen, a build-up of food crumbs and debris was seen under the dishwasher area. The DS stated it is hard to clean under the dishwasher area. During a phone interview on 2/15/24 at 4:01 p.m. with the Registered Dietician (RD), the RD stated her expectation was for staff to thoroughly clean the dishwasher area after each use. During a review of the facility's policy and procedure (P&P) titled, Environment, revised 9/2017, the P&P indicated, .POLICY STATEMENT: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition . During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, .(C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris .The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted . 2. During a concurrent observation and interview on 2/13/24 at 2:35 p.m. with the DS in the kitchen, a 12 inch by 12 inch portion of the ceiling was covered with a piece of plywood, unpainted. The DS stated, the ceiling should be smooth and easily cleanable. The DS stated, the plywood was not an acceptable surface for the kitchen ceiling. During a phone interview on 2/14/24 at 4:01 p.m. with the RD, the RD stated her expectation was to not have plywood on the ceiling. During a phone interview on 2/16/24 at 3:22 p.m. with the MS, the MS stated the leak in the kitchen ceiling was reported a month and a half ago. The MS stated he had attended to a few small leaks in the kitchen ceiling. The MS stated he had worked on the kitchen ceiling multiple times. The MS stated he screwed a wood patch in the kitchen ceiling. The MS stated he would need help to put in a dry wall for the ceiling. During a review of the facility's policy and procedure (P&P) titled, Environment, revised 9/2017, the P&P indicated, .POLICY STATEMENT: All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. PROCEDURES: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation . During a review of the FDA Federal Food Code, dated 2022, 4-101.19 indicated, Nonfood-contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material. In addition, Nonfood-contact surfaces of equipment routinely exposed to splash or food debris are required to be constructed of nonabsorbent materials to facilitate cleaning. Equipment that is easily cleaned minimizes the presence of pathogenic organisms, moisture, and debris and deters the attraction of rodents and insects.

Based on interview and record review the facility failed to provide a copy of the resident's medical record for one of one resident (Resident 1) when Resident 1 requested her medical records on 9/21/23. This failure was not the standard of practice according to the facility's policy and procedure (P&P) titled, Release of Information. Findings: During an interview on 10/6/23 at 12:23 p.m., with Resident 1, Resident 1 stated she requested her medical records on 9/21/23 and received her requested documents on 10/2/23. During a review of Resident 1's Medical Record Request form (MRR), dated 9/21/23, the MRR from indicated, Resident 1 and the Medical Records Director signed the MRR on 9/21/23. During a concurrent interview and record review on 10/6/23 at 11:55 a.m., with Medical Records Director (MRD), Resident 1's MMR and the facility's P&P titled, Release of Information, were reviewed. The MMR indicated Resident 1 requested the release of her medical records on 9/21/23. MRD stated Resident 1's medical records were delivered to Resident 1 a week later after the request. MRD stated he did not document when the medical records were delivered. MRD stated the facility did not require documentation of when requested documents were delivered. MRD stated, Resident 1's medical records should have been delivered within 72 hours as indicated in the facility's P&P titled, Medical Record Request. During an interview 10/6/23 12:00 p.m. with the Administrator (ADM), ADM stated receiving the requested documents 6 days after the requested date was not acceptable. ADM stated the standard of practice for delivering the requested documents was to follow the facility's P&P which indicated requested medical records were to be delivered to the resident within 72 hours. ADM stated it was unacceptable for the MDR to not document when requested documents were delivered to the residents upon request. During a review of the facility's P&P titled, Release of Information, dated 11/2009, the P&P indicated, Policy Interpretation and Implementation . 9. A resident may have access to his or her records within 72 hours (excluding weekends or holidays) of the resident's written or oral request .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity and in an environment that promotes and enhances quality of life for three out of 11 sampled residents (Residents' 25, 28 and 156) when: 1. Residents' 25 and 28 were not given coffee as requested and watched other residents in the dining room drink coffee. 2. Resident 156 waited for her lunch tray while watching other residents on the same table ate. These failures violated Residents' 25, 28 and 156 the right to be offered a dignified dining experience. Findings: 1. During an observation on 4/10/23, at 11:40 a.m., in the dining room, Resident 28 was observed sitting across the table from another resident. Resident 28 observed requesting coffee from Certified Nursing Assistant (CNA) 7, and Resident sitting across Resident 28 was heard requesting coffee for Resident 28. Resident 28 was not served coffee and watched other residents in the dining room drink coffee. During a review of Resident 28's admission Record, dated 4/12/23, the admission record indicated, Resident 28 was admitted to the facility on [DATE] with diagnoses which included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), dysphagia (difficulty swallowing) and muscle weakness. During a review of Resident 28's Order Summary Report, dated 4/13/23, the order summary report indicated, Resident 28's diet was regular diet dysphagia puree (soft, pudding-like consistency) diet, moderately thick-previously Nectar (slightly thicker, similar to honey or a milkshake) (MO3) consistency. During a review of Residents 28's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 156's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 3 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 28 was severely impaired. During an observation on 4/10/23, at 11:45 a.m., in the dining room, Resident 25 was observed raised his cup and asked for coffee. CNA 7 did not served coffee to Resident 25. Resident 25 watched other residents in the dining room drink coffee. During a review of Resident 25's admission Record, dated 4/12/23, the admission record indicated, Resident 25 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis (weakness or the inability to move on one side of the body), dysphagia (difficulty swallowing) and muscle weakness. During a review of Resident 25's Order Summary Report, dated 4/13/23, the order summary report indicated, Resident 25's diet was regular diet dysphagia puree (soft, pudding-like consistency) diet, moderately thick-previously Honey(slightly thicker, similar to honey or a milkshake) (MO3) consistency. During a review of Residents 25's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 25's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 6 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 25 was severely impaired. During a concurrent observation and interview on 4/10/23, at 11:50 a.m., with CNA 7 in the dining room, CNA 7 stated she was aware Resident 25 and Resident 28 wanted coffee but did not served coffee to Resident 25 and Resident 28. CNA 7 stated both Residents' 25 and 28 order was thickened liquid and she was not able to served the coffee. CNA 7 stated she could only asked the kitchen staff to make the coffee for Resident 25 and 28. CNA 7 stated the coffee cart did not have supplies to thicken liquids. CNA 7 stated Residents' 25 and 28 had to watch other residents drink coffee while waiting for their coffee. 2. During a concurrent observation and interview on 4/10/23, at 12:05 p.m., in the dining room, observed nursing staff passing out lunch trays to residents in the dining room except one resident. Resident 156 did not received a lunch tray and watched five other residents sitting on the same table eat. Resident 156 observed looking at other residents around her eating. Resident 156 stated, .I might like to have food in front of me instead of watching them eat . Resident 156 was served her lunch 25-30 minutes after other residents were served their lunch. During a review of Resident 156's admission Record, dated 4/12/23, the admission record indicated, Resident 156 was admitted to the facility on [DATE] with diagnoses which included heart failure, acute respiratory failure and muscle weakness. During a review of Residents 156's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], indicated Resident 156's Brief Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 9 of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 156 was moderately impaired. During an interview on 4/10/23, at 12:25 p.m., with CNA 7, she stated they are waiting for Resident 156's tray, CNA 7 stated Resident 156's tray could have been placed in the cart sent out to residents eating in their rooms. CNA 7 stated residents are to be served foods one table at a time so residents do not end up watching other residents eat. During an interview on 4/11/23, at 9:59 a.m., with CNA 9, stated the practice was to ask kitchen staff to make thickened coffee or any other drinks for residents on thickened liquids. CNA 9 stated residents should be given their food trays one table at a time and not have resident wait for their food while watching other residents eat. During an interview on 4/13/23, at 9:40 a.m., with Director of Staff Development (DSD), DSD stated, Residents' 25 and 28 should not have to wait a long for their coffee while watching other residents drink their coffee. DSD stated, . The staff needed to make sure Resident 25 and 28 were given their beverage of choice like any other residents in the dining room . DSD stated Resident 25 and resident 28 had the same rights as other residents. DSD stated Resident 156 did not have to watch other people eat in the dining room while waiting 25-30 minutes for her food. DSD stated it was not a home like environment. DSD stated nursing staff in the dining room should have notified the kitchen staff of the names of residents eating in the dining room so residents did not have to wait a long time for their food and for a thickened coffee. During an interview on 4/13/23, at 3:05 p.m., with the Director of Nursing (DON), she stated the expectation was for Resident 25 and Resident 28 who had orders for thickened liquids served coffee with the rest of the residents in the dining room. DON stated Resident 156 should have received lunch tray and not watched other residents eating while waited 25-30 minutes for her food to be served to her. DON stated staff in the dining room should have made sure to let the dietary staff know the names of residents eating in the dining room. DON stated, .Resident should not be waiting a long time for their trays and watched other people eat . During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated, 2/21, the P&P indicated, .be treated with respect, kindness and dignity . be free from corporal punishment or involuntary seclusions, and physical or chemical restraints not required to treat the resident's symptoms .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a physician Informed Consent (a process in which residents are given important information of the possible risk and benefits of the use of psychoactive medications) for the use of psychotropic medications (medication capable of affecting mind, emotions, and behavior) for one of three sampled residents (Resident 20) was obtained when Resident 20 was administered three psychotropic medications without an informed consent. These failures resulted for Resident 20 to be administered with psychotropic medications and not fully informed of the risk and benefits and did not have the knowledge to make an informed decision which could place Resident 20 at risk for negative side effects as he was not informed of the side effects. Findings: During a concurrent observation and interview on 2/10/23, at 4:10 p.m., in room [ROOM NUMBER], Resident 20 was lying in bed watching TV. Resident 20 stated he had been in the facility for three weeks for therapy and this was his seventh time going back in the facility. During a review of Resident 20's clinical record titled, admission Record (AR), (document with resident demographic information), dated 4/10/23, the AR indicated, Resident 20 was re-admitted on [DATE], with a diagnoses which included heart failure, muscle weakness, major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and anxiety (intense, excessive, and persistent worry and fear about everyday situations). During a review Resident 20's, Order Details dated, 4/12/23, the Order details indicated, .(Buspirone HCL)5 MG[one milligram-unit of measurement] one tablet by mouth two times a day for anxiety . (Duloxetine HCl[hydrochloride ]) Oral Capsule Delayed Release Particles 60 MG. Give 1 capsule by mouth two times a day for depression . (Fluoxetine hydrochloride) 40 MG Give 1 capsule by mouth one time a day for depression . During a review of Resident 20's, Medication Administration Record [MAR- a document that shows the medication ordered and taken by an individual], dated 2/1/23-2/28/23, the MAR indicated, fluoxetine medication was administered everyday starting from 2/27/23 thru 2/28/23, buspirone medication was administered 2/28/23, duloxetine medication was administered 2/28/23 . During a review of Resident 20's MAR, dated 3/1/23-3/31/23, the MAR indicated fluoxetine medication was administered everyday starting from 3/1/23 thru 3/31/23, buspirone medication was administered 3/1/23 thru 3/31/23, duloxetine medication was administered 3/1/23 thru 3/31/23 . During a review of Resident 20's MAR, dated 4/1/23-4/30/23, the MAR indicated fluoxetine medication was administered everyday starting from 4/1/23 thru 4/12/23, buspirone medication was administered 4/1/23 thru /12/23, duloxetine medication was administered 4/1/23 thru 4/12/23 . During a concurrent interview and record review on 4/12/23, at 11:45 a.m., with the Minimum Data Set Nurse (MDSN), MDSN reviewed Resident 20's electronic clinical record for psychotropic medications. MDSN stated the psychotropic medications were first ordered on 2/27/23 when Resident 20 was re-admitted in the facility. MDSN stated she did not find an informed consent for the pyschotropic medications ordered for Resident 20. MDSN stated the psychotropic medications were administered daily to Resident 20 since re-admitted to the facility on [DATE]. MDSN stated psychotropic medications should have an Informed Consent signed prior to administration of medications. During a concurrent interview and record review on 4/12/23, at 2:53 p.m., with the Unit Manager Registered Nurse (UMRN), UMRN reviewed Resident 20's clinical record and stated Resident 20 was admitted to the facility with psychotropic medications. UMRN stated she was not able to find Informed Consent for the psychotropic medications. UMRN stated psychotropic medications should not have been administered to Resident 20 prior to obtaining a signed Informed Consent. UMRN stated it is important to get the Informed Consent to explain the reason and side effects of the medications. During an interview on 4/13/23, at 2:05 p.m., with the Director of Nursing (DON), the DON stated Resident 20 was admitted to the facility with the psychotropic medications. DON stated Informed Consent needed to be signed prior to administering psychotropic medications. DON stated the Informed Consent is important because psychotropic medications are mind and mood altering medications. DON stated the psychotropic medications should have not been administered to Resident 20 without a signed Informed Consent. During a review of facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 6/2021, the P&P indicated, .The facility shall verify informed consent prior to the administration of a psychotropic medication for a resident .

Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 13) had their adaptive equipment when Resident 13 was put in the wrong wheelchair. This failure had the potential to result in Resident 13 experiencing an avoidable accident and injury. FINDINGS: During a concurrent observation and interview on 4/12/23, at 4:30 pm, Resident 13 was in the hallway, in a wheelchair, holding a plastic urinal, and calling for help. Resident 31 put his call light on for Resident 13 and started yelling Help!. Business Office Manager (BOM) answered the calls for help. Resident 13 stated he needed help getting up in his chair and was afraid to fall since he's fallen before out of his chair. BOM retrieved a nursing assistant to help. During a record review of Resident 13's Brief Interview Mental Status (BIMS)(used to screen and identify the ability to think and remember), dated 2/24/23, the BIMS indicated Resident 13 had a score of 11 which indicated moderate cognitive impairment. During a concurrent interview and record review on 4/12/23, at 6:01 pm, with Licensed Vocational Nurse (LVN) 4, LVN 4 Resident 13's Physician Orders, dated 4/11/22 was reviewed. LVN 4 stated, she didn't know if Resident 13 was supposed to have any adaptive devices on his wheelchair. LVN 4 reviewed Resident 13's Physician Orders and stated, Resident 13 had an order for anti-roll-back and anti-tippers (devices used to prevent the wheelchair from tipping over or backwards) to prevent future falls. LVN 4 stated, Resident 13 might be in the wrong wheelchair. During a concurrent interview and record review on 4/13/23, at 8:22 am, with LVN 2, LVN 2 reviewed Resident 13's Care Plan, dated 4/11/22, and stated, Resident 13 was supposed to have the anti-tippers and anti-roll-back on his wheelchair. CN stated, she was not sure what happened, and the resident was in the wrong wheelchair. During an interview, on 4/13/23, at 9:27 am, with the Director of Nursing (DON), DON stated, she didn't know how Resident 13 was put in the wrong chair. DON stated, the facility had a system to label residents wheelchairs to prevent CNAs from putting a resident in the wrong wheelchair, but it hadn't been started yet. DON stated, being in the wrong wheelchair was a safety issue for Resident 13. During a record review of Resident 13's Physician Orders, dated 4/11/22, the Orders indicated, While up in w/c must have anti-roll-back and anti-tippers to prevent future falls. During a record review of Resident 13's Care Plan, dated 4/11/22, the care plan indicated, [Resident 13] is at risk for falls .has history of falls .will not sustain serious injury .While up in [wheelchair] must have anti roll back and anti-tippers to prevent future falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 20) when Resident 20's smoking habits was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 20's care needs not met. Findings: During a concurrent observation and interview on 4/10/23, at 4:10 p.m., with Resident 20 in his room, Resident 20 was observed laying in bed watching TV. Resident 20 stated he had been in the facility for three weeks to work with therapy. Resident stated he is a smoker and never stopped smoking since 1991, goes outside to smoke everyday. Resident 20 stated they have a schedule to go outside to smoke and he goes outside to smoke everyday. Resident 20 stated when he was admitted in the facility the nursing staff did not asked him if he smoked because the staff knew he was a smoker because he had been in the facility before. During a review of resident 20's admission Record (document with resident demographic and medical diagnosis information), dated 4/12/23, indicated resident 20 was admitted to the facility on [DATE] with diagnosis which included nicotine (the substance in tobacco that people become addicted to) dependence, heart failure and muscle weakness. During a review of Resident 20's MDS assessment dated [DATE], indicated Resident 20's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was 12 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 20 had moderate cognitive deficit. During a review of Resident 20's, NSG Admission/readmission Evaluation, dated 2/27/23, the Smoking Safety Evaluation indicated, Resident 20 did not used tobacco. During a concurrent interview and record review on 4/12/23, at 11:35 p.m., with Minimum Data Set Nurse (MDSN), MDSN stated, Resident 20 was a smoker and his name was included in the list of residents who smoked. MDSN reviewed Resident 20's admission MDS assessment, dated 3/5/2023, section J which indicated, Resident 20's tobacco use was not coded on the MDS assessment. MDSC stated, Resident 20 should have been coded as a smoker because he goes out everyday to smoke. MDSN stated, .I should have asked him, he is alert and oriented . MDSN stated, she did not asked Resident 20 and relied on the admission assessment completed by the admission nurse. During an interview on 4/13/23, at 2:15 p.m., with the Director of Nursing (DON), DON stated, the MDS should be accurately coded. DON stated, the MDS was to ensure accuracy of the assessments for new admissions. DON stated, .All new admissions are assessed for smoking and asked the question if resident smokes or wished to smoke because it is part of the assessment . DON stated, the MDSN should have done her own assessment and not rely on other nurse assessment especially if resident had a history of smoking. During a review of the facility's policy and procedure (P&P) titled, Certifying the Accuracy of the Resident Assessment, dated 11/2019, the P&P indicated, .Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment . During a review of professional reference titled, Resident Assessment Instrument version #.0 Manual, dated 10/19, indicated, . Tobacco use includes tobacco used in any form . If the resident states he or she used tobacco in some form during the 7-day look back period code 1, yes . If the resident is unable to answer or indicates that he or she did not use tobacco of any kind during the look back period, review the medical record and interview staff for any indication of tobacco use by the resident during the look back period .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who are receiving dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment received services consistent with professional standards of practice for Resident 42 when Resident 42 had a water pitcher on the bedside table within Resident 42's reach for three consecutive days and in charge nurse did not monitor and record daily fluid intake. This failure placed Resident 42's care needs to go unmet and had the potential to result in fluid overload. Findings: During a review of Resident 42 's Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the face sheet indicated Resident 42 was readmitted to the facility on [DATE] with a diagnosis which included End Stage Renal Disease (ESRD) (a disease with kidney failure) dependence on Renal Dialysis (a medical procedure involves diverting blood to a machine to remove waste products and excess fluid from the blood when the kidneys stop working properly). During a review of Resident 42's physician ordered, dated 4/12/23 the physician ordered indicated, fluid restriction (limited amount of fluid intake each 24-hour period) 1.2 liters (L unit of measurement) per every 24 hours. Give 200 ml (milliliter- unit of measurement) of fluid with breakfast, lunch and dinner which equals 600ml; nursing to give 200 ml a.m. shift, 200 ml p.m. shift, 200 ml noc (night) shift which equals 600 ml for a total of 1200 ml in a 24-hour period every shift for ESRD ordered on 1/18/23. During a concurrent observation and interview on 4/10/23 at 1:00 p.m., with Certified Nursing Assistant (CNA) 10, in Resident 42's room, Resident 42 was observed to have a water pitcher with 250 ml's of fluid at the bedside within arm's reach. CNA 10 stated, Resident 42 is always pretty thirsty and will go through a couple of these water pitchers a shift,. CNA 10 stated, she did not get any report from in charge nurse that Resident 42 was on fluid restriction. CNA 10 also stated, she was unaware Resident 42 was on fluid restriction. During a concurrent observation and interview on 4/11/23 at 8:12 a.m., with CNA 6, in Resident 42's room, Resident 42 was observed to have a water pitcher with 500 ml's of fluid at the bedside within arm's reach. CNA 6 stated, she filled up the water pitcher at 8:10 a.m. During an observation on 4/12/23, at 8:40 a.m., in Resident 42's room, Resident 42 had a water pitcher with 450 ml of fluid at the bedside within arm's reach. During an interview on 4/12/23, at 12:15 p.m., with CNA 5, CNA 5 stated, she filled up Resident 42's water pitcher to 600 ml this morning. CNA 5 stated, Resident 42 was not on a fluid restriction because she did not get notifying from in charge nurse that Resident 42 was on a fluid restriction. During a concurrent interview and record review on 4/13/23, at 9:49 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 42's physician ordered 1.2 L/24 hours Fluid restriction dated on 1/18/23 was reviewed. LVN 2 stated, due to Resident 42 on fluid restriction, Resident 42 should not be getting a water pitcher at the bedside. LVN 2 stated, beginning every shift, in charge nurse would inform the CNA in charge of resident who had ordered Fluid restriction. Therefore, the CNA could closely monitor amount fluid intake and reported to in charge nurse how much fluid the resident drank. End of the shift, the in charge nurse would total all the fluid intake and documented in electronic medical record. LVN 2 unable to show Residnet 42's monitoring amount of fluid intake and recording fluid intake in electronic medical record. LVN 2 stated, Resident 42 would experience edema and symptoms of fluid overload if she consumed more than 1.2 Little fluid. During a phone interview on 4/13/23, at 11:23 a.m., with Clinical Manager Hemodialysis Center (CMHD), CMHD stated, Resident 42 came to the hemodialysis (HD) facility two times per week. CMHD stated, Resident 42 had been over her dry weight (normal weight without extra fluid in your body) three times since 3/18/23. CMHD stated, March 18th she came in at 2.8 liters over her dry weight, March 25th 3.6 liters over and April 1st 3 liters over. CMHD stated, it was very important for Resident 42 controlled her fluid intake so she would not experience fluid overload. During a phone interview on 4/13/23, at 11:45 a.m., with Renal Registered Dietician at Hemodialysis Center (RRD), RRD stated, Resident 42 had history episodes of fluid overload. Resident 42 shouldn't have a water pitcher at her bedside. RRD stated, it was very important the facility close monitored Resident 42's fluid intake to help Resident 42 controlled her fluid intake. RRD explained, when Resident 42 came to HD facility with fluid overload. The HD facility had to remove the extra fluid in her body which could cause Resident 42's blood pressure dropped and Resident 42's heart had to work harder to pump her blood. This could ruin Resident 42's heart. During a concurrent interview and record review on 4/13/23 at 10:19 a.m., with Director of Staff Development (DSD), DSD stated, CNAs received report from in charge nurse regarding which Residents on fluid restriction and CNAs also gave oncoming CNAs report about which Residents on fluid restrictions. DSD stated, in charge nurse should be monitoring and recording the amount of fluid intake of Resident on Fluid restriction. DSD could not find the in charge nurse documentation of fluid monitor and recording amount in electronic medical record for Resident 42. DSD stated, without monitor Resident 42's fluid intake, Resident 42 could get fluid overloaded, and a bad outcome could occur to her. Resident 42 could get very sick. DSD stated, Residents on Fluid restriction not supposed to have water pitchers at the bedside. During a concurrent interview and record review on 4/13/23, at 1:16 p.m., with Director of Nursing (DON), DON stated, In regard to a fluid restriction, nursing staff should be monitoring, measuring and documenting the fluid intake residents are getting. DON stated, A resident on a fluid restriction can't tolerate fluids overload. A person who has a heart failure or renal failure can go into fluid overload easily. DON stated, Residents with heart failure and Renal failure experienced fluid overload would cause them hard to breath and put too much stress on the hearts and the Residents could even die. DON stated, Some of these symptoms could occur in the resident for sure if getting fluid more than what is ordered. DON stated, Water pitcher should not be on the side of the bed for a fluid restriction resident. If it was then that is a big mistake. DON stated, In charge nurse should be making CNAs aware of Residents who on fluid restriction and they should also be getting that information in report. DON stated, We definitely need to do some chart audits here because the in charge nurse should be charting actual numerical intake to closer monitor the resident with the fluid restriction. During a review of the facility's policy and procedure (P&P) titled, Encouraging and Restricting Fluids, dated 10/2010, the P&P indicated, PURPOSE: The purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging or restricting fluids. GENERAL GUIDELINES: 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake. 3. Record fluid intake on the intake side of the intake and output record. Record fluid intake in milliliter .7. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room.

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash was found outside on the floor surrounding the dumpster. And the lid of the dumpster was not close properly. This failure had the potential to attract pests and rodents. Findings: During an observation on 4/10/23, at 9:03 a.m., one of three dumpsters which was brown color, had trash, clear gloves and a glass bottle on the ground around the brown dumpster. During an observation on 4/11/23, at 8:10 a.m., observed one of the brown dumpster lids was not close and there was trash, blue and clear used glove on the ground around the brown dumpster. During a concurrent observation and interview on 4/11/23, at 8:26 a.m., with the Dietary Manager (DM), in front of the dumpster, the DM confirmed one of the brown dumpster lids was not close and there was trash, blue and clear used glove on the ground around the brown dumpster. The DM stated, the brown dumpster's lid should be close and there was supposed no trash around the brown dumpster. During an interview on 4/11/23 at 5:32 p.m., with the Registered Dietician (RD), the RD stated, it should not be trash around the dumpsters and all dumpsters' lids should be closed to prevent the attraction of pests. During a review of the facility's policy and procedure (P&P) titled, Environment,, revised 9/2017, the P&P indicated, .7. All trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. During a review of the facility's policy and procedure (P&P) titled, Dispose of Garbage and Refuse, revised 8/2017, the P&P indicated, POLICY: All garbage and refuse will be collected and disposed of in a safe and efficient manner. PROCEDURE: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a homelike environment for the residents in rooms 17, 3,10, and 26, and those using the dining room when: 1. Resident rooms 17, 3, 10, and 26 were in disrepair. 2. The noise level in the dining room was too loud. These failures resulted in an unhomelike atmosphere. FINDINGS: 1. During a concurrent observation and interview on 4/11/23, at 9:51 a.m., in room [ROOM NUMBER] with Resident 48, Resident 48 stated, she had been in the facility almost 7 months. Resident stated the entire building needed repair. Resident stated, there was tile coming up, sheet rock exposed, paint in bad condition over the entire building, and the dining room needed to be redone. During an observation on 4/10/23, at 10 a.m. in room [ROOM NUMBER], the bathroom was missing the paper towel dispenser from the wall and the wall had been damaged from where the paper towel dispenser had previously been. During a resident council meeting, on 4/11/23, at 3:28 p.m., the residents (Residents 17, 29, 10, 45, 26, 15, 23, and 6) collectively stated, the facility was not in good repair and broken items took a long time to be fixed. During an observation, on 4/13/23, at 9:46 a.m., the residents' rooms were viewed. 17 B had multiple large scratches on the wall behind the bed. 3 B had multiple large scratches on the wall behind the bed, a brownish/red substance dried on the floor, and no toilet seat on the toilet in the bathroom. room [ROOM NUMBER] had badly cracked tiles on the floor and a large dent/scratch along the bottom of the bathroom wall. During a concurrent observation and interview, on 4/13/23, at 10:30 a.m., Resident 31's room (room [ROOM NUMBER]) was observed. Resident 31's headboard had a large chunk broken out of it and gone. Resident 31 stated, he felt like he lived in a dump, and, at home he kept everything in good repair. Resident 31 stated he did not know how the headboard was broken; it was like that when he moved in. During an interview, on 4/12/23, at 11 a.m., with Maintenance Director (MD), MD stated he had been in his position about 10 months and was responsible for the maintenance throughout building and operations. MD stated he tried to make rounds and fix what needed to be fixed. If there is a need I get to it right away, I try to get to them. Asked about paper towel dispenser being off wall. He stated the facility was an older building, could be updated and he wouldn't consider it to be a home like environment. During an interview on 4/13/23, at 10:30 am, with the Director of Nursing (DON), the DON indicated, some of the facility's rooms were worse than others, we have some problematic residents, whose rooms are worse than others. She indicated, there was currently debris on the floor, and it was not a home like environment to have the paper towel dispenser missing from wall. 2. During an observation, on 4/10/23, at 11:40 am, in the dining room residents were waiting for their food to be served. The television was playing an old movie and the radio was playing upbeat music at the same time. The noise level was loud. During an interview, on 4/10/23, at 12:18 pm, with Resident 156, Resident 156 stated, she didn't like the loud noise in the dining room. During an interview, on 4/10/23, at 12:50 pm, with Resident 23, Resident 23 stated, The music is too loud here. During a resident council meeting, on 4/11/23, at 3:28 pm, the residents (Residents 17, 29, 10, 45, 26, 15, 23, and 6) collectively stated the noise level in the dining room was too loud because the television and the radio were both played at the same time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide effective interventions to meet the needs of residents and in accordance with standards of practice for one of five sampled residents, Resident 41, when Resident was diagnosed with leg varicose veins and nursing staff did not implement every two hour repositioning and range of motion. This failure resulted in Resident 41 acquiring new venous ulcers, delay in wound healing, pain, suffering, and decreased mobility. This failure also had the potential to result in infection. Findings: During a review of Resident 41's admission Face Sheet (AFS-document containing resident demographic information and medical diagnosis), dated 4/13/23, the AFS indicated, Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnoses included .Type 2 Diabetes Mellitus (high blood sugar) .Muscle weakness (lack of muscle strength) .Chronic atrial fibrillation (an irregular, often rapid heart rate) .Non-pressure chronic ulcer (wound due to lack of blood flow) of left foot .right heel and midfoot .left heel and midfoot .Varicose veins of right lower extremity with both ulcer of calf .varicose vein of left lower extremity with both ulcer of calf (leg wound due to lack of blood flow to extremities) .Atherosclerosis of coronary artery bypass graft (narrowing and hardening of arteries resulting in lack of blood flow) . During a review of Resident 41's Minimum Data Set (MDS- a standardized assessment and care-planning tool), dated 2/23/23, the MDS indicated, Resident 41 had a BIMS (Brief Interview for Mental Status) score of 14 which (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating, Resident 41 had no cognitive impairment. During a review of Resident 41's Order Summary Report (OSR), dated 4/13/23, the OSR indicated, .Physical therapy evaluation and treatment as indicated . order date 12/6/22. During a review of Resident 41's Physical Therapy Treatment Note (PTTN), dated 12/8/22-2/5/23, PTTN indicated, .Pain Assessment .Management .what relieves pain .Remaining still, change in body position. During a review of Resident 41's PTTN, dated 1/24/23, the PTTN indicated .Skilled Interventions .position/pressure relieving techniques .in order to improve safe functional mobility and quality of life .Patient Progress .Patient has reached maximum potential with skilled services at this time .Mobility Bed Mobility = Max ; Transfers = Max .Discharge Recommendations .Up with nursing as tolerated. During a review of Resident 41's Care Plan (CP), dated 4/13/23, the CP indicated, Focus: [Resident 41] has an ADL self-care performance deficit related to muscle weakness, status post COVID-19 positive; at risk for ADL decline .date imitated: 12/7/22 .Goal .[Resident 41] will improve current level of function through the review date .date initiated 12/7/22 .Bed Mobility: [Resident 41] requires extensive assistance by (2) staff to turn and repositioning in bed .date initiated 12/14/22. During a review of Resident 41's CP, dated 4/13/23, the CP indicated, Focus [Resident 41] has vascular ulcer to left foot 5 digit at risk for complication .date initiated 2/24/23 .revision date 2/24/23 .Goal [Resident 41] will have no s/sx (signs and symptoms) of infection through the review date .date initiated 2/24/22 .target date 6/15/23 .Interventions .administer treatment as ordered .date initiated 2/24/23 .revision date 3/8/23 .notify MD of any changes . date initiated 2/24/23 . revision date 3/8/23 .Observe/document/report PRN for s/sx of infection . date initiated 2/24/23 . revision date 3/8/23 .Weekly treatment documentation to include measurements of each area of skin breakdown date initiated 2/24/23 .Focus [Resident 41] has venous stasis ulcer to left and right calf, at risk for complications .date initiated 2/3/23 .revision on 2/3/23 .Goal [Resident 41] will have no s/sx of infection through the review date .date initiated 2/3/23 . revision 2/27/23 .[Resident 41] ulcer will be healed by the review date .date initiated 2/3/23, revision 2/27/23 .Interventions .Notify MD of any changes in condition .date initiated 2/3/23 .revision date 3/8/23 .Observe/document/report PRN for s/sx of infection .date initiated 2/3/23 .revision date 3/8/23 .Focus [Resident 41] has vascular ulcers to bilateral heels; at risk for complications .date initiated 12/21/22 .revision 2/27/23 .Goal .[Resident 41 will be free from complications .date initiated 2/21/22 .target date 6/15/23 .Interventions .Notify MD for complications .date initiated 12/21/22 .revision date 3/8/23 .place on 72 alter charting .date initiated 12/21/22 . revision date 3/8/23, (name brand) boot as per order .date initiated 2/4/23 . revision date 3/8/23 .treatment as ordered .date initiated .12/21/22 . revision date 3/8/23. During a review of Resident 41's Nursing Skin and Nutrition Review (NSNR), dated 12/27/22, the NSNR indicated, .Impaired integrity type: new .vascular ulcer to right and left heel. NSNR dated 12/27/22-1/18/23, did not monitor wound condition by documenting, improved .worsening .stalled. During a review of Resident 41's Progress Note (PN) , dated 3/29/23, the PN indicated, Staff to offer changing and repositioning q2h (every two hours) or as needed. During a review of Resident 41's 'Bed Mobility Task (BMT), dated 3/30/23-4/12/23, the BMT indicated .Bed Mobility: Self-performance - How resident moves to and from lying position, turns side to side and positions body while in bed or alternate sleep furniture .checkmarks are documented under Extensive Assistance-Resident involved in activity, staff provide weight-bearing support. During a review of Resident 41's Wound Evaluation (WE), dated 3/11/23 and 4/1/23, the WE indicated, .Right Venous Heel: 3/11/23 evaluation: area 4.89 cm2 (centimeters squared-unit of measurement), Length 2.99 cm, Width 2.16 cm .4/8/23: area 6.53 cm2, Length 3.53, Width 2.65 cm .Right Venous Calf: 3/11/23 area 23.38 cm2, Length 12.36 cm, Width 2.87 cm .4/8/23 area 21.11 cm2, Length 10.63 cm, Width 3.28 cm . Left Venous Heel: 4/1/23 area 5.48 cm2, Length 3.79 cm, Width 1.78 cm .Left Venous calf: 3/11/23 area 18.39 cm2, Length 8.48 cm, Width 3.01 cm .4/8/23 area 30.73 cm2, Length 12 cm, Width 3.32 cm .Left Venous left foot 5th digit: 3/11/23 area 1.54 cm2, Length 1.86 cm, Width 1.13 cm .4/8/23 area 0.97 cm2, Length 1.66 cm, Width 0.94 cm. During on observation on 4/10/23, at 10:00 a.m., at Resident 41's bedside, Resident 41 was observed sleeping, supine (lying on back), bed at 35-degree angle, under blankets. During an observation on 4/11/23, at 8:00 a.m., at Resident 41's bedside, Resident 41 was observed sleeping, laying supine, bed at 35-degree angle, under blankets. During a concurrent observation and interview on 4/11/23, at 8:30 a.m., with Resident 41 at bedside, Resident 41 was observed supine, bed at 35- degree angle, and provided minimal response. Resident 41 stated he had been at the facility for 4 years, stated he feels safe and stated he has no injuries. Resident 41 fell asleep during interview. During a concurrent observation and interview on 4/11/23, at 12:00 p.m., with Family Member (FM) at Resident 41's bedside, Resident was observed sleeping, supine, bed at 35-degree angle. FM stated she visited Resident 41, 2 hours a day and assisted with meals. FM stated Resident 41 is fully dependent on staff. FM stated Resident 41 stays in the same position all morning, staff do not change his position often. During an interview on 4/12/23, at 10:00 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 41 is repositioned minimally. LVN 2 stated Resident 41's pain prevent staff from turning him. LVN 2 stated CNA's will reposition residents and chart. LVN 2 stated it is important to turn every 2 hours to prevent further skin breakdown and help with circulation. LVN 2 stated Resident 41 does not like to get out of bed. LVN 2 stated charting and documentation for repositioning is completed under the bed mobility task in the facilities point click care system. During a review of Resident 41's Monitoring Record (MR), dated 4/1/23-4/30/23, MR indicated, no documentation of pain reported. During an interview on 4/12/23, at 11:08 a.m., with Certified Occupational Assistant (COTA), COTA stated Resident 41 is completely dependent on staff. COTA stated repositioning every 2 hours and air lock mattress will help prevent skin breakdown. COTA stated range of motion and repositioning helps to maintain level of function, prevent skin break down, and may prevent failure to thrive. During an interview on 4/12/23, at 11:35 a.m., with Director of Staff Development (DSD), DSD stated all Activities of Daily living (ADLs), repositioning, Restorative Nursing Assistance (RNA), is charted under the bed mobility tab. DSD stated all care areas for ADLs are checked off with a checkmark that the task was completed. DSD stated point of care system needs to be fixed. DSD stated the point of care system does not include treatment type, time or monitoring. DSD stated it is important to document treatment to include specific care area details (like time, how resident tolerated, side to reposition) because if it is not charted it did not get done. DSD stated there is a potential risk for residents to get contractures if they are not being repositioned. DSD stated residents could get pressure ulcers. DSD stated it would be beneficial to have charting for position changes and range of motion to make sure interventions are being completed and monitored for effectiveness. During an interview on 4/13/26, at 10:06 a.m., with (CNA) 3, CNA 3 stated she was a new employee (been at the facility for 4 days) and was not aware of repositioning Resident 41. CNA 3 stated she usually worked on a different unit. CNA 3 stated she had not repositioned any residents yet since starting employment at the facility and had not charted changing positions. CNA 3 stated it is important to reposition residents to promote healing and prevent pressure wounds. During an interview on 4/13/23, at 3:16 p.m., with Director of Nursing (DON), DON stated the facility recently changed charting systems. DON stated all Restorative Nursing Assistance (RNA), Range of Motion, toileting care, Activities of Daily Living care, are all charted under the bed mobility task. DON stated there is no specific section to chart care-specific details. DON stated the facility is developing an updated system to include specific care provided. DON stated the facility should be monitoring Resident's needs. DON stated Resident 41 would benefit from range of motion (ROM) activities. DON stated ROM may improve circulation, improve grip with daily living activities. DON stated there is a risk for decrease strength if a resident had decreased ADL (activities of daily living). During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 2018, the P&P indicated, .Monitoring .2. The physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. During a review of the facility's P&P titled, Repositioning, dated 2013, the P&P indicated, .Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulating, and providing pressure relief .2. Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care .3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning .Evaluation .2. Evaluate the resident for an existing pressure ulcer .Interventions .1. A turning/repositioning program includes a continuous consistent program for changing the resident's position and realigning the body .2. Frequency of repositioning a bed-bound resident should be determined .3. Residents who are in bed should be on at least an every two hours (q2 hour) repositioning schedule .If ineffective, the turning and repositioning frequency will be increased .documentation .The following information should be recorded in the resident's medical record: 1. The position in which the resident was placed .3 Any change in the resident's condition .4. Any problems or complaints made by the resident .5. If the resident refused the care and the reason(s) why .Reporting .1. Notify the Supervisor if the resident refuses the procedure. During a review of the facility's P&P titled, Activities of Daily Living (ADLs), Supporting, dated 2018, the P&P indicated, .Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .2. Appropriate care and services will provide 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: .b. mobility (transfer and ambulation) .3. Care and services to prevent and/or minimize functional decline will include appropriate pain management .6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice .7. The resident's response to interventions will be monitored, evaluated and revised as appropriate. During a review of the facility's P&P titled, Charting and Documentation, dated 2017, the P&P indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .2. The following information is to be documented in the resident medical record .c. Treatments or services performed .7. Documentation of procedures and treatments will include care-specific details, including a. the date and time the treatment was provided .c. the assessment data and/or any unusual findings .d. how the resident tolerated treatment .e whether the resident refused the treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring systems to maintain acceptable parameters of nutritional status for one of five sampled residents (Resident 41). The facility failed to ensure a Registered Dietitian (RD) provided nutritional interventions despite documented meetings acknowledging weight loss. The facility failed to ensure RD effectively monitored nutrition interventions, after an unplanned severe and continuous weight loss of 13.6-pound (lbs.) 8 percent weight loss in five months from 12/6/22-4/2/23. There was no plan of care to address the weight loss and prevent further weight loss. Findings: 1. During a review of resident 41's medical record, titled, admission Face Sheet (AFS-document containing resident demographic information and medical diagnosis), dated 4/13/23, the AFS indicated Resident 41 was admitted to the facility on [DATE]. The AFS indicated Resident 41's diagnoses included .Type 2 Diabetes Mellitus (high blood sugar) .Muscle weakness (lack of muscle strength) .Chronic atrial fibrillation (an irregular, often rapid heart rate) .Non-pressure chronic ulcer of left foot .right heel and midfoot left heel and midfoot (wound due to lack of blood flow) .Varicose veins of right lower extremity with both ulcer of calf .varicose vein of left lower extremity with both ulcer of calf (leg wound due to lack of blood flow to extremities) .Atherosclerosis of coronary artery bypass graft (narrowing and hardening of arteries resulting in lack of blood flow). During a review of Resident 41's Minimum Data Set (MDS- a standardized assessment and care-planning tool), dated 2/23/23, the MDS indicated, Resident 41 had a BIMS (Brief Interview for Mental Status) score of 14 which (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 41 had no cognitive impairment. During a review of Resident 41's Weight Record indicated:, Resident 41 had a 13.6-pound (lbs.) 8 percent (8%) weight loss in five months from 12/6/22-4/2/23. 12/6/22- 163 lbs. 12/11/22- 158 lbs. 12/18/22- 159.6 lbs. 12/25/22-154.8 lbs. 1/1/23 -154.2 lbs. 1/15/23- 154.8 lbs. 1/22/23 -156.4 lbs. 1/31/23 -156.2 lbs. 2/5/23 -155.6 lbs. 2/19/23- 153.2 lbs. 3/19/23 - 149.2 lbs. 4/2/23 -149.4 lbs. During a review of Resident 41's Physicians Orders (PO), dated 4/13/23, PO orders indicated, Regular diet Regular texture, thin consistency-fortified breakfast cereal with breakfast-buttered noodles with dinner -bowl of soup of choice with lunch .date ordered 1/5/23 .[Brand name] nutritional drink .four times a day for prevent weight loss offer 120 ml (milliliter-unit of measurement) .date ordered 1/2/23 .snack of choice two times a day for prevent weight loss .date ordered 12/16/22 . During a review of Resident 41's Care Plan, (CP) dated 4/13/23, the CP indicated, .potential nutritional problem .at risk for nutritional decline .date initiated: 12/7/22 .Intervention .Registered Dietician to evaluate and make diet change recommendations PRN (as needed). After the CP was reviewed, there was no documented evidence the CP address the weight loss and prevent further weight loss. During a concurrent interview and observation on 4/11/23 at 12:00 PM, with Family Member (FM) at Resident 41's bedside, FM stated she visited Resident 41, 2 hours a day and assisted with meals to make sure he eats. FM stated Resident 41 had lost weight since being at the facility. FM stated facility rarely brings Resident's preference of food (soup and salad). Lunch tray was observed, no salad was provided. FM stated she was concerned with Resident 41's care at the facility. During a concurrent interview and record review on 4/13/23 at 2:29 PM, with Registered Dietician (RD) , Resident 41's, Nutritional Screen (NS) dated 12/8/22 was reviewed. NS indicated, recent weight: 163 .date: 12/6/22 .Additional Notes: Diet: 2g Sodium (2 G NA), thin consistency .snack offered .fair appetite .1600-1800 ml (1ml/kcal [kilocalories-calorie unit of energy] per MD (medical doctor) order .consider adding a multivitamin with minerals .recommend to add nutritional drink 90 ml QD (every day) to supplement po intake .RD will continue to monitor and follow up per protocol During a concurrent interview and record review on 4/13/23 at 2:30 PM, with Registered Dietician (RD), Resident 41's Nursing Skin and Nutrition Review (NSNR), dated 12/20/22, was reviewed, the NSNR indicated, .Diet: 2g Sodium (2G NA) . Snack of choice BID (two times a day) .Recent weight 159.6 pounds .date: 12/18/22 .previous weight 158 pounds .previous weight date: 12/11/22 .Additional comments: Recommend to add liquid protein 30 ml QD (4 times a day) to help in wound healing .NSNR dated 12/27/22 .Diet: 2g Sodium .Recent weight 154.8 pounds .date: 12/25/22 .Previous Weight 159.6 .date of previous weight: 12/18/22 .Additional comments: MD with new orders [brand name] nutritional drink 120ml TID (three times a day) .variable PO (oral) intake .nutritional drink increased this week NSNR dated 1/2/23 indicated, .Diet: 2 g Sodium .snack of choice of BID .Most recent weight 154.2 .date: 1/1/23 .previous weight 12/18/22 .159.6 pounds .Additional Comments: MD new orders for 120 ml QID (four times a day). RP made aware 1) Recommend to liberalize diet to regular, Regular texture, thin consistency .NSNR dated 1/11/23 indicated, .Diet: Regular .snack of choice BID .most recent weight 152.2 .date: 1/8/23 .previous weight 154.2 .date of previous weight 1/1/23 .Additional Comments: .PO intake is fair. 1)Recommend to send fortified breakfast cereal w/ breakfast. 2) Recommend to send fortified mashed potatoes w/ lunch and dinner NSNR dated 1/18/23, indicated, .Order: Regular, fortified[blank] .Thin .Recent weight 154.8 .date: 1/15/23 .Previous Weight 152.2 .Date of previous weight 1/8/23 .Additional Comments: none. NSNR dated 1/23/23 indicated, .Regular, fortified breakfast, fortified mashed potatoes with lunch/dinner .Recent weight 156.4 pounds .date 1/22/23 .Previous weight .154.8 .date of previous weight 1/15/23 .B Additional Comments: Slight increase in weight this week, not sig. Stable po intake .weight stabilization .continue with current plan NSNR dated 1/31/23 indicated, .Regular, fortified breakfast, fortified mashed potatoes with lunch/dinner .Recent weight .156.2 .date 1/31/23 .previous weight 154.8 .date of previous weight 1/15/23 .Additional comments: wound notes=cellulitis to right and left calf. NSNR dated 2/7/23, indicated, .Regular, fortified breakfast, fortified mashed potatoes with lunch/dinner .Recent weight 155.6 .date 2/5/23 .previous weight: 154.8 .date of previous weight: 1/15/23 .Additional Comments: treatment cont. as ordered. NSNR dated 2/14/23 indicated, .Regular, fortified breakfast, fortified mashed potatoes with lunch/dinner .recent weight 155.6 .date: 2/5/23 .previous weight: 156.2 .previous weight date .1/31/23 .Additional comments: continue with current plan. NSNR dated 2/20/23 indicated, .Regular, fortified cereal, fortified mashed potatoes with lunch/dinner .recent weight 153.2 .date: 2/19/23 .previous weight 155.6 pounds .date of previous weight: 2/5/23 .Additional comments: weight stabilization .1) Recommend to d/c fortified mashed potatoes for lunch and dinner, resident's request. 2) Recommend to send buttered noodles w/ dinner per resident's request 3) Recommend to send bowl of soup of choice with lunch, per resident's request. NSNR dated 3/13/23 indicated, .Regular, fortified cereal, buttered noodles at dinner, soup at lunch .Recent weight 153.2 .date 2/19/23 .previous weight 155.6 .date of previous weight: 3/5/23 .Additional comments: None NSNR dated 3/22/23 indicated, .Regular, fortified cereal, buttered noodles at dinner, soup at lunch .Recent Weight 149.2 .date 3/19/23 .previous weight 155.6 .date of previous weight 3/5/23 .Additional Comments: Continue with plan of care. NSNR dated 3/28/23 indicated, .Regular, fortified cereal, buttered noodles at dinner, soup at lunch .Recent weight 149.2 .date: 3/19/23 .Previous weight 155.6 .date of previous weight: 3/5/23 .Additional Comments: Continue w/ current care. NSNR dated 4/4/23 indicated, .Regular fortified cereal, buttered noodles at dinner, soup at lunch .Recent weight 149.4 .date 4/2/23 .previous weight 149.2 .date of previous weight: 3/19/23 .Additional Comments: No Significant weight loss this month. Weight stabilization .continue w/ current plan. There was no documented evidence the RD reevaluated Resident 41's nutrition status for 2 weeks after 2/20/23. There were weekly NSNR follow up during 3/13/23- 4/4/23 but there were no nutrition interventions. The RD stated, she did not have weekly weights so she could not recommend nutrition interventions. The RD stated she did not have weekly weights because Licensed Nurses did not record weekly weights. The RD stated she should have followed up and monitored resident's nutrition interventions after 1/11/23 assessment, weekly instead of following up 2/20/23 which was 5 weeks later. The RD stated it is standard of practice to monitor interventions and if they are effective or not. The RD stated resident's weight was stable; however, after review of weight documentation the resident continued to have unplanned significant weight loss since 12/6/22. During an interview on 4/13/23, at 3:16 p.m., with Director of Nursing (DON), DON stated weekly weights are completed for 4 weeks for new admits. If there is a significant weight loss in a week, a month or 6 months the facility will investigate weight loss and have the Registered Dietician involved to assess and make recommendation. DON stated it is the expectation for the RD to obtain weights (even if weights were not documented in the system). DON stated the RD should still be monitoring nutritional status if resident refuses to be weighted. DON stated the expectations is to monitor weights, complete a full assessments and chart. DON stated the expectations is for the staff to follow the weight assessment and interventions policy to monitor residents as appropriate. DON stated the risk for staff not following the weight loss policy, places residents at risk for continued weight loss, worsening wounds, overall decline if residents do not have energy. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated 2022, the P&P indicated, Policy Statement .Resident weights are monitored for undesirable or unintended weight loss or gain .Weight Assessment .3. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation .5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. 1 month- 5% weight loss is significant; greater than 5% is severe .Evaluation 1. Undesirable weight change is evaluated by the treatment team .Interventions .1. Interventions for undesirable weight loss are based on careful consideration of the following: a. Resident choice and preferences. During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated 2017, the P&P indicated, Policy Statement .As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted .1. The dietitian will conduct a nutritional assessment for each resident upon admission .and as indicated by a change in condition that places the resident at risk for impaired nutrition .2. The nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition .3. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: .4) A history of reduced appetite or progressive weight loss .10) Food preferences and dislikes .d)Dietitian: 1) An estimate of calories, protein, nutrient and fluid needs .2 whether the resident's current intake is adequate .8) Individualized care plan shall address, to the extent possible: b) the resident's personal preferences .c)goals and benchmarks for improvement. During a review of a professional reference, retrieved from American Academy of Family Physician journal Volume 6 Number 4, dated February 15,2002, the reference indicated, Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. During a review of a professional reference, retrieved from www.aafp.org/afp, on April 18, 2023 titled American Academy of Family Physician journal Volume 65, Number 4, dated February 15, 2002, the reference indicated Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. During a review of a professional reference, 2009 National Pressure Ulcer Advisory Panel [NAME] Paper, titled The Role of Nutrition in Pressure Ulcer Prevention and Treatment dated 2009 the reference indicated Compromised nutritional status such as unintentional weight loss, undernutrition, protein energy malnutrition (PEM), and dehydration deficits are known risk factors for pressure ulcer development.

Based on observation, interview and record review, the facility failed to post the total number of licensed and unlicensed staff and actual hours worked per shift within two hours of the start of each shift in accordance with the facility policy and procedure when the posting did not represent actual hours worked but projected hours. This failure resulted in residents and visitors not having the benefit of viewing the actual hours and total number of staff providing care per shift and possibly not meeting the needs of the residents FINDINGS: During a concurrent observation and interview, on 4/12/23, at 12:07 p.m., the bulletin board on C hall was observed with the Administrator (ADM) and Director of Staff Development (DSD). The ADM indicated, the projected hours of licensed and unlicensed personnel was posted instead of actual hours. The DSD stated she had been posting the projected hours and was unaware she was supposed to port the actual hours. ADM stated, per policy, they were supposed to post the actual hours within 2 hours of the shift starting. During a review of the facility's Policy and Procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers:, dated July 2016, indicated, Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents .Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location .

Based on dietary production observation, interviews and record reviews, the facility failed to ensure the pureed bread recipe was followed by an A.M. [NAME] for lunch on 4/11/23. This failure result in twelve out of twelve sampled residents (Residents' 3, 4, 18, 21, 22, 24, 25, 28, 34, 152, 155, 352) who on pureed bread received less nutritive value and unappetizing pureed bread. This failure had potential result in negatively impact the residents' nutritional status and further compromising residents' medical status. Finding: ( Cross reference 801, 802) During a concurrent observation and interview on 4/11/23, at 11:51 a.m., with an AM [NAME] (CK), in the kitchen, CK was observed pouring unmeasured hot water while preparing pureed bread. CK confirmed she was adding unmeasured hot water while preparing pureed bread. During a concurrent observation and interview on 4/11/23, at 1:04 p.m., with the Dietary Manager (DM) and District Dietary Manager (DDM), at dining room, a test meal was performed for food temperature and palatability (taste and/or flavor) of the regular and puree diet meals. The DM and DDM agreed the taste of the pureed bread was weird not good. The DDM stated, the pureed bread was supposed to have milk or broth added not water. The DDM stated, by adding milk or broth would increase the nutrition value and the palatability of the pureed bread. During an interview on 4/11/23, at 3:41 p.m., with the Registered Dietitian (RD), the RD stated, cooks needed to follow the recipe by adding milk or broth not water for pureed bread. The RD further stated, by adding water into pureed bread could dilute the nutritive value and taste of the pureed bread. During a concurrent interview and record review, on 4/13/23, at 9:03 a.m., with the Dietary Manager (DM) the record titled, Dinner Roll Recipe, undated was reviewed. The recipe indicated, . For Pureed: . Add liquid if product needs thinning. The DM stated the liquid in the recipe referring as milk. During a record review on 4/11/12, at 9:30 a.m., of the facility's, Lunch Meal Tray Ticket (which indicated food items residents received with their meal), dated 4/11/12, the lunch meal tray ticket indicated, Residents (3, 4, 18, 21, 22, 24, 25, 28, 34, 152, 155, 352) received pureed bread. During a review of the facility's policy and procedure (P&P) titled, Food: Quality and Palatability, Revised 9/2017, the P&P indicated, Policy Statement: Food will be prepared by methods that conserve nutritive value, flavor . Food will be palatable, . Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to . standardized recipes. 4. The Cook(s) prepare food in accordance with the recipes, .

Based on observation, interview, and record review, the facility failed to follow its policy on Food: Quality and Palatability to provide appetizing food at appropriate temperatures according to residents' preferences for ten of 46 sampled residents (Residents' 6, 20, 23, 33, 39, 45, 48, 49,155, 353). This failure had the potential risk to decrease nutritional intake and affect the residents' nutritional status and further compromising residents' medical status. Finding: During an interview on 4/10/23, at 9:56 a.m., with Resident 48, Resident 48 stated, Food is not appealing, no taste, no options, no presentation, it is not good. That is my main concern. During an interview on 4/10/23, at 10:27 a.m., with Resident 39, Resident 39 stated, Food does not taste good. During an interview on 4/10/23, at 12:55 p.m., with Resident 49, Resident 49 stated, There is no taste of provided foods and soup is always cold. During an interview on 4/10/23, at 3:05 p.m., with Resident 155, Resident 155 stated, provided foods tasted horrible. During an interview on 4/10/23, at 3:30 p.m., with Resident 353, Resident 353 stated, provided foods did not taste good, needed seasoning. During an interview on 4/10/23, at 4:10 p.m., with Resident 20, Resident 20 stated, Food is cold all the time. Even when the time food supposed to be hot, by the time it gets to me is cold. During a concurrent observation and interview on 4/11/23, at 1:04 p.m., with the Dietary manager (DM) and District Dietary Manager (DDM), at dining room, a test meal was performed for food temperature and palatability of the regular and puree diet meals. DM and DDM agreed that noodle tasted bland. During a Resident council meeting on 04/11/23, at 3:28 p.m., Resident 6 and Resident 45 stated, food was not appetizing, not much flavor and cold. Resident 23 stated she received cold egg. During an interview on 4/11/23, at 3:41 p.m., with the Registered Dietitian (RD), the RD stated, providing unappetizing and cold foods to residents could cause decreased food intake and potential result for unplanned weight loss. During an interview on 4/13/23, at 10:00 a.m., with Resident 33, Resident 33 stated, terrible food; everything about the food is terrible, taste, temperature During a review of the facility's policy and procedure (P&P) titled, Food: Quality and Palatability, Revised 9/2017, the P&P indicated, Policy Statement: Food will be prepared by methods that conserve nutrition value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the appropriate food and beverage textures were provided as evidence by: 1. Three of six sampled residents (Residents'11, 30, 42 ) received Dysphagia Mechanically Altered diet (a diet with food texture need to chop up or ground into small piece for residents who have limited chewing and swallowing ability) received 3-inch-long green bean salad for lunch on 4/10/23. 2. Resident 25 was ordered with honey thick consistency, was served unmixed regular consistency coffee with lumpy thickeners during lunch on 4/10/23. 3. Twelve of twelve sampled residents (Residents' 3, 4, 18, 21, 22, 24, 25, 28, 34, 152, 155, 352) ordered Dysphagia Puree diet (a diet with food texture need to blend until smooth into mashed potatoes consistency for residents who have severe chewing and/or swallowing ability) received chunks meatball during lunch on 4/11/23. 4. Seven out of seven sampled residents (Residents' 3, 22, 24, 25, 34, 155, 352) ordered Dysphagia Puree diet, received chunks noodles during lunch on 4/11/23. These failures had the potential to place the residents at risk of choking and aspiration. Findings: ( Cross reference 801, 802) 1. During a concurrent observation and meal [NAME] tickets review on 4/10/23, at 12:16 p.m., in the dining room, Resident 30 was observed being serve approximate 3-inch-long green bean salad. Resident 30's, Meal Tray Ticket, indicated. Resident 30 was on Dysphagia Mechanically Altered diet. During a concurrent observation and meal tray ticket review on 4/10/23, at 12:41 p.m., in the dining room, Resident 11's, Meal Tray Ticket indicated, Resident 11 was on Dysphagia Mechanically Altered diet. Resident 11 was observed being serve approximate 3-inch-long green bean salad. Resident 11 did not touch the served green bean salad. During a concurrent observation and interview on 4/10/23, at 12:42 p.m., in the dining room, with Resident 30, Resident 30 was observed leaving the green beans on her plate uneaten. Resident 30 stated, she could not eat the green beans, because she needs the green beans cut into small pieces. During a concurrent observation and meal tray ticket reviewed on 4/10/23, at 12:56 p.m., in the dining room, Resident 42 was observed being serve approximate 3-inch-long green bean salad. Resident 42's, Meal Tray Ticket, indicated, Resident 30 was on Dysphagia Mechanically Altered diet. Resident 42 finished all served foods except the green bean salad. During an interview on 4/11/23, at 4:57 p.m., with the Registered Dietitian (RD), the RD stated, the 3-inch-long green bean salad was not the appropriate diet texture to serve residents on a Dysphagia Mechanically Altered diet. The RD stated the 3-inch-long green beans were too big and residents were unable to chew on 3-inch-long green beans. The RD stated, the 3-inch-long green bean salad could potentially cause a choking hazard. The RD stated, she expect the dietary staff to follow the vegetable chopped size described in the diet manual for Dysphagia Mechanically Altered diet. During an interview on 4/12/23, at 10:42 a.m., with the Speech Language Pathology (SLP), the SLP stated, the served 3-inch-long green bean salad to residents on a Dysphagia Mechanically Altered diet, was not the appropriate texture. The SLP stated, the green beans needed to be soft and easily to break down. The SLP stated the green beans could cause a choking hazard for residents. During a review of the facility's policy and procedure (P&P) titled, Food: Quality and Palatability, Revised 9/2017, the P&P indicated, Policy Statement: . Foods . are prepared and served in a manner, form, and texture to meet resident's needs. Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. 3. Food . are prepared in a manner, form and texture that meets each resident's needs. During a review of the facility's, Diet and Nutrition Care Manual, titled, Dysphagia Mechanically Altered diet, undated, the Dysphagia Mechanically Altered diet indicated, . Vegetables to Avoid . Any pieces larger than ½ in size . During a review of the facility's, Lunch Meal Tray Ticket (which indicated food items residents received with their meal) on 4/10/23, the lunch meal tray ticket indicated, (Residents' 9, 11, 30, 42, 46, 47) received green bean salad. 2. During a concurrent observation, interview and meal tray ticket reviewed on 4/10/23, at 12:34 p.m., in the dining room, with Certified Nurse Aide (CNA) 8, Resident 25 was observed being served a regular consistency coffee with lumpy thickener on the side and bottom of the coffee mug. Review of Resident 25's, Meal Tray Ticket the ticket indicated, Resident 25 was on Honey thickened liquid (adding thickener to regular liquid to form honey thick consistency for resident who has swallow issue). CNA 8 stated, the served coffee was not honey thick consistency. CNA 8 stated, the dietary staff did not mix the coffee well with the thickener, so the coffee was not a honey consistency. CNA 8 stated there were thickener lumps on the side and bottom of the coffee mug. The Dietary Manager (DM) confirmed Resident 25 was serveed coffee thas was not honey thick consistency and the coffee had lumpy thickeners on the side and bottom of the coffee mug. The DM stated, Resident 25 was not supposed to have the unmixed well coffee. During an interview on 4/11/23, at 5:10 p.m., with the RD, the RD stated, Resident was ordered a honey thick consistency. RD stated the coffee received was not honey thick consistency coffee and had the potential risk of aspiration and choking. The RD stated her expectation was for the dietary staff to follow the Guidelines for Serving Thickened Liquids for proper consistency of thickenined liquid for Residents. During a review of the facility's policy and procedure (P&P) titled, Food: Quality and Palatability, Revised 9/2017, the P&P indicated, Policy Statement: . Liquids are prepared and served in a manner, form, and texture to meet resident's needs. Procedures: . 3. liquids/beverages are prepared in a manner, form and texture that meets each resident's needs. During a review of the facility policy and procedure (P&P) titled, Thickened Liquids, revised May 2007, the P&P indicated, Residents who are unable to safely or comfortably swallow may have dysphagia. Thickened liquids may be ordered to provide or promote safe swallowing of Liquids. Thickened liquids will be provided for any resident who has an appropriate physician's order. Procedure: . 3. The resident's diet card (meal tray ticket) will have the order for appropriately thickened liquids. During a review of the facility's, Diet and Nutrition Care Manual titled, Guidelines for Serving Thickened Liquids, undated, the Guidelines for Serving Thickened Liquids indicated, . All liquids should be thickened to the proper consistency, including . all other beverages. 3. During a concurrent observation and interview on 4/11/23, at 11:44 a.m., in the kitchen, with AM [NAME] (CK), CK was observed using the immersion handheld blende for the meatballs in a serving pan. CK stated, the pureed meatball needed to be a mush consistency. During a concurrent observation and interview on 4/11/23, at 1:04 p.m., with the Dietary manager (DM) and District Dietary Manager (DDM), in the dining room, a test meal was performed for food temperature and palatability (taste/favor) of the puree diet meal. During the test meal, chunks of meatballs were found in the pureed meatballs. The DM and DDM both confirmed chunks of meatballs were found in the pureed meatballs. The DDM stated, the texture of pureed meatballs were not supposed to have chunks. The DDM stated the texture of pureed meatballs were supposed to taste smooth. During an interview on 4/11/23, at 5:10 p.m., with RD, the RD stated, puree texture should be smooth, with no lumps/chunks at all, like a mashed potatoes consistency. RD stated, the potential risk of pureed food with chucks/lumps could be a choking and aspiration risk. The RD stated the expectation was for the dietary staff to follow the recipe for the proper consistency of pureed meatballs. During a review of the facility's policy and procedure (P&P) titled, Food: Quality and Palatability, Revised 9/2017, the P&P indicated, Policy Statement: . Foods . are prepared and served in a manner, form, and texture to meet resident's needs. Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the . standardized recipes. 3. Food . are prepared in a manner, form and texture that meets each resident's needs. 4. The cook(s) prepare food in accordance with the recipes . During a review of the facility's recipe titled, Meatballs, undated, the recipe indicated, . For Pureed: . Blend until smooth . During a review of the facility's, Lunch Meal Tray Ticket, on 4/11/23, the lunch meal tray ticket indicated, (Residents' 3, 4, 18, 21, 22, 24, 25, 28, 34, 152, 155, 352) received pureed meatball. 4. During a concurrent observation and interview on 4/11/23, at 11:13 a.m., in the kitchen, with CK, CK was observed using a immersion handheld blender to blended the noodle in a serving pan. CK stated the pureed noodles needed to be a pudding consistency. During a concurrent observation and interview on 4/11/23, at 1:04 p.m., with the DM and DDM, in the dining room, a test meal was performed for food temperature and palatability of the puree diet meal. During test meal, chunks of noodle were found in the pureed noodles. The DM and DDM confirmed chunks of noodle were found in the pureed noodles. The DDM stated, the texture of pureed noodles are not supposed to have chunks.The DDM stated the texture of pureed noodles wer supposed to taste smooth. During an interview on 4/11/23, at 5:10 p.m., with the RD, the RD stated, puree texture should be smooth, with no lumps/chunks at all and a mashed potatoes consistency. RD stated the potential risk for a pureed diet to have chucks/lumps could be a choking and aspiration hazard. The RD stated, her expectation was the dietary staff would follow the recipe for the proper consistency of pureed noodles. During a review of the facility's lunch, Meal Tray Ticket on 4/11/23, the lunch meal tray ticket indicated, (Residents' 3, 22, 24, 25, 34, 155, 352) received pureed Noodle. During a review of the facility's policy and procedure (P&P) titled, Food: Quality and Palatability, Revised 9/2017, the P&P indicated, Policy Statement: . Foods . are prepared and served in a manner, form, and texture to meet resident's needs. Procedures: 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the . standardized recipes. 3. Food . are prepared in a manner, form and texture that meets each resident's needs. 4. The cook(s) prepare food in accordance with the recipes . During a review of the facility's recipe titled, Pasta, Egg Noodles, undated, the recipe indicated, . For Pureed: .Blend until smooth .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete, accurately documented and readily accessible for three of six sampled residents (Residents' 22, 32 and 103) when: 1. Resident 22's copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was signed and dated thirteen months by the Medical Doctor (MD) after it was prepared and readily available as part of Resident 22's current medical records. 2. Resident 32's copy of POLST was incomplete and readily available as part of Resident 32's current medical record. 3. Resident 103's copy of POLST was inaccurate and readily available as part of Resident 103's current medical record. These failures had the potential risk for Residents' 22, 32 and 103's decisions regarding their healthcare and treatment options not being honored. Findings: 1. During a review of Resident 22's clinical record titled, admission Record (AR-document containing resident profiles) dated 4/12/23, the AR indicated, Resident 22 was admitted to the facility on [DATE], with diagnosis which included Alzheimer's Disease (a disease that destroys memory and other important mental functions), Atrial Fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow ) and dysphagia (difficulty swallowing). 2. During a review of Resident 32's AR dated 4/12/23, the AR indicated, Resident 32 was admitted to the facility on [DATE], with diagnosis which included muscle weakness, end stage renal disease and dysphagia. 3. During a review of Resident 103's AR dated 4/12/23, the AR indicated, Resident 103 was admitted to the facility on [DATE], with diagnosis which included end stage renal disease, heart failure and anemia (blood doesn't have enough healthy red blood cells). During a concurrent interview and record review on 3/12/23, at 11:35 a.m., with Minimum Data Set Nurse (MDSN), she stated the Social Service Director (SSD)was responsible in reviewing the POLST form with family and residents. MDSN stated the expectation was for SSD to complete the POLST form the next day after admission or when family are available. MDSN reviewed Residents' 22, 23 and 103's POLST forms, she stated Residents' 22, 23 and 103's POLST forms are incomplete and inaccurate. MDSN stated the expectation was for resident records to be complete and accurate. During a concurrent interview and record review on 3/12/23, at 2:41 p.m., with Unit Manager Registered Nurse (UMRN), UMRN reviewed Residents' 22, 32 and 103. She stated Resident 22's POLST was prepared on 8/11/18 and MD did not signed the POLST until 9/4/19. The UMRN stated the facility should had MD signed the POLST right away. UMRN stated Resident 32's POLST was incomplete, and it should have been completed. UMRN reviewed Resident 103's POLST form and stated it was not accurate because the last name did not match in the AR and the POLST form. UMRN stated Resident 103's clinical record should have been accurate and completed. During a concurrent interview and record review on 4/13/23, at 8:04 a.m., with Social Service Designee (SSD), the SSD stated she was responsible in filling out the POLST form and explaining with family and resident. SSD stated she made sure POLST form are accurate and signed by MD. SSD stated it was her responsibility to follow up with the MD and the family if it was not signed. During an interview on 4/13/23, at 2:30 p.m., with the Director of Nursing (DON), the DON stated her expectations are for the POLST form to be complete and accurate. DON stated the staff filling up the POLST form be thorough and had to be done on admission. DON stated if POLST are incomplete and not signed, the POLST defaults to full code which may not be what resident or family wants. DON stated she was not able to find a policy regarding the completeness and accuracies of resident clinical records. During a review of facility document titled, Job Description, Social Services Director, undated, the Job Description indicated, .Assist the resident and resident's family in discharge and placement planning. Organize family groups to promote communication, education and support between family members, facility staff and administration, and provide counseling as needed . Must adhere to Code of Conduct and Business Ethics policy, including documentation and reporting responsibilities . During a review of facility document titled, .Job Description, Health Information Manager, dated 8/28/18, the Job Description indicated, . To oversee and manage the planning, development, and maintenance of clinical records and health information systems in accordance with federal and state guidelines, as well as professional practice standards, corporate quality assurance standards and company policies to assure that a complete health information management program is maintained company wide . During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 12/16, the P&P indicated, .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive of he or she chooses to do so . If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative . Prior to or upon admission of a resident, the social service director or designee will inquire of the resident, his/her family members and/or his or legal representative, about the existence of any written advance directives .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection control and prevention program to provide a safe, sanitary and comfortable environment to help prevent infections for seven of 50 sampled residents (Residents 6, 22, 41, 31, 33, 49, 353, ) when: 1.Bedpans were observed placed on the top of the two toilets (that are shared with three other residents). One bedpan was observed in Resident 31 restroom, and one bedpan was observed in Resident 33's restrooms. Resident 31's toilet seat contained a brown substance. 2. Resident 49 had concerns of smell and cleanliness of her restroom. 3. Facility did not follow policy to replace trash receptacle liners, when trash receptacle liners (used to keep the inside of trash receptacle clean and to easily contain and transport trash from trash receptacles) were missing from Resident 353, Resident 6 and Resident 22's room and Resident 41 restroom. These failures had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transmission of infection between residents. Findings: 1.During an observation on 4/10/23, at 9:52 a.m., in Resident 31's restroom, a bedpan (a receptacle used for toileting) was observed on the back of resident's toilet. A brown substance was observed on the back of the toilet seat. A foul odor was noted in the restroom. During an observation on 4/10/23, at 10:13 a.m., in Resident 33's restroom, a bedpan was observed on the back of the resident's toilet. During a review of Resident 31's admission Face Sheet (AFS-document containing resident demographic information and medical diagnosis), dated 4/13/23, the AFS indicated, Resident 31 was admitted to the facility 1/12/21. Resident 31's diagnosis included .type 2 diabetes mellitus (high blood sugar) .muscle weakness (lack of muscle strength) .difficulty in walking. During a review of Resident 33's AFS, dated 4/13/23, the AFS indicated, Resident 33 was admitted to the facility 7/8/21. Resident 33's diagnose included .hemiplegia and hemiparesis following cerebral infarction (muscle weakness or partial paralysis on one side of the body) .type 2 diabetes mellitus .muscle weakness. During a concurrent interview and record review on 4/12/23, at 9:41 a.m., with Housekeeping Supervisor (HKS), Healthcare services group-Housekeeping In-Services (HSG), dated 2000 was reviewed. HSG indicated In-services .Subject: Complete Room Cleaning .Patient Room .3. Starting in a clockwise rotation from patient room door; clean, polish, scrub, scrape, dust, disinfect, sweep, wipe, and mop everything in the room .Bathroom .e. Toilet-scrub and disinfect toilet bowl. Use cleanser on interior of bowl only. Remove all stains and build up. HKS stated housekeeping are in charge of sweeping, cleaning, mopping floors, dusting and laundry. HKS stated rooms are cleaned two times a day or more if needed. HKS stated bedpans should not be on the back of the toilet but should be thrown away. HKS stated trash should be thrown away. HKS stated the toilets should be cleaned and disinfected to prevent cross contamination. HKS stated there is a potential for residents to get sick from bacteria. 2.During a review of Resident 49's AFS, dated 4/12/23, the AFS indicated, Resident 49 was admitted to the facility 10/28/22. Resident 49's diagnosis included .atherosclerosis of coronary artery bypass graft (narrowing of arteries resulting in decreased blood flow) .dysphagia (difficulty swallowing) .muscle weakness. During an interview on 4/13/23, at 9:28 a.m., with Resident 49's family member (FM), FM stated Resident 49 will not use the restroom in her room and stated the restroom is gross. FM also stated the restroom is disgusting. FM stated he had reported lack of cleanliness to staff; however, staff had not resolved the issue. During a concurrent interview and record review on 4/12/23, at 9:41 a.m., with Housekeeping Supervisor (HKS), Healthcare services group-Housekeeping In-Services (HSG), dated 2000 was reviewed. HSG indicated In-services .Subject: Complete Room Cleaning .Patient Room .3. Starting in a clockwise rotation from patient room door; clean, polish, scrub, scrape, dust, disinfect, sweep, wipe, and mop everything in the room .Bathroom .e. Toilet-scrub and disinfect toilet bowl. Use cleanser on interior of bowl only. Remove all stains and build up. HKS stated housekeeping are in charge of sweeping, cleaning, mopping floors, dusting and laundry. HKS stated rooms are cleaned two times a day or more if needed. HKS stated bedpans should not be on the back of the toilet but should be thrown away. HKS stated trash should be thrown away. HKS stated the toilets should be cleaned and disinfected to prevent cross contamination. HKS stated there is a potential for residents to get sick from bacteria. During an interview on 4/13/23 at 11:00 a.m., with Director of Nursing (DON), DON stated restrooms and rooms should be cleaned and disinfected at least once a day, more if needed. DON stated the expectation is that the facility needs to be cleaned , and free of clutter. DON stated education will need to be done with CNA and housekeeping staff on proper cleaning techniques. DON stated the potential risk for resident's is cross contamination. During a review of the facility's policy and procedure (P&P) titled, Interim Recommendations for Routine & Terminal COVID-19 Isolation Rooms/Unit Cleaning, dated 2021, the P&P indicated .Cleaning-when you clean a surface you remove all visible debris .5. Clean and Disinfect the Bathroom .Clean and disinfect toilet exterior, toilet seat surface. 3 During an observation on 4/10/23, at 10:17 a.m., in Resident 353's room, a trash receptacle was observed to have no liner. During an observation on 4/12/23, at 9:50 a.m., in Resident 41's room, the bathroom trash receptacle was observed to have no trash receptacle liner, with trash placed beside the trash receptacle on the floor. During an observation on 4/10/23, at 10:30 a.m., in Resident 6's room, Resident 6's trash receptacle at bedside was observed with no trash receptacle liner and was filled with dirty briefs. During an observation on 4/10/23, at 10:45 a.m., in Resident 22's room, Resident 22's trash receptacle at bedside was observed with no trash receptacle liner and was filled with dirty briefs and gloves. During a review of Resident 353's admission Face Sheet (AFS-document containing resident demographic information and medical diagnosis), dated 4/13/23, the AFS indicated, Resident 353 was admitted to the facility 3/23/23. Resident 353's diagnosis included .Facture of first lumbar vertebra (broken vertebra of lower back) .muscle weakness (lack of muscle strength) .difficulty walking . During a review of Resident 41's admission Face Sheet (AFS-document containing resident demographic information and medical diagnosis), dated 4/13/23, the AFS indicated, Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnoses included .Type 2 Diabetes Mellitus (high blood sugar) .Muscle weakness (lack of muscle strength) .Chronic atrial fibrillation (an irregular, often rapid heart rate) .Non-pressure chronic ulcer (wound due to lack of blood flow) of left foot .right heel and midfoot .left heel and midfoot .Varicose veins of right lower extremity with both ulcer of calf .varicose vein of left lower extremity with both ulcer of calf (leg wound due to lack of blood flow to extremities) .Atherosclerosis of coronary artery bypass graft (narrowing and hardening of arteries resulting in lack of blood flow) . During a review of Resident 6's AFS, the AFS dated 4/12/23 indicated, Resident 6 was admitted to the facility 11/30/22. Resident 6's diagnoses included, .heart failure (decrease in heart function) .muscle weakness (decrease in muscle strength) .abnormalities of gait and mobility . During a review of Resident 22's AFS dated 4/12/23, the AFS indicated Resident 22 was admitted to the facility 9/4/19. Resident 22's diagnoses included, .Alzheimer's disease (memory loss) .atrial fibrillation (an irregular often rapid heartbeat) .dementia (impaired ability to remember, think or make decisions) . During a concurrent interview and record review on 4/12/23, at 9:41 a.m., with Housekeeping Supervisor (HKS), Healthcare services group-Housekeeping In-Services (HSG), dated 2000 was reviewed. HSK stated housekeeping complete the in-services on-line. HSG indicated, In-services .Subject: Complete Room Cleaning .Patient Room .3. Starting in a clockwise rotation from patient room door; clean, polish, scrub, scrape, dust, disinfect, sweep, wipe, and mop everything in the room .f. Trash receptacles-remove liner, wipe down can with disinfectant and remove all excess build up. Reline can with new bag .Subject: 7-Step Daily Washroom Cleaning .2. Empty Trash .Reline receptacles and sanitize as needed .Subject: 5-Step Daily Patient Room Cleaning .1. Empty Trash .[NAME] trash from all rooms as a first priority .Replace liner as needed .HKS stated housekeeping are in charge of sweeping, cleaning, mopping floors, dusting and laundry. HKS stated rooms are cleaned two time a day or more if needed. HKS stated trash should be thrown away and trash can liners replaced. HKS stated the toilets should be cleaned and disinfected to prevent cross contamination. HKS stated there is a potential for residents to get sick from bacteria. During an interview on 4/13/23 at 11:00 a.m., with Director of Nursing (DON), DON stated restrooms and rooms should be cleaned and disinfected at least once a day, more if needed. DON stated building needs to be cleaned, and free of clutter to create a homelike environment for residents. DON stated education will need to be done with CNA and housekeeping staff on proper cleaning techniques. DON stated the potential risk for resident's is cross contamination and clutter and trash on the ground could be a potential trip hazard for residents.

Based on dietetic services observations, interviews, and record reviews, the facility failed to ensure the Registered Dietitian conducted effective oversight of the food and nutrition department in accordance with the facility's executed contract and professional standards of practice. These failures had the potential to result in ineffective and inadequate directing of the day-to-day Food and Nutrition operations to ensure the nutritional needs for 46 of 48 sampled residents were met in a safe and sanitary manner. (Cross reference: F692, F802, F803, F804, F805, F806 and F812) Findings: During the initial kitchen tour on 4/10/23, beginning at 9:32 AM, observations and concurrent interviews were conducted with the Dietary Manager (DM) regarding overall kitchen sanitation and cleanliness. There were multiple areas and equipment in the kitchen that were not clean including but not limited to: a. The prep sink (sink used to preparation of foods) did not have an air gap (a fixture that provides back-flow prevention). b. Several places in the kitchen covered with brown, grey and black debris. c. Trash, dust, and food particles were observed in several places in the kitchen under equipment's floor. d. There was calcium buildup found on the dishwasher and ice machine's curtain. e. Unsanitary can opener found in kitchen. f. The red bucket filled with cleaning solution was stored next to clean containers and food. g. There was a torn gasket found on the milk refrigerator's door. h. The milk refrigerator's door was covered with white substance, brown particles and brown grime. i. Rust was found on several kitchen equipment: milk refrigerator's storage shelves, Refrigerator # 2's storage shelves and inside microwave. j. Unsanitary microwave. k. Two marred cutting boards found in the kitchen. l. There was black and brown particles found on the toaster. m. There were several opened bags of food items exposed to the air found in the Veggetable Reach in Freezer and Meat Reach in Freezer #3. During an interview on 4/11/23, at 3:41 p.m., with the Registered dietitian (RD) regarding the observed concerns in the kitchen, the RD stated, part of the standard of practice as a RD was making sure the kitchen was safe and sanitary for food preparation and storage. The RD agreed that she did not perform the standard of practice and did not have effective oversight of kitchen practices. (Cross Reference F 812). During observations of dietary staff conducting day to day kitchen activities on 4/11/23, the following were observed: a. One of the dietary staff and the Dietary Manager did not know the right location to check dish machine sanitizer (Cross referred 802). b. One of the dietary staff and the Dietary Manager did not know the proper steps for washing dishes in two-compartment sinks (Cross referred 802). c. The AM [NAME] did not follow pureed bread recipe for preparing pureed bread during lunch on 4/11/23 (Cross referred 802 and 803). d. Dietary staff served 3-inch-long green bean salad for Residents on Dysphagia Mechanically Altered diet (a diet with food texture need to chop up or ground into small piece for residents who have limited chewing and swallowing ability) during lunch on 4/10/23 (Cross referred 802 and 805). e. Resident 25 received inappropriate coffee consistency during lunch on 4/10/23 (Cross referred 802 and 805). f. The Am [NAME] did not follow the recipe for making pureed meatball and noodle during lunch on 4/11/23 (Cross referred 802 and 805). g. Dietary staff served unpalatable, unattractive, and unappetizing temperature foods to ten residents (Cross referred 802 and 804). During an interview on 4/11/23, at 3:41 p.m., with the RD regarding above findings, the RD stated, she did not participate any in service for the dietary staff in this facility. The DM was responsible to do the in services to the dietary staff. The RD stated she had no idea how often the DM provided the in-services and what kind in-services the DM provided. Resident 49 and her family told staff including the RD that Resident 49 disliked chopped foods. No food upgrade options were provided for Resident 49 (Cross referred 806). Despite the RD documented weekly meetings acknowledging unplanned weight loss for Resident 41, there were no nutrition interventions from 3/13/23 until 4/4/23 for Resident 41. The RD recommended nutrition interventions on 1/11/23 and there was no effective monitoring of interventions after 5 weeks. There was no care plan that addressed Resident 41's weight loss and to prevent further weight loss (Cross referred 692). During an interview and record review on 04/12/23, at 11:12 AM, with the Administrator, the facility's Dietitian contract was reviewed. The Administrator acknowledged that the Registered Dietitian did not fully comply with her contract. During a review of the facility's Dietitian contract titled, EMPLOYMENT AGREEMENT, dated on 2/26/2022, the Dietitian contract indicated, DESCRIPTION OF SERVICES: Registered dietitian will provide the following services as many be requested by the facility: a. Employee shall maintain Facility's dietary functions pursuant to this Agreement in compliance with applicable laws and regulations, and assist Facility in providing therapeutic diets and meals as prescribed by the physician ., in a palatable and appetizing manner, and under safe and sanitary conditions . d. Employee shall review residents' care plans, if requests, e. Employee shall counsel residents and their families on special diets and nutritional assessments, as requested by facility. f. Employee shall provide guidance and training to the Food Service Director and dietary staff as required. g. Employee shall participate in the planning and conducting of in-service education programs related to Dietary rules, policies and procedures as requested by facility.k. Employee shall inspect all areas of the dietary department, including, but not limit to, sanitation, equipment functioning, food service operations and compliance with applicable federal, state, and local laws. Employee shall be available at various mealtimes to observe dining operations.

Based on observations, interviews and record reviews, the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. One of the dietary staff and the Dietary Manager did not know the right location to check dish machine sanitizer. This failure had the potential to cause foodborne illness for 46 out of 48 sampled residents who received food from the kitchen. 2. One of the dietary staff and the Dietary Manager did not know the proper steps for washing dishes in two-compartment sinks. This failure had the potential to cause foodborne illness for 48 out of 50 sampled residents who received food from the kitchen. 3. The AM [NAME] did not follow pureed bread recipe for preparing pureed bread during lunch on 4/11/23. This failure result in 12 out of 12 sampled residents who were on pureed bread received less nutritive value and unappetizing pureed bread. (Cross referred 803) 4. Dietary staff served 3-inch-long green bean salad for Residents on Dysphagia Mechanically Altered diet (a diet with food texture need to chop up or ground into small piece for residents who have limited chewing and swallowing ability) during lunch on 4/10/23. This failure had the potential to place the three out of six sampled residents who received 3-inch-long green bean salad at risk of choking. (Cross referred 805) 5. Resident 25 received inappropriate coffee consistency during lunch on 4/10/23. This failure had the potential to place the Resident 25 at risk of choking and aspiration. (Cross referred 805) 6. The Am [NAME] did not follow the recipe for making pureed meatball during lunch on 4/11/23. This failure had the potential to place the twelve out of twelve sampled residents on Dysphagia Puree diet (a diet with food texture need to blend until smooth into mashed potatoes consistency for residents who have severe chewing and/or swallowing ability) received chunks meatball at risk of choking. (Cross referred 805) 7. The Am [NAME] did not follow the recipe for making pureed noodle during lunch on 4/11/23. This failure had the potential to place the seven out of seven sampled residents received chunks noodle at risk of choking. (Cross referred 805) 8. Dietary staff served unpalatable, unattractive, and unappetizing temperature foods to residents. This failure had the potential to place the ten out of 48 sampled residents at risk of decrease nutritional intake. (Cross referred 804) These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food), negatively impact the residents' nutritional status and further in a medically compromised residents who received foods from the kitchen. Findings: (Cross referred F801, F803, F804, F805) 1. During a concurrent observations and interviews on 4/10/23, at 3:20 p.m., with Dietary Aide 1 (DA 1) and the Dietary Manager (DM), in dishwashing area, the DA1 tested the chlorine sanitation level of the dish machine by dipping a chlorine test strip inside the dish machine liquid once the dish machine was done washing. The DM stated, the appropriate location to test chlorine sanitation level for the dish machine was either dipping a chlorine test strip inside the dish machine liquid or on plate level. During an interview on 4/11/23, at 3:41 p.m., with the Registered Dietitian, the RD stated, appropriate location to test chlorine sanitation level for the dish machine was on dish rack (plate level) not by dipping a chlorine test strip inside the dish machine liquid. The RD stated, she never did any kind of in serve for the dietary staff in this facility. During a concurrent interview and record review on 4/13/23, at 9:03 a.m., with the DM, Chlorine Sanitizer Test Procedure for low-Temperature Dish Machine provided by the Sanitizer company was reviewed. The DM stated, according to the Chlorine Sanitizer Test Procedure for low- Temperature Dish Machine provide by the Sanitizer company, the appropriate location to test chlorine sanitation level for the dish machine was on plate level not by dipping a chlorine test strip inside the dish machine liquid. During a review of the facility's Job description titled, Dining Services Director/Account Manager (Dietary Manager), undated, the job description indicated, .POSITION SUMMARY . Must be able to perform the essential job functions of dietary aide, cook, and dishwasher positions for purpose of training and assisting when there are call-outs. During a review of the facility's Job description titled, Dietary Aide, undated, the job description indicated, .POSITION SUMMARY . washes dishes and clean and sanitizes kitchen according to health standards. 2. During a concurrent observations and interviews on 4/10/23, at 4:23 p.m., with DA 1, the DM and the Regional Certified Dietary Manager (RCDM), in front of two-compartment sinks in the kitchen, DA1 washed dishes by using two-compartment sinks. DA 1 stated, she filled first sink with soap and water then washed the dirty dishes. DA 1 stated, second step was to fill second sink with sanitizer and sanitize the dishes. DA 1 stated, the last step was rinsed the dishes by using hot water directly come out from tap. The DM stated, the proper steps by using two-compartment sinks were wash, sanitizer and rinse the dishes. The RCDM demonstrated the proper steps of washing dishes to DA 1 and the DM. The RCDM filled the first sink with soap and water washed the dirty dishes. Then RCDM filled the second sink with water for rinsing dishes and then she created another 3-compartment sink with using large container for sanitizing dishes. During an interview on 4/11/23, at 3:41 p.m., with the Registered Dietitian, the RD stated, appropriate steps of washing dishes by using 2 compartment sink was wash, rinse and sanitize. The RD claimed, she never in-serviced dietary staff in this facility on the proper steps of washing dishes by using two-compartment sinks. During a review of the facility's Job description titled, Dining Services Director/Account Manager (Dietary Manager), undated, the job description indicated, . POSITION SUMMARY . Must be able to perform the essential job functions of dietary aide, cook, and dishwasher positions for purpose of training and assisting when there are call-outs. During a review of the facility's Job description titled, Dietary Aide, undated, the job description indicated, .POSITION SUMMARY . washes dishes and clean and sanitizes kitchen according to health standards. 3. During a production observation on 4/11/23 at 11:51 a.m., with AM [NAME] (CK), in the kitchen, CK was observed pouring unmeasured hot water while preparing pureed bread. During an interview on 4/11/23, at 3:41 p.m., with the Registered Dietitian (RD), the RD stated, cooks needed to follow recipe by adding milk or broth not water for pureed bread. The RD further stated by adding water into pureed bread could dilute the nutritive value of the pureed bread and also affect the taste of the pureed bread. The RD stated, she never conducted in-services for the dietary staff in this facility. During a review of the facility's Job description titled, Dining Services Director/Account Manager (Dietary Manager), undated, the job description indicated, . JOB FUNCTION: People Management & Development . Supervises . all dining services employees in preparing and serving food Customer Service: insuring food is prepared by methods that . meets the needs of residents . Food preparation and safety: .Oversees and participates in the preparation and serving of food. During a review of the facility's Job description titled, Cook, undated, the job description indicated, . JOB FUNCTION: Food Preparation/Delivery. Prepares food by methods that conserve nutritive value and flavor. 4. During a concurrent dining observation on 4/10/23, between 12:16 p.m. until 12:56 p.m., in the dining room, Residents (11, 30, 42) who were on Dysphagia Mechanically Altered diet received 3-inch-long green bean salad. During an interview on 4/11/23, at 4:57 p.m., with the Registered Dietitian (RD), the RD stated, the 3-inch-long green bean salad was not the appropriate diet texture to serve residents on Dysphagia Mechanically Altered diet. The RD stated the 3-inch-long green bean salad was too big in size and residents were unable to chew on 3-inch-long green beans. The RD stated, the 3-inch-long green bean salad could potentially cause choking hazard. The RD stated, she expect dietary staff followed the vegetable chopped size described in diet manual for Dysphagia Mechanically Altered diet. The RD stated, she never did any kind of in serve for the dietary staff in this facility. During a review of the facility's Job description titled, Dining Services Director/Account Manager (Dietary Manager), undated, the job description indicated, . JOB FUNCTION: People Management & Development . Supervises . all dining services employees in preparing and serving food Customer Service: . insuring food is prepared by methods that . meets the needs of residents . Food preparation and safety: .Oversees and participates in the preparation and serving of food. During a review of the facility's Job description titled, Cook, undated, the job description indicated, . JOB FUNCTION: Food Preparation/Delivery. Prepares food for meals, including modified textures for restricted and therapeutic diets. Supervises dietary aides in the preparation and serving of foods . Insurers foods are .in the proper form to meet the individual needs of the residents. 5. During a concurrent dining observation, interview and meal tray ticket reviewed on 4/10/23, at 12:34 p.m., at dining room, with Certified Nurse Aide (CNA) 8, Resident 25 was observed serve unwell mixing regular consistency coffee with lumpy thickener on side and bottom of the coffee mug. Reviewed Resident 25's meal tray ticket indicated Resident 25 was on Honey thickened liquid. CNA 5 stated, the served coffee was not honey thick consistency. CNA 5 stated, the dietary staff did not mix the coffee well with the thickener so there was thickener lumps on the side and bottom of the coffee mug. The Dietary Manager (DM) confirmed Resident 25 was served unwell mixing regular consistency coffee with lumpy thickeners on side and bottom of the coffee mug. The DM stated, Resident 25 not supposed to have the coffee. During an interview on 4/11/23, at 5:10 p.m., with the RD, the RD stated, Resident on honey thick consistency received regular consistency coffee had potential risk of aspiration and choking. The RD expectation was dietary staff should follow Guidelines for Serving Thickened Liquids for thickening proper consistency liquid for Residents. The RD stated, she never did any kind of in serve for the dietary staff in this facility. During a review of the facility's Job description titled, Dining Services Director/Account Manager (Dietary Manager), undated, the job description indicated, . JOB FUNCTION: People Management & Development . Supervises . all dining services employees in preparing and serving food . Customer Service: insuring food is prepared by methods that . meets the needs of residents . Food preparation and safety: . Oversees and participates in the preparation and serving of food. During a review of the facility's Job description titled, Dietary Aide, undated, the job description indicated, .JOB FUNCTION: Food Preparation/Delivery . Prepares trays with hot .beverages as written on tray tickets. 6. During a concurrent observation and interview on 4/11/23, at 1:04 p.m., with the Dietary manager (DM) and District Dietary Manager (DDM), at dining room, a test meal was performed for the puree diet meal. During test meal, chunks of meatballs found in pureed meatballs. The DM and DDM were confirmed chunks of meatballs found in pureed meatballs. The DDM stated, the texture of pureed meatballs not supposed to have chunks. The DDM stated, the texture of pureed meatballs supposed to taste smooth. During a review of the facility's Job description titled, Cook, undated, the job description indicated, . JOB FUNCTION: Food Preparation/Delivery: Prepares food for meals, including modified textures for restricted and therapeutic diets. Insurers foods are . in the proper form to meet the individual needs of the residents. 7. During a concurrent observation and interview on 4/11/23, at 1:04 p.m., with the DM and DDM, at dining room, a test meal was performed for the puree diet meals. During test meal, chunks of noodle found in pureed noodle. The DM and DDM were confirmed chunks of noodle found in pureed noodle. The DDM stated, the texture of pureed noodle not supposed to have chunks. The DDM stated the texture of pureed noodle supposed to taste smooth. During a review of the facility's Job description titled, Cook, undated, the job description indicated, . JOB FUNCTION: Food Preparation/Delivery: Prepares food for meals, including modified textures for restricted and therapeutic diets. Insurers foods are . in the proper form to meet the individual needs of the residents. 8. During Residents' interviews on 4/10/23, 4/13/23 and Resident council meeting on 4/11/23. Ten residents (Residents' 6, 20, 23, 33, 39, 45, 48, 49,155, 353) stated, they received unpalatable, unappetizing, and cold foods. During a review of the facility's Job description titled, Dining Services Director/Account Manager (Dietary Manager), undated, the job description indicated, . JOB FUNCTION: . Customer Service: . insuring food is prepared by methods that . is palatable and attractive to residents, and of a quality that is acceptable to and meets the needs of the residents. During a review of the facility's Job description titled, Cook, undated, the job description indicated, . JOB FUNCTION: Food Preparation/Delivery: Prepares food by methods that conserves . flavor. Insurers foods are palatable, attractive . Prepare and serve meals that are palatable and appetizing in appearance. Customer Service: .insuring food is prepared by methods that . is palatable and attractive to residents, and of a quality that is acceptable to and meets the needs of residents. During a review of the facility's Job description titled, Dietary Aide, undated, the job description indicated, .JOB FUNCTION: Food Preparation/Delivery . Prepares trays with meals that are palatable and appetizing in apperance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There was no air gap (a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevents drain water from backing up into the sink and possibly contaminating the area used for washing food) under the prep sink (sink used to preparation of foods). 2. There was brown, grey and black debris observed several places in the kitchen: exit door to hallway, on the insect lamp, two ventilator's fans inside milk refrigerator, the exit door to the dining hall, in the dry storage room's storage shelves and door, the air conditioning and heating unit next to hand washing sink, the window, fans, ventilator in dishwashing area 3. There was calcium buildup on the dishwasher and ice machine's curtain. 4. There can opener and can opened based was unsanitary. 5. There was a red bucket filled with cleaning solution stored next to clean containers, clean utensils and food. 6. Trash, black and brown debris, food particles and black particles were found on the floor under the milk refrigerator, ice machine, dry storage, refrigerator #2 and the dishwashing area. 7. There was a torn gasket found on the milk refrigerator's door. 8. The milk refrigerator found grey and black debris on the shelving. 9. There was white substances, brown particles, and brown grime on the milk refrigerator's door. 10. Rust found in the milk refrigerator's storage shelves found rust, the refrigerator number (#) 2's storage shelves and inside microwave. 11. There was yellow, brown and black grime found inside the microwave. 12. There were black particles found in both ovens. 13. There were two marred cutting boards (red and brown color) found in the kitchen. 14. There were black and brown particles found on the toaster. 15. There were several opened bags of food items exposed to the air found in Veggie freezer and Meat freezer # 3. These failures had the potential for cross contamination and exposure of microorganisms (a microscopic organism, especially a bacterium, virus, or fungus) that harbor foodborne pathogens (a bacterium, virus, or other microorganism that can cause disease) of residents' food resulting in food-borne illness (stomach illness acquired from ingesting contaminated food) to a population of 46 out of 48 sample residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 4/10/23 at 10:28 a.m., with the Dietary Manager (DM), in the kitchen in front of the prep sink, there was no air gap under the prep sink. The DM stated, dietary staff used this sink for food preparation. The DM confirmed there was no air gap for the prep sink. During a concurrent observation and interview on 4/11/23 at 10:33 a.m., with the Maintenance Director (MD), in the kitchen in front of the prep sink, the MD verified there was no air gap under the prep sink. During an interview on 4/11/23 at 3:41 p.m., with the Registered Dietician (RD), the RD stated, I don't know what an air gap is. During a review of FDA (Food and Drug Administration) Food Code 2022, Section 5-203.14 Backflow Prevention Device , the FDA Food Code indicated, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap .; or (B) Installing an APPROVED backflow prevention device . 2. During a concurrent observation and interview on 4/10/23 at 9:34 a.m., with the DM, in the kitchen, an observation was made of black debris on and around the exit door to the hallway. The DM stated, Dust on and around the exit door. During a concurrent observation and interview on 4/10/23 at 9:34 a.m., with the DM, in the kitchen, an observation was made grey debris on the insect lamp. The DM confirmed the grey debris was dust on the insect lamp. During a concurrent observation and interview on 4/10/23 at 10:04 a.m., with the DM, in the kitchen inside the milk refrigerator, an observation of two ventilator's fans covered with black debris. There was foods and beverage stored under the two ventilator's fans. The DM confirmed the black debris covered with the two ventilator's fans was dust and dirt. During a concurrent observation and interview on 4/10/23 at 10:33 a.m., with the DM, in the kitchen in front of the exit door to the dining hall, an observation of brown debris on and around the door. The DM confirmed brown debris on and around the exit door were dust. During a concurrent observation and interview on 4/10/23 at 10:39 a.m., with the DM, in the dry storage room, black and brown debris were observed on the five storage shelves and around the dry storage room's door. The DM acknowledged black and brown debris were covered on the five storage shelves and around the dry storage room's door. During a concurrent observation and interview on 4/10/23 at 10:57 a.m., with the DM, in the kitchen in front of the air conditioning and heating unit next to hand washing sink, an observation was made of grey and black debris in the crevices of the unit. DM stated, Dust on the air conditioning and heating unit During a concurrent observation and interview on 4/10/23 at 11:20 a.m., with the DM, in the kitchen in front of the window, an observation of grey and black particles around the window seal. The DM stated, Dust on the window. During a concurrent observation and interview on 4/10/23 at 3:20 p.m., with the DM, in the kitchen in the dishwashing area, an observation of the fan above the sink had black and grey debris on the fan and around the edges. An observation of the ventilator had black and grey debris. DM stated, Dust on the fan and on the ventilator. During a concurrent observation and interview on 4/10/23 at 4:18 p.m., with the DM, in the kitchen in front of the prep sink, an observation of grey and black debris hanging from the fan above the prep sink. The DM stated kitchen should be clean without any black debris, grey debris, brown debris, dust, and black and grey particles. The potential risk had black debris, grey debris, brown debris, dust, and balck and brown particles was cross contamination. The DM stated, We have old people here with weak immune systems and they could get sick with cross contamination. During a review of FDA (Food and Drug Administration) Food Code 2022, 4-602.13 Nonfood-Contact Surfaces, the FDA Food Code indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During a review of the facility's policy and procedure (P&P) titled, Environment, revised 9/2017, indicated, POLICY STATEMENT: All food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary condition. PROCEDURES: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation .3. All food contact surfaces will be cleaned and sanitized after each use. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be clean, sanitary, and in proper working order. PROCEDURES: .3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. 3. During a concurrent observation and interview on 4/10/23 at 3:20 p.m., with the DM, in the kitchen in the dishwashing area, an observation of the dishwasher had white substances buildup on the dishwasher. The DM stated, the white substances was calcium buildup which not supposed to be there. During a concurrent observation and interview on 4/11/23 at 10:33 a.m., with the Maintenance Director (MD) and the RD, in the kitchen in front of the ice machine, an observation was made of white substances buildup on the curtain (a piece of plastic covered the ice maker where ice touch before ice travel to ice storage bin) of the ice machine. The MD stated, the white substances buildup on the curtain was calcium from hard water. The MD stated, the ice machine curtain not supposed to have calcium buildup. The RD verified the calcium build up on the curtain and agreed it should not have calcium build up in the ice machine. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be clean, sanitary . PROCEDURES: .3. All food contact equipment will be cleaned and sanitized 4. All non-food contact equipment will be clean . 4. During a concurrent observation and interview on 4/10/23 at 4:18 p.m., with the DM, in the kitchen in front of the can opener, the can opener based was observed had black build up and can opener's blade had white substances. The DM stated, the can opener should not have white substances on the blade and black build up on the based. The DM stated the potential risk for unsanitary can opener was cross contamination. During a review of the Food and Drug Administration (FDA) Food Code 2022, Can Openers section 4-204.19, indicated, Since the cutting or piercing surfaces of a can opener directly contact food in the container being opened, these surfaces must be protected from contamination. 5. During a concurrent observation and interview on 4/10/23 at 4:06 p.m., with the Regional Certified Dietary Manager (RCDM), in the kitchen, an observation of a red bucket filled with cleaning solution stored next to a bread product, clean utensils and six clean containers. The RCDM stated, the red bucket not supposed stored next to a bread product, clean utensils and six clean containers because it could cause cross contaminate. During a review of FDA (Food and Drug Administration) Food Code 2022, 7-201.11 Separation, the FDA Food Code indicated, Separation of poisonous and toxic materials in accordance with the requirements of this section ensures that food, equipment, utensils, linens, and single-service and single-use articles are properly protected from contamination. For example, the storage of these types of materials directly above or adjacent to food could result in contamination of the food from spillage. 6. During a concurrent observation and interview on 4/10/23 at 10:23 a.m., with the DM, in the kitchen under the milk refrigerator found black, grey debris and trash (paper, butter and white plastic spoon) on the floor. The DM confirmed there was trash, dirt and dust under the milk refrigerator. The DM stated under the milk refrigerator not supposed to have trash, dirt, and dust because it was sanitation issue. The DM expectation was floor in the kitchen need to be clean all the time. During a concurrent observation and interview on 4/10/23 at 10:31 a.m., with the DM, in the kitchen in front of the ice machine, an observation of trash, black debris and a dirty water pitcher under the ice machine. The DM verified there was trash, black debris and a dirty water pitcher under the ice machine. During a concurrent observation and interview on 4/10/23 at 10:40 a.m., with the DM, in the dry storage room, food particles and black debris were observed on the floor under storage shelves. The DM confirmed the food particles were oatmeal and black debris was dust. The DM stated, his expectation was dry storage room floor should be clean all the time; otherwise, it would attract pests. During a concurrent observation and interview on 4/10/23 at 11:02 a.m., with the DM, brown and black debris and trash were observed under the refrigerator #2. The DM confirmed brown and black debris and trash were observed under the refrigerator #2. During a concurrent observation and interview on 4/10/23 at 3:36 p.m., with the DM, in the dishwashing area, black particles buildup was observed on the floor. DM stated the black particles buildup were food buildup which could attract pest and promote mold grow. During a review of the facility's policy and procedure (P&P) titled, Environment, revised 9/2017, indicated, POLICY STATEMENT: All food preparation areas, food service areas and dining areas will be maintained in a clean and sanitary condition. PROCEDURES: 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors . 7. During a concurrent observation and interview on 4/10/23 at 9:57 a.m., with the DM, in the kitchen in front of the milk refrigerator, an observation was made of a torn gasket (rubber piece that lined) on the refrigerator door. The DM verified the torn gasket on the milk refrigerator's door. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be . in proper working order . 8. During a concurrent observation and interview on 4/10/23 at 10:04 a.m., with the DM, in the kitchen in front of the milk refrigerator, an observation was made of grey and black debris on the shelving. DM stated, there was dust on the shelving. The DM stated, those dust could cross-contamination the drinks and foods stored in the milk refrigerator. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be clean, sanitary . PROCEDURES: .3. All food contact equipment will be cleaned . 9. During a concurrent observation and interview on 4/10/23 at 9:57 a.m., with the DM, in the kitchen in front of the milk refrigerator, an observation was made of a white substances, brown particles and brown grime on the bottom of the refrigerator's door. The DM confirmed, the white substances, brown debris, and brown grime on the bottom of the door. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be clean, sanitary . 10. During a concurrent observation and interview on 4/10/23 at 9:57 a.m., with the DM, in the kitchen in front of the milk refrigerator. There was 4 storage shelves found had rust. There was food and drinks stored on those rust storage shelves. DM confirmed there was foods and drink stored on those 4 rusting shelves. The DM stated, Rust could cause cross contamination and get on the foods. During a concurrent observation and interview on 4/10/23 at 11:02 a.m., with the DM, in the kitchen in front of refrigerator #2, 8 storage shelves were observed had rust. The DM verified, there was rust on those 8 shelves in the refrigerator #2. During a concurrent observation and interview on 4/10/23 at 11:24 a.m., with the DM, in the kitchen in front of the microwave, inside the microwave was observed to have rust on top of microwave. The DM stated, rust inside the microwave could cause cross contamination and he expected the microwave should rust free. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be clean, sanitary, and in proper working order . 11. During a concurrent observation and interview on 4/10/23 at 11:24 a.m., with the DM, in the kitchen in front of the microwave, food particles, yellow, brown, and black grime were observed on the inside of the microwave. The DM stated, the yellow, brown, black grime and food particles inside the microwave was splashed from the foods. The DM stated, unsanitary microwave could cause cross contamination. The DM expected dietary staff keep the microwave clean. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be clean, sanitary . PROCEDURES: .3. All food contact equipment will be cleaned and sanitized after every use . 12. During a concurrent observation and interview on 4/10/23 at 3:54 p.m., with the DM, in the kitchen in front of the oven, an observation of black particles at the base of both ovens. The DM stated, The black particles are spilled from foods and grease. It is not expected to look like that and that could cause a fire. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be clean, sanitary . PROCEDURES: .3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. 13. During a concurrent observation and interview on 4/10/23 at 3:50 p.m., with the DM, in the kitchen, an observation of two cutting boards (red and brown color) with deep visible cuts on them. The DM admitted the red and brown color cutting boards were heavily marred and need replaced. During a review of FDA (Food and Drug Administration) Food Code 2022, Section 4-501.12 Cutting Surfaces, the FDA Food Code indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 14. During a concurrent observation and interview on 4/10/23 at 3:50 p.m., with the DM, in the kitchen in front of the toaster, the black and brown particles was observed on the toaster. DM stated, the toaster not supposed to have black and brown particles because it could cause cross contamination. During a review of the facility's policy and procedure (P&P) titled, Equipment, revised 9/2017, indicated, POLICY STATEMENT: All foodservice equipment will be clean, sanitary . PROCEDURES: .3. All food contact equipment will be cleaned and sanitized after every use . 15. During a concurrent observation and interview on 4/10/23 at 9:53 a.m., with the DM, in the kitchen in front of the Veggie freezer, an observation of an opened bag of corn kernels and rolled dough were not sealed and exposed to the air. The opened bag of corn kernels did not label open date. The DM stated, Opened bag food items in freezer supposed to be seal, otherwise cross contamination and freezer burn could happen. The DM confirmed opened bag of corn kernel did not label with open date. During a concurrent observation and interview on 4/10/23 at 3:08 p.m., with the DM, in the kitchen in front of Meat freezer #3, an opened packages of beef ravioli, pork sausage patties and biscuit dough were observed exposed to the air. The DM confirmed the opened packages of beef ravioli, pork sausage patties and biscuit dough. The DM stated, those opened packages needed to be seal. During a review of the facility's policy and procedure (P&P) titled, Food Storage: Cold Foods, revised 9/2017, indicated, POLICY STATEMENT: All time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. PROCEDURES: .5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .