Based on interview and record review the facility failed to ensure criminal background checks were completed prior to direct resident care employment for one of three direct care staff (Certified Nurse Assistant 1 [CNA 1]) when CNA 1's criminal background check was completed nine months after he was hired. This failure had the potential to result in resident abuse, neglect and/or mistreatment by hiring staff with possible criminal records.A review of the facility's document titled, General Orientation List, dated 1/17/23, indicated CNA 1's date of hire was 1/17/23. A review of an undated facility document titled, Background Report, indicated a background report was conducted on 10/16/23 for CNA 1 by the facility.During an interview on 7/30/25 at 3:32 p.m., the Director of Staff Development (DSD) verified CNA 1's date of hire was 1/17/23. The DSD confirmed CNA 1's background check was ordered after the employee was hired and began to work directly with residents in the facility. The DSD further stated, I don't have a good answer for you. Usually, I don't let anyone get an offer letter or start orientation until it [background check] is complete.A review of the facility's policy and procedure titled, Background Screening Investigations, dated 2019, indicated, Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents.Background and criminal checks are initiated within two days of an offer of employment or contract agreement, and completed prior to employment.

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were met for one of five sampled residents (Resident 1) when supervisory staff did not provide oversight and follow-up after Resident 1 did not receive any showers or baths for seventeen days.This failure had the potential to increase Resident 1's susceptibility to infections, skin problems, and negatively impact his mental health and activities of daily living (ADL, activities such as bathing, dressing and toileting a person performs daily).A review of Resident 1's admission record indicated he was admitted to the facility in May 2025 with medical diagnosis which included vertebrogenic low back pain (chronic low back pain originating from the vertebral endplates, the surfaces of the vertebrae that meet the intervertebral discs in the spine), absence of left leg above the knee, schizophrenia (a mental illness that is characterized by disturbances in thought), depression (depression (a mental health condition characterized by symptoms like sadness, loss of interest and low energy) and PTSD (Post traumatic stress disorder- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event).A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 5/23/25 indicated his Brief Interview of Mental Status (BIMS-a cognition [the processes of thinking and reasoning] assessment) score was 12, which indicated his cognition was moderately impaired (a score of 1-7 indicates cognition is severely impaired, 8-12 indicates cognition is moderately impaired, and 13-15 indicates cognition is intact). In addition, this document indicated Resident 1 had impairment on one side of his lower extremity (hip, knee, ankle & foot) and required substantial/maximal assistance (helper does more than half the effort) with showers and baths. Resident 1's MDS also indicated Resident 1 was wheelchair dependent for ambulation.A review of Resident 1's care plan report, initiated date 5/16/25, indicated, Skin: [Resident 1] is at risk for skin breakdown related to impaired mobility.[staff were expected to] Keep skin clean and dry to the extent possible.A review of Resident 1's care plan report, initiated date 5/17/25, indicated, Mood: [Resident 1] At risk for decreased psychosocial well-being and adjustment issues, emotional distress.[staff were expected to] Encourage participation in ADL's.A review of Resident 1's progress notes, type SBAR [Situation, Background, Assessment, and Recommendation] Summary for Providers, dated 7/03/25 at 10:12 p.m., indicated, Patient [Resident 1] c/o [complain of] pain to R [right] forearm, area assessed and observed to have redden protruding pimple with white head. Slight swelling with firm induration (hardening of tissue) peri pimple and tender to touch observed.A review of Resident 1's progress notes, type Skin/Wound Note, dated 7/7/25 at 2:13 p.m., indicated, This pimple area ruptured now presenting as a abscess. The area is open very bright red with yellow thin pus draining on dressing.with increased swelling forearm to down to hand.now order to start po (by mouth) ATB (antibiotics- a medication used to treat infections).A review of the facility's document titled Shower Schedule, dated 7/16/25, indicated Resident 1 was scheduled to shower on Wednesdays and Saturdays.A review of a facility document titled, Documentation Survey Report v2, for Resident 1 dated 6/1/25-6/30/25, indicated a shower or bath was given on 6/1/25, 6/3/25, 6/12/25, 6/23/25, and 6/26/25. This document indicated Resident 1 refused a shower/bath on 6/30/25. The remaining dates were documented as no (not scheduled for this shift).A review of a facility document titled, Documentation Survey Report v2, for Resident 1 dated 7/1/25-7/31/25, indicated a shower/bath was given on 7/13/25. This document indicated Resident 1 refused a shower/bath on 7/10/25 and was unavailable on 7/3/25, and 7/11/25. The remaining dates were documented as no (not scheduled for this shift).During an interview on 7/31/25 at 1:30 p.m., Certified Nurse Assistant 2 (CNA 2) stated when she offered showers to Resident 1 he would tell her Later. CNA 2 further stated, I will follow up with the resident, but he will continue to say Later and then it's another shift and I did not get to it. During an interview on 7/31/25 at 2:30 p.m., Resident 1 stated, It's been a few weeks since I've taken one [a shower], yesterday was the first time in two weeks. Resident 1 further stated, Since the incident [a reported allegation of abuse that occurred in the shower room between himself and a direct care staff member], I'm just not comfortable with it.During an interview and concurrent record review on 8/1/25 at 10:55 p.m., the Director of Nursing (DON) stated the Director of Staff Development (DSD) was responsible for overseeing and auditing (examine) shower check offs. The DON further stated, If showers have not been given, the DSD should interview the nurse and the resident about it. The DON reviewed Resident 1's Documentation Survey Report v2, dated 6/1/25-6/30/25, and verified, based on the documentation, Resident 1 did not receive a shower or bath between the dates of 6/4-6/11 [indicating eight days without bathing], and 6/13-6/22 [indicating ten days without bathing]. The DON reviewed Resident 1's Documentation Survey Report v2, dated 7/1/25-7/31/25, and verified, based on the documentation, Resident 1 only received one shower or bath for the entire month of July. The DON confirmed all other dates were documented as no (not scheduled for this shift). The DON stated, According to the documentation it appears the resident has not been receiving his showers and it's not documented as refused. The DON further stated, If they [the resident] refuse, the CNA is expected to tell the nurse and they [CNA] need to document it as refused.During an interview and concurrent record review on 8/1/25 at 11:31 a.m., the DSD stated she was responsible for auditing the shower check offs, and further stated, Auditing has been a hit and miss. The DSD stated residents were supposed to receive showers twice a week. The DSD stated, We don't want them to go more than a week without a shower, because of skin issues, amongst other things that can happen. The DSD reviewed Resident 1's Documentation Survey Report v2, dated 6/1/25-6/30/25, and stated, Oh my goodness.yeah, 11 days or more.he's gone too long without a shower. That doesn't look good. The DSD reviewed Resident 1's Documentation Survey Report v2, dated 7/1/25-7/31/25, and confirmed a shower was documented as given on 7/13/25 and documented as no (not scheduled for this shift) for the remaining month through 7/30/25. The DSD verified Resident 1 did not receive a shower or bath for seventeen consecutive days. The DSD confirmed Resident 1's lack of bathing could be an underlying psychosocial (a combined influence of psychological [the mental and emotional state of a person] factors and the surrounding social environment on physical, emotional, and/or mental wellness) concern. A review of the facility's policies and procedure (P&P) titled Activities of Daily Living (ADL), Supporting dated 2001 indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.Residents will be provided with care, treatment and services to ensure their ADLs do not diminish.Appropriate care and services.including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).Interventions to improve or minimize a resident's functional abilities will be in accordance with.recognized standards of practice.The resident's response to interventions will be monitored, evaluated, and revised as appropriate.A review of the facility's P&P titled Bath, Shower/Tub dated 2001 indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin.Reporting.Notify the supervisor if the resident refuses to shower/tub bath.Report other information in accordance with facility policy and professional standards of practice.A review of the facility's document titled Job Description: Certified Nursing Assistant dated 2024 indicated, The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessments and care plan.

Based on observation, interview, and record review, the facility failed to ensure resident care met professional standards for one resident (Resident 1) of eight sampled residents when following Resident 1's unwitnessed fall nursing and neurological (neuro, relating to the nervous system, includes: brain, spinal cord, and nerves) assessments were not conducted, monitored, or documented in Resident 1's medical record. These failures had the potential to misrepresent Resident 1's actual condition status post (after) fall, which could lead to a delay in treatment and other negative outcomes. Findings:A review of Resident 1's admission record indicated admission to the facility in September 2024 with diagnosis of malignant neoplasm (a cancerous tumor) of unspecified part of the left lung. A review of a Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 9/20/24, indicated Resident 1: Had moderate cognitive (relating to or involving the processes of thinking and reasoning) impairment; Required substantial/maximal assistance (helper does more than half the effort) sit to lying, sit to stand, chair/bed-to-chair transfer, toilet transfer, walk 10-50 feet; and, Was wheelchair dependent.A review of Resident 1's care plan initiated on 9/17/24 indicated, Falls: Resident is at risk for falls with or without injury related to weakness. A review of Resident 1's Situation, Background, Assessment and Recommendation (SBAR, a communication technique used in healthcare to facilitate clear and concise information) progress note dated 9/19/24 at 11:33 p.m., indicated Resident 1 had an unwitnessed fall on 9/19/24 at 10:45 p.m. A review of Resident 1's SBAR Communication form dated 9/19/24 indicated, Resident/Patient Evaluation.Functional Status Evaluation [check marked] Falls.Skin Evaluation [check marked] Not clinically applicable to the change in condition being reported.Pain Evaluation [check marked] Not clinically applicable to the change in condition being reported.Neurological Evaluation [check marked] Not clinically applicable to the change in condition being reported. The form further indicated, APPERANCE- Summarize your observations and evaluation: Per report given this morning, [Resident 1] had an unwitnessed fall on 9/19/24 at 10:45 p.m. [Resident 1] was found on the floor in her room, next to her bed and the wall. A review of Resident 1's care plan report initiated on 9/19/24 indicated, Resident had unwitnessed fall found lying on her back.Interventions/Tasks [for nursing staff to implement included] Neuro assessment, nursing assessment. During an interview on 7/21/25 at 3 p.m., the Director of Nursing (DON) stated if a resident had an unwitnessed fall, post fall protocol indicated neuro checks would be initiated automatically. The DON stated the expectation was for neuro checks to be completed every 15 minutes (min) for the first hour (hr), every 30 min. for one hr., every hr. for four hrs., and then every four hrs. for 24 hrs. and documented on a neurological flow sheet. The DON stated, The reason neuro checks are conducted after an unwitnessed fall is because we [facility staff] are not sure if the resident hit their head or not. We [facility staff] want to make sure they [the resident] are monitored and to make sure there is no initial or lasting effects indicating any kind of brain injury. The DON stated it was her expectation for 72 hr monitoring to be conducted at least once a day and documented in the resident's progress notes after a fall was reported. During an interview and concurrent record review on 7/22/25 at 1:05 p.m., the Licensed Nurse 1 (LN 1) stated it was expected for licensed nurses to initiate monitoring with vital signs, neuro assessments, and a nursing assessment following a resident fall every 15 minutes (Q 15 min). LN 1 stated the nursing assessment included an assessment for injury, pain, and any changes to skin (ex: bruising and swelling) and the assessment should be documented when completing the resident's Change of Condition (COC) or SBAR report. LN 1 further stated neuro assessments were expected to be conducted for 72 hrs. post fall and COC progress notes would be completed up to 3 days and documented under the resident's progress notes. LN 1 reviewed Resident 1's progress notes dated 9/19/24 to 9/21/24 and confirmed there were no COC 72 hr. progress notes for Resident 1 status post fall. During an interview and concurrent record review on 7/22/24 at 2 p.m., the DON reviewed Resident 1's SBAR report dated 9/19/25 and confirmed pain, skin, neuro, and appearance should have been thoroughly assessed. The DON further confirmed the nursing assessment was not adequate. After a review of Resident 1's medical record, the DON stated, There is no proof of neuro checks being complete following the fall based on the lack of documentation. A review of the facility's policies and procedure (P&P) titled Change in a Resident's Condition or Status dated 2001 indicated, .the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication form.A review of the facility's P&P titled Assessing Falls and Their Causes dated 2001 indicated, If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities.Observe for delayed complications of a fall for approximately forty-eight hours.and document findings in the medical record.Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility; and any changes in the level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings.

Based on interview and record review, the facility failed to provide services that met professional standards of quality for one resident (Resident 1) of three sampled residents when prescriber order to hold a blood pressure (BP - the force of your blood pushing against blood vessels) medication when BP measurement was below a certain parameter was not followed.This failure had the potential for Resident 1 to become hypotensive (low blood pressure) and experience dizziness, lightheadedness, fatigue, visual disturbances, and/or fainting, especially when standing up quickly.Findings:A review of Resident 1's admission record indicated admission to the facility on 6/6/25 with diagnoses including lung cancer, chronic lung disease, heart failure, and hypertension (HTP- high blood pressure).A record review of Resident 1's Medication Administration Record (MAR) dated June and July 2025 indicated an order for doxazosin mesylate (a medication used to control high blood pressure) oral tablet 2 milligrams (mg - a unit of measure), give 1 tablet by mouth at bedtime for HTN, hold if Systolic Blood Pressure (SBP - the higher number on a blood pressure reading) was less than 100 or pulse (P - heart rate) was less than 60. These MARs also indicated doxazosin mesylate was administered to Resident 1 on the following days: 6/23/25 with an SBP of 99; on 6/25/25 with an SBP of 93; and, on 7/2/25 with an SBP of 96. During a concurrent interview and record review on 7/18/25 at 1:28 p.m., Licensed Nurse A (LN A) stated parameters for BP medication were provided to prevent a resident's BP from becoming too low. LN A stated symptoms of low BP included lethargy and/or dizziness. When shown a copy of Resident 1's MAR dated June 2025 and July 2025, LN A stated she would have held the doxazosin mesylate on 6/23/25, 6/25/25, and 7/2/25 because the resident's SBP was below the ordered parameter for administration. LN A further stated it was important to follow the physician's orders, especially for critical medications. LN A stated BP medications were considered critical medications. During a concurrent interview and record review on 7/18/25 at 1:50 p.m., the Director of Nursing (DON) stated LNs were expected to check the resident's BP before administering BP medications for accuracy. The DON stated the physician wrote parameters because some BP medications can drop the BP and/or the heart rate. The DON stated signs of hypotension were dizziness, lethargy, and/or fainting. When shown Resident 1's MAR dated June 2025 and July 2025, the DON stated she expected the doxazosin to have been held on 6/23/25, 6/25/25, and 7/2/25. The DON further stated the LN did not follow the physician's orders if the doxazosin mesylate had been administered despite SPB being outside of the ordered parameters.A record review of the facility's policy titled, Administering Medications revised in April 2019, indicated, The director of nursing services supervises and directs all personnel who administer medications and.medications are administered in accordance with prescriber orders.

Based on interviews and record reviews the facility failed to provide services that meet professional standards for one of three sampled residents (Resident 1), when Resident 1 was administered glucose gel (medical product used to treat low blood sugar levels) in his mouth while unresponsive and unable to follow directions. The failure had the potential to cause Resident 1 to choke on or aspirate (accidental entry of food, liquid or other material into the lungs) the glucose gel. Findings: During a review of Resident 1 ' s admission record indicated, Resident 1 was admitted to the facility in February 2025, with a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). A review of Resident 1 ' s care plan titled, Diabetes ., initiated on 2/20/25, indicated, .Resident has a diagnosis of diabetes and is at risk for complications . with goals including, .will minimize the risk for complication of diabetes to the extent possible . During an interview on 5/15/25 at 1:22 p.m., Paramedic 1 (PMD 1) stated he responded to a 911 call a for a hypoglycemic emergency on 4/26/25. PMD 1 stated upon arriving at the facility he observed Resident 1 unconscious with clear gel around his mouth and in his mouth, and with a blood glucose level measuring in the low 30s mg/dL (milligrams per deciliter, a unit of measure used for sugar in blood). The paramedic added, the nurse who was in the room with Resident 1, stated she gave Resident 1 glucose gel into his mouth, despite him being unconscious. The paramedic explained, giving glucose gel in the mouth while the resident was unconscious, created a choking or aspiration (accidental entry of food, liquid or other material into the lungs) risk. The paramedic stated, to be aligned with professional standards, he expected a glucagon injection (an emergency medicine used through syringe/need a to treat hypoglycemia for situations where someone cannot take glucose/sugar by mouth) should have been administered to Resident 1 while unconscious. An interview on 5/15/25 at 2:31 p.m., Resident 1 stated on 4/26/25 he had very low blood sugar, measured in the low 30s mg/dL, doesn ' t remember much about the emergency, but remembered waking up in the ambulance on the way to the hospital. An interview on 5/15/25 at 3:01 p.m., the Director of Nursing (DON) confirmed on 4/26/25 Resident 1 experienced a hypoglycemic emergency which rendered Resident 1 unconscious. The DON stated the Lead Nurse (LN 1) called 911 and Resident 1 was ultimately taken to the hospital for care related to his low blood sugar. An interview on 5/15/25 at 3:13 p.m., Licensed Nurse 1 (LN 1) stated she was the Lead Nurse on 4/26/25 when at approximately 10:30 a.m. she was alerted that Resident 1 was found unconscious. LN 1 confirmed Resident 1 was unresponsive . he could not follow commands . he did not respond to voice, and she gave Resident 1 glucose gel in the mouth to try to bring up his blood sugar. An interview on 5/15/25 at 3:47 p.m., LN 4 stated he has been trained when a resident is found unconscious or unresponsive in a hypoglycemic emergency, he would, give a glucagon needle shot . there is a glucagon needle shot in every medication cart . it ' s in the [facility ' s] policy. LN 4 added giving glucose gel in an unresponsive or unconscious resident ' s mouth would be a risk for aspiration or choking. A review of the facility ' s policy and procedure titled, Management of Hypoglycemia, revised March 2025, indicated, .To provide guidelines for managing hypoglycemia . in the diabetic resident .signs and symptoms of hypoglycemia .may include .(more severe) .unconsciousness . Level 3 hypoglycemia: altered mental and/or physical status requiring assistance for treatment . if a resident has Level 3 hypoglycemia and is unresponsive .administer 1 mg of glucagon subcutaneously [into the layer of tissue just beneath the skin] .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet the requirements for a safe discharge for one of three sampled residents (Resident 1) when Resident 1 was discharged due to being unable to get a ride back to the facility at the agreed upon return time during an approved leave. This failure resulted in emotional distress for Resident 1 as she did not have access to equipment for safe ambulation (walking) or her essential medications (medications ordered by a physician for treating/and or preventing symptoms of a significant health condition). Findings: A review of Resident 1's admission record indicated she was admitted on [DATE] with diagnoses including type 2 diabetes (a chronic condition characterized by difficulty in blood sugar control and poor wound healing), acute and chronic respiratory failure (a serious condition that makes it difficult to breathe on your own. It develops when the lungs can't get enough oxygen into the blood), acute kidney failure (a sudden and significant decline in kidney function that leads to an accumulation of waste products in the blood), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), anxiety disorder (a mental health disorder where a person experiences frequent, intense, excessive, and persistent worry and fear about everyday situations), muscle weakness, need for assistance with personal care, hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), and hypertension (HTN-high blood pressure). A review of a document titled Order Summary Report for Resident 1 indicated the following medication orders: Albuterol Sulfate Aerosol Solution (a medication breathed through the mouth to open the air passages in the lungs), 1 puff every 4 hours as needed for shortness of breath /wheezing (a high-pitched whistling sound that occurs when air flows through narrowed airways in the lungs); Aspirin Oral Tablet (a medication used to prevent a heart attack or stroke) Chewable 81 mg (milligram, a unit of measure), give 1 tablet by mouth one time a day; Atorvastatin Calcium (a medication used to lower cholesterol [a fat like substance found in all the cells of the body] and prevent heart attacks and strokes) Oral Tablet 40 mg, give 1 tablet by mouth at bedtime; Bupropion HCL Tablet Extended Release (a medication used to treat depression) 12-hour 100 mg, give 1 tablet by mouth two times a day; Fluoxetine Capsule (a medication used to treat depression) 10 mg by mouth one time a day; Insulin Glargine (an injectable medication used to treat high blood sugar in individuals with diabetes)100 unit/ml (milliliter, a unit of measure) solution pen injector, inject 17 units subcutaneously (under the skin) at bedtime; Lorazepam (a medication used to treat anxiety) Oral Tablet 0.5 mg, give 1 tablet by mouth every 8 hours as needed; Lyrica (a medication used to treat neuropathic pain [pain that occurs when there is damage to your nerves due to disease or injury]) Oral Capsule 75 mg, give 1 capsule by mouth 2 times a day; Methocarbamol (a medication used to treat muscle pain and stiffness) Oral Tablet 500 mg, give 3 tablets by mouth two times a day; and, Metoprolol Tartrate (a medication used to treat high blood pressure) Tablet 25 mg, give 1 tablet by mouth two times a day. During an interview on 3/19/25 at 2:15 p.m., Resident 1 stated she had been on an approved leave from the facility when her ride/driver received an emergency call and was unable to drive her back to the facility. Resident 1 stated she called the facility and explained the situation. Resident 1 received a call from the facility the following afternoon and was informed she had been discharged from the facility. Resident 1 stated she begged them to let her come back to the facility. Resident 1 further stated she had a cane but needed a walker. Resident 1 also stated she did not have her medications, and the facility refused to provide them. Resident 1 stated she had suffered two strokes in an acute care facility prior to transferring to the current facility. Resident 1 stated she had no access to care, she was experiencing withdrawal symptoms from her medications, and she was very scared. Resident 1 was crying during the interview. A record review of Resident 1's Care Plan Report, initiated 2/20/25, indicated under focus area of Discharge/Transfer, the following interventions: Assess residents needs for discharge; coordinate durable medical equipment (DME - reusable medical devices and equipment prescribed by a healthcare provider to assist with treatment, monitoring, or management of a medical condition or disability), pharmacy, home health, and/or in home support services; nursing to provide discharge instructions and education for all physician orders including but not limited to level of activity, medications, and follow up appointments; provide community resources for discharge needs; provide post-discharge plan of care in a language that caregivers and resident can understand. During an interview on 3/19/25 at 4:18 p.m., the Social Services Director (SSD) stated Resident 1 had a planned discharge on [DATE]. The SSD stated Resident 1 was on an approved leave on 3/11/25 and wanted to come back to the facility and not be discharged . The SSD further stated Resident 1 told him her ride was unavailable due to an emergency with her ride's family member. During an interview on 3/19/25 at 5:10 p.m., the Director of Rehabilitation (DOR) stated Resident 1 had been discharged from Physical Therapy Services (PT - a healthcare profession focused on promoting, maintaining, or restoring health through movement, exercise, and patient education) but had not been discharged from Occupational Services (OT - a healthcare profession focused on developing and improving skills that are needed to live life as independently as possible). The DOR further stated the rehabilitation department had planned to order Resident 1 an ankle foot orthosis (AFO - a medical device, often a brace, designed to support and improve the function of the foot and ankle) for left foot drop (a condition where the muscles that lift the front of the foot are weakened or paralyzed). During an interview on 3/19/25 at 5:10 p.m., the director of Nursing (DON) stated the facility received a phone call from a friend of Resident 1 and the friend explained he had an emergency with a family member and was unable to drive Resident 1 back to the facility. When asked if Resident 1 left the facility against medical advice (AMA) the DON stated AMA was when a resident left the facility even though they were advised not to for medical reasons. The DON stated this did not apply to Resident 1 as she wanted to stay in the facility. During an interview on 3/19/25 at 6 p.m., the DON stated when residents were discharged from the facility the nursing department ensured adequate medications were on hand and provided to the resident on the day of discharge. During an interview on 3/20/25 at 10:10 a.m., Licensed Nurse B (LN B) stated the facility had a consistent process for discharging residents. When the nursing department was notified of an upcoming discharge, they called the pharmacy and ordered enough medications for the resident to transition to home or another facility. The goal was for the discharged resident to have time to get their medications from their primary care provider (PCP) at their usual pharmacy. The discharging nurse provided education to the resident regarding dosage, timing, and any special considerations such as blood pressure parameters (refers to keeping blood pressure within a safe range). Certain medications prescribed to Resident 1 were considered essential and therefore vital to maintaining Resident 1's well-being. LN B stated Resident 1 had been taking a medication for blood clot prevention and medications for depression. LN B further stated it had not been safe for Resident 1 to suddenly stop taking antidepressant medication as this could have caused a deeper depression, suicidal ideation (thoughts or ideas centered around death or suicide), and interference with mental stability and daily life. During an interview on 3/20/25 at 10:55 a.m., Licensed Nurse C (LN C), LN C stated the facility procedure had been to order medications from the pharmacy four to five days before a discharge. LN C stated Resident 1 should have continued her medications after she was discharged from the facility. LN C further stated Resident 1 had an order for insulin, which was considered an essential medication to treat diabetes. LN C stated Resident 1 could have suffered from hyperglycemia (high blood sugar) if she did not have insulin available. LN C also stated it was standard practice for a physician to taper (gradually decrease) the dose of an antidepressant instead of stopping it suddenly. LN C stated stopping an antidepressant suddenly could have affected Resident 1's mental health and Resident 1 could have experienced withdrawal effects such as insomnia (inability to sleep), mood swings, agitation, and sweating. During an interview on 3/20/25 at 11:30 a. m. Licensed Nurse D (LN D) stated Resident 1 had been prescribed essential medications. LN D stated aspirin, atorvastatin, and metoprolol were important to prevent high blood pressure and decrease Resident 1's risk for another stroke. LN D stated insulin was an essential medication for Resident 1 to prevent hyperglycemia. LN D also stated Resident 1's medications for depression should have been tapered to prevent increased feelings of depression. During an interview on 3/20/25 at 12:55 p.m. the DOR stated he had seen Resident 1 in front of the facility with a single cane. The DOR stated the facility only issued quad canes (a mobility aid featuring a four-point base for enhanced stability, offering more support than a standard cane, and designed for individuals with limited mobility or balance issues) when a resident was discharged . He further stated quad canes were a lot safer than single canes for ambulation. The DOR stated the Interdisciplinary Team (IDT - a team of healthcare providers that collaborate on health care planning) decided what was necessary for a home discharge and arranged for equipment to be supplied. The DOR confirmed Resident 1 did not receive any DME when discharged from the facility. A record review of the facility policy titled, Transfer or Discharge, Facility-Initiated, revised October 2022, indicated, Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: a. the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility b. the transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility c. the safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident d. the health of individuals in the facility would otherwise be endangered e. the resident has failed, after reasonable and appropriate notice, to pay for (or have paid under Medicare or Medicaid) a stay at this facility f. the facility ceases to operate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure two residents (Resident 1 and Resident 2) of three sampled residents had access to a telephone, to make private calls with friends and family. The facility only had one working wireless telephone for resident use, and this phone could not be located during an onsite visit on 1/30/25. This failure decreased the facility's potential to ensure residents, including those who were bedbound, were to free to speak to family members or acquaintances in private. Findings: Record review of Resident 1's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Fracture of Right Femur (Broken thigh bone, right leg) and Chronic Obstructive Pulmonary Disease (A chronic lung disease that causes ongoing inflammation and narrowing of the airways, leading to difficulty breathing). During an observation on 1/29/25 at 6:15 p.m., the Surveyor attempted to reach Resident 1 by phone, at the facility ' s official phone number. The phone was never answered, therefore Resident 1 could not be reached. During an interview on 1/30/25 at 8 a.m., Family Member X stated she was unable to get through to Resident 1 by phone. Family Member X stated she had attempted multiple times but either facility staff did not pick up the phone; staff left her on hold indefinitely; or she was notified by staff she could not be transferred to Resident 1 because the resident phone could not be located. Family Member X stated she did not live in the area and could not visit the resident in person and was concerned about this situation. During three observations on 1/29/25 at 8:18 a.m., 8:22 a.m. and 8:25 a.m., the Surveyor attempted to reach Resident 1 by phone at the facility ' s official phone number, but the phone was never answered. During a concurrent interview and record review on 1/30/25 at 10:08 a.m., the Director of Nursing (DON) stated the facility two of the three phones used for residents to receive and make calls were no longer working. The DON could not locate the only active phone for resident use. The charging base was in the nursing station, but the phone was not there. During an interview on 1/30/25 at 10:30 a.m., with the DON present, Unlicensed Staff A stated the wireless resident phone was not charging and could not be located since the beginning of her shift that day which started at around 8:30 a.m. Unlicensed Staff A stated on most days, the wireless resident phone was not charging when she arrived at work. Unlicensed Staff A stated she located the phone by dialing the phone number, to see if somebody answered it, or physically looked for it around the facility. Unlicensed Staff A stated if a family member were to call at this time to speak to a bedbound resident, she would not be able to transfer the call and would have to explain the situation with the phones to the calling family member. During an interview with Unlicensed Staff B on 1/30/25 at 12:08 p.m., he stated residents had complained about not being able to use a phone to make calls. Unlicensed Staff B stated he believed the facility had two wireless resident phones, but they frequently got lost and staff had to look for them room to room. Unlicensed Staff B stated he believed the facility needed more resident phones. During an interview with Resident 1 on 1/30/25 at 12:45 p.m , he confirmed being unable to use the wireless resident phone to make or receive personal phone calls and added facility staff did not notify him when he received outside calls. Resident 1 stated if he wanted to make a call, he either had to use the land phones in the nursing station, which did not provide him with privacy, or borrow another resident ' s cell phone. Resident 1 stated outside phone calls were not transferred to him. During an interview with Resident 2 on 1/30/25 at 1 p.m., he stated the wireless phone for resident use was never available, and the only way for him to make calls was using the land phones in the nursing station. Resident 2 stated calls made at the nursing station were not private as everybody in the nursing station could hear his conversations. Record review of the facility policy titled, Resident Rights, last revised in August of 2009 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to .Use a telephone in privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review [AES1] the facility failed to provide pain medicine in the form of a cream (lidocaine) for one out of two sampled residents (Resident 1). This failure potentially caused Resident 1 pain and further suffering by missed medication administrations. Findings: During a review of Resident 1 ' s admission Record, dated 1/23/2007, indicated Resident 1 had initially been admitted to the facility on [DATE] with a medical history of stroke (blockage of blood supply in parts of the brain), quadriplegia (as defined as the dysfunction or loss of motor and sensory function of the cervical area [AES3] of the spinal cord, leading to partial or total loss of function in the arms legs, trunk and pelvis) and high blood pressure. During an interview with Resident 1 on 6/13/24 at 10:38 a.m., Resident 1 stated the medication, Lidocaine (ointment type cream which when applied relieves pain) Ointment was to be administered two times a day and it had not been administered for days and the facility was giving excuses like it been refused (by resident) or it was back ordered. Resident 1 stated when the medication had not been applied, to the buttocks area and could be painful. During a concurrent review of Resident 1 ' s, Medication Administration Record and Physician orders, for the month of Jun, 2024 indicated Resident 1 was administered Lidocaine External Ointment 5%, two times a day (06:30 am, 9pm) on 6/1/24. The Medication Administration Record indicated on 6/2/24 both am and pm doses had a code of nine (indicating the medication was not administered), 6/3/24 the am dose documentation space was left blank, indicating the medication had not been given and at 9 pm, the same code of 9 was documented. On 6/4/24 at 06:30 am the same code of nine was documented but the 9 pm dose was documented to be given as ordered. During a concurrent observation and interview on 6/13/24 at 3:30 pm, at the medication cart , with Licensed Staff A, Licensed Staff A indicated by pulling out a drawer that Resident 1 had a tube of Lidocaine cream with Residents 1 ' s name and prescription information on the tube. The tube filled with medication appeared to be almost full and when Licensed Staff A was asked when would the medication be re-ordered, Licensed Staff A indicated by gesturing, using the thumb and index finger when the top was approximately 1/3 left of the medication and would be re-ordered so it would not run out. Licensed Staff A reviewed the Medication Administration Record, dated 6/1/24 to 6/4/24 and stated the code documented on 6/2/24, 6/3/24 and 6/4/24 meant the medication had not been administered. Licensed Staff A indicated on the Medication Administration Record, dated 6/1/24 to 6/4/24 was reviewed and stated the code documented on 6/2/24, 6/3/24 and 6/4/24, indicated the code meant the medication had been re-ordered but had not yet arrived at the facility. Licensed Staff A stated Resident 1 had received the medication on 6/4/24 at the 9 pm dose but had missed the 6:30 am dose. Licensed Staff A could not explain when the medication had been originally re-ordered but there was documentation to indicate the medication had to be re-ordered for a second time on 6/3/24 and was delivered after the 6:30 am dose and prior to the 9 pm. dose. During an interview on 6/13/24 at 3:35 pm. with Director of Nursing (DON), DON indicated the Lidocaine cream for Resident 1 had been ordered on 6/1/24 (when last dose administered) and then had to be re-ordered again, on 6/3/24 and was then delivered on 6/4/24 (this timeline explains why Resident 1 did not receive the doses of lidocaine cream). DON could not explain why the medication had not been re-ordered prior to the medication running out and would not explain the outcome of not having the medication. There was no documentation that indicated when did Resident 1 ran out of Lidocaine cream or when the Lidocaine cream was ordered to the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that Licensed Nurses and Unlicensed nurses received competency (Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) training and techniques necessary to install a bed alarm pad and to request for an order for bed alarm from the resident ' s doctor before installing for one resident, Resident 1 when: The Director of Staff Development (DSD) did not provide adequate training to staff on how to correctly place a bed alarm. This failure resulted in staff incorrectly placing the bed alarm to Resident 1 ' s bed which potentially caused the alarm to not sound off in order to alert the staff when was getting out of bed. Findings: A review of records for Resident 1 revealed, she was recently readmitted to the facility on [DATE] from the hospital due to left knee fracture after a fall in the facility. Resident 1 had a Brief Interview Mental Services (BIMS) score of 9 which indicated, she ' s not cognitively intact. Resident 1 takes a blood thinner medication for heart condition. Resident 1 had fractures due to falls on 3/15/2022, 5/17/22, 9/10/22 and a fall without injury on 9/25/22. During an observation on 9/26/2022 at 4:35 p.m., Resident 1 ' s room was in the middle of the hallway, not near the nurse ' s station. Resident 1 was sleeping on her bed near the window, and the bed was in a low position, had a floor mat, a chair alarm on a wheelchair, and a bed alarm was not observed attached to the bed. During an interview on 9/26/2022 at 4:40 p.m., Licensed Staff A stated that any resident who was at fall risk, the management would discuss preventions at every morning meeting and would discuss with the resident's family. Licensed Staff A stated, to prevent falls, in resident ' s room, the bed would be in a low position, a floor mat would be placed, a bed alarm would be placed, and a chair alarm would be placed, and the resident would received a rehabilitation evaluation. During a concurrent observation and interview on 9/26/2022 at 4:45 p.m., Unlicensed Staff B stated, when a resident was a high risk for fall, the bed must be in a low position, needs a floor mat, a bed alarm without a clip (a long metal chain with snaps that connected resident ' s nightgown and to bed alarm) attached to the clothing. Unlicensed Staff B showed the bed alarm placement for Resident 1 and found the bed alarm pad underneath the mattress. Unlicensed Staff B stated that the bed alarm pad was placed incorrectly. Unlicensed Staff B stated, the bed alarm pad must be on top of the mattress under a sheet and should be directly under Resident 1. Unlicensed Staff B stated that the alarm pad must be under the sheet, so when Resident 1 attempted to get out of bed, the alarm would go off and that would alert the staff that Resident 1 was getting out of bed. Unlicensed Staff B stated, only Resident 1 had a bed alarm in the facility. Unlicensed Staff B stated that the morning unlicensed staff placed the bed alarm pad under the mattress. During a concurrent observation and interview on 9/26/2022 at 4:50 p.m., this Surveyor Informed DON that the bed alarm pad was not placed on top of the mattress. DON entered Resident 1 ' s room and Unlicensed Staff B pointed out that the bed alarm was placed underneath the mattress. DON verified that the bed alarm pad was placed under the mattress. DON stated the bed alarm pad must be placed on top of the mattress. DON stated that no one should be using a bed alarm. DON stated that he was not aware that Resident 1 had bed alarm. During an interview on 9/26/2022 at 5:05 p.m., Director of Staff Development (DSD) stated she provided trainings on Fall Prevention every two years. DSD stated that a resident with a high risk for fall must have the bed in low position, call light within reach, free of clutter, floor mat was sometimes optional, a licensed nurse to get an order from the doctor before installing bed alarm. DSD stated that she provided verbal training to staff on how to place the bed alarm properly. DSD stated that she did not have any signed documentation or returned demonstrations by staff who received training for bed alarm and no date specified for verbal training. DSD stated that she would have documented the date of training this time. During a phone interview on 10/11/2022 at 3:21 p.m., Medical Doctor (MD) stated he expected the facility to follow their Policy and Procedures on Fall Risk and Fall Precautions. MD stated that any bed alarm or chair alarm placement must have a doctor ' s order. MD stated that the facility usually called him to get a bed alarm order. During an interview on 1/11/23 at 10:00 a.m. with Administrator (ADM) stated Resident 1 was placed on hospice and passed away last week. ADM stated a bed alarm was considered a restraint. ADM stated, a resident on a bed alarm kept them from moving due to the sound of the alarm. During an interview on 1/11/23 at 10:05 a.m. with Assistant Director of Nursing (ADON) stated, the usage of a bed alarm for resident was the last option for fall prevention. ADON stated, the reason for a bed alarm as a last option because it was considered as a restraint and the sound was a disturbance to the roommates. ADON stated, she gave verbal in-service(s) to Unlicensed Staff F (CNA-Certified Nurse Assistant) how to place a bed alarm accurately. ADON stated, she instructed Unlicensed Staff F that a bed alarm pad should be under a resident in between top sheet and a mattress. During a concurrent interview and record review on 1/11/23 at 10:30 a.m., DSD stated she provided training titled, Pressure Sensitive Alarm Placement related to Fall Prevention to all staff dated 9/27/22, and 9/28/22. A review of facility ' s Inservice for Nursing dated 9/21/2022 revealed discussion to evaluate and understanding of Fall Prevention and Staff will be able to verbalize Definition of Fall. A review of Policy and Procedures titled Fall Preventions-Potential Interventions revised 4/2012 revealed, under Interventions, Bed bed brakes, locked, mattress placed on floor, bed alarm. Staff Education Orientation for staff and volunteers about fall prevention efforts and strategies. A review of the facility ' s Policy & Procedures titled Sufficient and Competency Training revised 8/2022 revealed, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Under Competency: 2) All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 3) Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: Communication; Basic nursing skills 4) Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. 5) Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: a. programming for staff training results in nursing competency. b. gaps in education are identified and addressed. c. education topics and skills needed are determined based on the resident population. d. tracking or other mechanisms are in place to evaluate effectiveness of training; and e. training includes critical thinking skills and managing care in a complex environment with multiple interruptions.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) accurately and completely for two out of 25 residents (Resident 10 and Resident 34). This failure resulted in Resident 10 and Resident 34 not receiving Specialized Services needed. Findings: Resident 34 During an observation and concurrent interview on 3/23/22 at 08:41 a.m., Resident 34 stated feeling sad, depressed, and having little energy. During an interview and concurrent record review on 3/24/22 at 3:09 p.m., Medical Record Director (MRD), verified multiple sections on Resident 34's PASRR, dated 4/15/21, were not filled out accurately. MRD verified Resident 34 had a diagnosis of Dementia (a condition characterized by impairment of at least 2 brain functions, such as loss of memory and judgement). MRD verified Resident 34's PASRR was inaccurately filled out when it did not indicate Resident 34 having a diagnosis of Dementia. MRD stated receiving very minimal PASRR training from the facility's corporate staff. MRD stated the risk of not filling out the PASRR accurately was that Medicare would not pay for services and Resident 34 might miss out on receiving psychiatric treatments (treatment of mental disorders with counselling and or medications). During an interview on 03/24/22 3:32 p.m., Medical Records Assistant (MRA) verified Resident 34 had not received Psychiatric nor Behavioral Services since being admitted to the facility on [DATE]. During an interview and PASRR record review on 03/25/22 at 8:57 a.m., Director of Nursing (DON) verified Resident 34's PASRR was inaccurate when PASRR did not indicate Resident 34 had a diagnosis of Dementia. DON stated if PASRR was inaccurate, Resident 34 might not receive psychological services he needed. During an interview and concurrent chart review on 3/29/22 at 1:53 p.m., DON verified Director of Dining Services (DDS) wrote a progress note for Resident 34 on 3/24/22, stating Resident 34 was refusing his meals due to depression (a mental health disorder characterized by depressed mood or loss of interest causing significant impairment in daily life). Resident 10 During an observation and concurrent interview on 3/23/22 9:19 a.m., Resident 10 was in wheelchair at the nursing station. Resident 10 appeared uninterested and stated his breakfast was messed up today because he was served tofu again. During an interview and concurrent record review on 3/24/22 at 3:09 p.m., MRD verified 8 out of 39 questions on Resident 10's PASRR dated 3/17/2021, were not filled out. MRD stated risk of not filling out PASRR completely and accurately was that Medicare would not pay for services and Resident 10 might have missed out on receiving psychiatric treatment. During an interview and concurrent PASRR record review on 3/24/22 at 3:24 p.m., MRA stated Resident 10's PASRR form, dated 3/17/21, was completed upon admission. MRA stated Resident 10 migh have missed out on receiving psychiatric treatment and worsening of mental and behavioral issues when PASRR was not fully completed. During an interview on 3/24/22 3:32 p.m., MRA verified Resident 10 had not received Psychiatric nor Behavioral Services since being admitted to the facility on [DATE]. During an interview and record review on 03/25/22 at 8:57 a.m., DON verified Resident 10's PASRR was filled out inaccurately. DON stated if PASRR was inaccurate, Resident 34 might not receive psychological services he needed. During an interview and chart review on 3/25/22 at 9:40 a.m., DON stated Resident 10 requested to be sent out to Acute Care Hospital again, for the second time today for a psychological evaluation. DON verified Resident 10 was first sent out to Acute Care Hospital at 2:00 a.m. today for Auditory Hallucination (a form of hallucination that involves perceiving sounds without auditory stimulus). DON verified Resident 10 was sent out twice to Emergency Department today for psychological evaluation (a series of formal or structured psychological test). During an interview and concurrent chart review on 3/25/22 3:00 p.m., Infection Preventionist (IP) verified Resident 10 has a diagnosis of Schizoaffective disorder (a mental health disorder including schizophrenia and mood disorder). IP verified Resident 10 had no previous order for psychological evaluation until 3/24/22. Review of facility's policy and procedure titled Pre-admission Screening and Resident Review dated December 2016, indicated, the objective of the PASRR is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need and be evaluated annually and upon any significant change for those individuals identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a Nosey Cup (drinking cup with cut out for nose) and Plate Guard (curved to prevent food from falling off the plate and can be used as a barrier to push food against when scooping food onto a spoon or fork) when meal tray was served for one of 25 sampled residents (Resident 6), who had a CVA (cerebrovascular accident, stroke), causing flaccid (floppy or without muscle tone) hemiparesis (weakness or the inability to move one side of the body), of his left upper extremity (dominant side). This failure had the potential to impact Resident 6's: dignity, nutritional status, independence in self-feeding skills being maintained or improved when consuming meals and snacks, and swallowing difficulties, which could cause aspiration (when liquids enter the airway), leading to negative clinical outcomes. Findings: A review of Resident 6's Meal Card indicated: Diet Order: Puree (foods with a soft, pudding-like consistency), Regular, Thick Fluids-Nectar texture, adaptive equipment: nosey cup and plate guard. Notes: Upright posture during intake, small sips/bites, alternate sips/bites, monitor for coughing and wet vocal quality. A review of Resident 6's admission Record indicated Resident 6 was admitted on [DATE], with a diagnosis including Parkinson's disease (progressive nervous system disorder that affects movement), unsteady on feet, lack of coordination, and muscle weakness. A review of Resident 6's Nurses Progress Notes, dated 9/7/21, indicated Resident 6 was transferred to the Emergency Department because of a possible stroke affecting his upper left extremity and left side facial drooling. Resident 6's acute hospital History and Physical, dated 9/7/22, indicated Resident 6 had Parkinson's disease, which has caused significant right sided tremors and stiffness, and an acute CVA (cerebrovascular accident, stroke) causing left facial droop, left lower extremity weakness, dysarthria (motor speech disorder), CVA caused flaccid (floppy or without muscle tone) hemiparesis on left side, requiring Resident 6 to require significant assistants with ADLs (Activities of Daily Living: fundamental skills required to independently care for oneself, such as eating, bathing, and mobility), and swallowing difficulty. A review of Resident 6's Nurse's Progress Notes, dated 9/13/22, indicated Resident 6 arrived back to the facility, and was asked how eating was for him. Resident 6 said, hard. A review of Resident 6's Order Summary Report, dated 3/2021, indicated Resident 6 was started on a regular pureed textured diet, thickened liquids (Nectar consistency), small sips/bites, alternate sips/bites, monitor for coughing and wet vocal quality, and add a Nosey Cup and Plate Guard relate to dysphagia (difficulties swallowing), start date 9/16/21. During an observation on 3/22/22 at 12:43 p.m., Resident 6 was upright in his bed and was served his meal tray without a Nosey Cup and Plate Guard. Resident 6's thickened juice was in a regular 120 ml (milliliter) juice cup. During a concurrent observation and interview on 3/22/22 at 12:52 p.m., Resident 6's CNA (Certified Nursing Assistant) brought in a two-handled plastic Sippy Cup and poured Resident 6's juice into the cup. Resident 6 was trying to drink his juice with the Sippy Cup, but he was having difficulty because he needed to lean his head back, trying to drink his juice. During an observation on 3/22/22 at 12:53 p.m. Resident 6's CNA had to go back for a Plate Guard. Resident 6 was still waiting to eat lunch. During an observation on 3/22/22 at 12:57 p.m., Resident 6 received his Plate Guard. Resident 6's CNA placed the Plate Guard on Resident 6's plate and Resident 6 started to feed himself. During an interview on 3/23/22 at 9:00 a.m. the DDS (Director of Dining Services) was asked about Resident 6 not receiving his Nosey Cup and Plate Guard yesterday (3/22/22) at lunch time. The DDS stated Resident 6's adaptive eating equipment was a trayline error, but the CNA came into to get the items. The DDS stated Resident 6 needed a special cup because Resident 6 was on cough/chock dysphagia precautions. The DDS stated the Dietary Aides were the first contact in making sure the resident's tray was correct and the CNAs/Nurses were the next contact to check and make sure the residents' meal tray were correct. The facility policy/procedure titled, Self-Feeding Devices, dated 2018, indicated: Policy: Residents will receive self-feeding devices to maintain or improve their ability to eat or drink independently. Procedure: . 2. Devises commonly used, such as divider plates and feeder cups, will be kept in stock. A doctor's orders is recommended. The Food & Nutrition Services Department will store self-feeding devises. Residents needing devices will receive them with each meal and snack, on their meal trays. Tray cards and diet profile will record which device is needed . The facility job description titled, Position: Dietary Aide, dated 2018, . Duties and Responsibilities, . 2. May include any of the following as written on the work schedule: . b. Prepare nourishments, c. Prepare juices, milk water and other beverages . assist with trayline .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of 25 sampled residents (Resident 57), who's Annual MDS (Minimum Data Set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/24/22, indicated Resident 57 was incontinent of bowel and bladder, but no care plan was developed. This failure had the potential for Resident 57 not to be checked frequently for incontinence, which could lead to skin breakdown, a urinary tract infection (an infection in any part of the urinary system), feeling of low self-esteem and further impact Resident 57's physical and psychosocial wellbeing. Findings: A review of Resident 57's admission Record indicated Resident 57 was admitted on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (stroke) affecting the right side (dominant side), aphasia (loss of ability to understand or express speech), unsteadiness on feet, muscle weakness, difficulty with walking, dysphagia (difficulty swallowing) amongst others. A review of Resident 57's Quarterly MDS, dated [DATE], indicated Resident 57 was always incontinent of bowel and bladder. A review of Resident 57's Annual MDS CAA (Care Area Assessment process provides guidance on how to focus on key issues identified during a comprehensive MDS assessment), dated 2/24/22, indicated Urinary Incontinence was triggered. A review of Resident 57s Bladder and Bowel Incontinent task from 2/27/22 through 3/24/22, indicated Resident 54 was completely incontinent of bladder and bowel. A review of Resident 57's ADL's list (Activities of Daily Living: fundamental skills required to independently care for oneself, such as eating, bathing, and mobility), initiated 3/8/21, indicated one bowel/bladder intervention, assist with toileting. There were no interventions regarding Resident 57 being totally incontinent of bowel/bladder. During a concurrent interview and record review on 3/28/22 at 10 a.m., the MDS Coordinator looked for Resident 57's Bowel and Bladder care plan. The MDS Coordinator could not find one. The MDS Coordinator stated Bowel and Bladder was a little intertwined in her ADL care plan. The MDS Coordinator stated, Yes, Resident 57 was incontinent of Bowel/Bladder. The MDS Coordinator stated if the CAA triggered for Resident 57 being incontinent of Bowel/Bladder, a Bowel/Bladder care plan should have been developed for Resident 57. The policy/procedure titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation: . 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes, b. Describe the services that are to furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) During an interview and observation on 3/23/22 at 11:25 p.m., Resident #48 was observed in his wheelchair, at his bedside, with a nasal cannula (a small plastic tubing that carries oxygen from an oxygen source to a resident's nostrils, through a small, two-pronged plastic device), connected to his oxygen tank, and the portable oxygen tank was turned on. Observation of the oxygen tank volume gauge indicated the oxygen volume level was on the line above the empty/red zone that indicated the oxygen tank volume was empty. Resident #48 stated I asked Unlicensed Staff R to replace the oxygen tank because I have a doctor's appointment soon and I don't want it to run out. I get short of breath when that happens. At 11:45 p.m., Resident #48 was observed in his bedroom sitting at his bedside in a wheelchair, and his portable oxygen tank gauge was observed to be in the empty/red zone. During an observation on 3/23/22 at 1:30 p.m., Resident #48 was observed in a wheelchair at the nurse's station, and his portable oxygen tank volume gauge was observed to read empty in the red zone, and the oxygen flow was turned on. During an interview on 3/23/22 at 1:55 p.m., Unlicensed Staff T stated, [Resident #48] asked me for a full portable oxygen tank, to replace his empty portable oxygen tank before he was picked up and transported to a doctor's appointment on 3/23/22, between 1:30 p.m. and 1:55 p.m. Unlicensed Staff T stated, I replaced it with a new one and turned it onto 2 or 3 liters per minute. She stated if Resident #48 ran out (of oxygen) he might have experienced shortness of breath. She stated, Shortness of breath is not a good feeling, it is like you just can't get enough air. During an observation and interview on 3/23/22, at 5 p.m., Resident #10 was observed to be seated in his wheelchair, with a nasal cannula connected to a portable oxygen tank located on the back of his wheelchair. Resident #10 was leaning against the nursing station counter. An observation of his portable oxygen tank, located on the back of his wheelchair indicated it was turned on. The observation indicated the portable oxygen tank volume gauge was on the line in the empty/red zone. During an observation on 3/23/22, at 5:05 p.m., Resident #48 had returned from his doctor's appointment and was observed to be seated next to his bed, in his wheelchair, wearing a nasal cannula that was connected to a portable oxygen tank located on the back of his wheelchair. The portable oxygen tank flow was observed to be turned on and the portable oxygen tank volume gauge was observed to be in the low volume area of the oxygen volume gauge, just above the red empty volume zone. During an observation, on 3/24/22, at 9:05 a.m., in the Therapy Room, Resident #48 was observed seated in his wheelchair, without wearing an oxygen nasal cannula, but had a portable Oxygen tank on the back of his wheelchair. No other residents were observed in the room. Occupational Therapist U and Unlicensed Staff V were observed seated in the room, not engaged in any resident therapy or documentation activity. They were observed talking and engaged with Resident #48 in a social atmosphere. During an interview and observation on 3/24/22, at 9:06 a.m., Occupational Therapist U stated Resident #48 only needed Oxygen when he was short of breath. When she checked Resident #48's electronic medical record, it indicated he had a physician's order for continuous Oxygen at 2 liters per minute, not only if needed. Unlicensed Staff V was observed to get a new portable Oxygen tank and Occupational Therapist U got a new nasal cannula and placed it on Resident #48 and turned the Oxygen on. During an interview on 3/24/22, at 9:55 Director of Staff Development A stated she had competencies for licensed and unlicensed staff for Oxygen administration. She was unable to provide documentation that any staff had completed an employee orientation program that addressed Oxygen Therapy Safety with a validation check off list for Licensed and unlicensed staff. She stated she reviews materials related to Oxygen administration, but it was an informal discussion, and nothing was documented. She stated all staff should know to look at the portable Oxygen tanks to determine if the Oxygen supply was full or empty. She stated if it was empty or close to empty her expectation of unlicensed staff was to inform the licensed staff, replace the portable Oxygen tank and have the licensed staff conduct an assessment and administer Oxygen flow according to the physician's orders. She stated if that is not being done and a resident runs out of Oxygen it had the potential to result in shortness of breath, difficulty breathing or possibly respiratory failure. During an observation and interview, on 3/24/22, at 10 a.m., Resident #17 was observed seated at the nurse's station, leaning against the counter. His oxygen tank gauge was observed to be in the red/empty zone. Resident #17 stated I run out of the portable tanks a lot. He stated he was the one who monitored the Oxygen tank supply and reported it to staff when empty. He stated he would get dizzy or short of breath when the tank would get empty. Resident #17 stated that staff do not monitor it and he is responsible for telling them when to change it. He stated staff are busy and would not change it for a long time and staff have told him it is not a high priority for them. He stated he offered to have his Oxygen concentrator (A medical device that gives you extra Oxygen. An Oxygen concentrator isn't the same thing as an Oxygen tank, which delivers gas Oxygen. Instead, the concentrator is a machine that pulls in the ambient air around you and filters out the nitrogen. A thin tube runs from the device to your face, giving you purified Oxygen through two open prongs below your nostrils - nasal cannula), moved into the facility lobby during the day, so he would not waste the oxygen tanks by sitting in the lobby all day. He stated it made him feel unimportant and worthless when staff did not check his Oxygen tanks and make sure he had enough portable Oxygen. During an interview at the nurses station, on 3/24/22, at 4:30 p.m., Nurse Practitioner K stated Oxygen administration safety included making sure the portable Oxygen tank did not run out of Oxygen. He stated staff must check the tank consistently because if a resident did not receive the prescribed Oxygen there was a risk of shortness of breath and hypoxia (n absence of enough Oxygen in the tissues to sustain bodily functions). Review of Resident # 48's electronic medical record document titled admission RECORD, indicated he was admitted [DATE], with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD-chronic lung disease), Atrial Fibrillation (abnormal heart rhythm), Heart Failure (inefficient pumping of the heart), Hypertension (high blood pressure), Muscle Weakness and Obstructive Sleep Apnea (intermittent airflow blockage during sleep). Review of a document titled, Order Summary Report, dated 3/24/22, indicated a physician order dated 2/9/22, for O2 (Oxygen) @ (at) 2LPM VIA (two liters per minute by way of) NASAL CANNULA CONTINUOUS PER CONCENTRATOR/TANK every shift for COPD. Review of Resident #10's electronic medical record document titled, admission RECORD, indicated he was admitted [DATE], with diagnoses that included Acute Chronic Diastolic (Congestive) Heart Failure (The left side of the heart becomes stiffer than normal. Because of that, the heart can't relax the way it should. When it pumps, it can't fill up with blood as it's supposed to. Because there's less blood in the ventricle, less blood is pumped out to your body), Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease Hypertension, and Obstructive Sleep Apnea. A document titled Order Summary Report, dated 3/24/22, indicated a physician order for Oxygen 2 L/min via NC every shift. Review of a facility Policy and Procedure (P&P) titled Oxygen Administration, revised October 2010, indicated, Purpose: The purpose of this procedure is to provide for safe oxygen administration.Report other information in accordance with facility policy and professional standards of practice. There was no indication in the P&P for monitoring Oxygen levels on portable Oxygen tanks to ensure Oxygen was available, or a process to have back up oxygen supply available for transfer or emergencies. Review of a document titled FACILITY ASSESSMENT TOOL, (A Facility Assessment is a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operation and emergencies.), dated March 2022, indicated Common diseases, conditions physical and cognitive disabilities, or combinations of conditions that [Facility] can treat / provide care for : . Respiratory System - Chronic Obstructive Pulmonary Disease (COPD), Pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid. With pneumonia, the air sacs may fill with fluid or pus. The infection can be life-threatening to anyone, but particularly to infants, children, and people over 65. Symptoms include cough with phlegm or pus, fever, chills, and difficulty breathing), Asthma (a condition in which a person's airways become inflamed, narrowed, and swell, and produce extra mucus, which makes it difficult to breathe. Asthma can be minor, or it can interfere with daily activities. In some cases, it may lead to a life-threatening attack. Asthma may cause difficulty breathing, chest pain, cough, and wheezing.), Respiratory Failure (Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide. Sometimes you can have both problems).Special Treatments and Conditions, Respiratory Treatments, Oxygen therapy .Staff are testing annually on the following competencies .Specialized care .oxygen administration.Physical environment and building / plant needs .Physical equipment Resources .oxygen tanks and tubing. 4. During an observation on 3/23/22, at 8 a.m., Licensed Staff G was observed passing morning medications to Resident #31. During an interview on 3/23/22, at 8:10 a.m., Resident #31 stated she was afraid the nurse did not know what she was doing because she could not find a medication. She stated she did not have confidence that Licensed Staff G was doing the right thing because she looked through the entire medication cart and told Resident #31 she could not find a medication the doctor ordered for her. During an interview on 3/23/22, at 8:30 a.m., Licensed Staff G stated she told Resident #31 she could not find her Epoetin, (a physician prescribed medication, used to help stimulate the body's production of red blood cells, and treat anemia). She stated she thought it might be in the facility's locked medication storage room. During an interview on 3/23/22, at 5:24 p.m., Licensed Staff G stated she had not administered Epoetin medication to Resident #31 yet. She stated she could not find it in her medication cart and had not asked the Director of Nursing where it would be. During an observation and interview on 3/23/22, at 5:26 p.m., the Director of Nursing stated the Epoetin medication was stored in the locked medication storage room medication refrigerator. He stated he saw it there this morning. Director of Nursing was observed to enter the locked medication storage room and look in the medication refrigerator. He exited the room and stated he ordered a refill from the pharmacy yesterday and had thought it was delivered. He stated the pharmacy must not have delivered it yet and stated to Licensed Staff G to call Resident #31's physician and inform him of a missed dose of Epoetin and then to call the pharmacy to check on the Epoetin delivery. During an observation and interview on 3/23/22, at 5:30 p.m., Licensed Staff G stated she did not know if the Epoetin medication needed to be refrigerated. She stated she would look it up on her computer. During an interview on 3/24/22, at 7:55 a.m., Licensed Staff B stated she was waiting to give Resident #31 the morning dose of Epoetin medication until after breakfast. During an interview on 3/24/22, at 9:40 a.m., Director of Nursing stated the Pharmacy was supposed to deliver the Epoetin medication last night, but they did not. He stated the Epoetin never came in. He stated Resident #31 had missed two doses of Epoeitin medication. He was unable to stated what the risk was to Resident #31 if she did not get her medication administered according to the physician's order. During an interview on 3/24/22, at 3:05 p.m., Director of Nursing stated Resident #31 had been administered her Epoetin medication this afternoon. He stated Resident #31 did not have a missed medication because the Nurse Practitioner had changed the order for administration from 3/23/22 at 8 a.m., to 3/24/22. He stated a medication error was when a medication was not administered to a resident in the one hour before or after the medication was ordered. During a concurrent interview and document review, on 3/24/22, at 3:05 p.m., Director of Nursing reviewed the electronic medical record document for Resident #31 titled, Order Summary Report, dated 3/28/22, indicated a physician order for Epoetin Alfa Solution 10000 UNIT (How much Epoetin/ mL (milliliter) Inject 0.5 mL subcutaneous (right under the skin, into the fatty tissue) one time a day every Tue, Thu, Sat related to ANEMIA. He stated it did not reflect the original Monday, Wednesday Friday administration order for Epoetin, because the facility did not have the medication to administer on Monday. He stated the facility had called the Nurse Practitioner and told her of the missed medication dose and she changed the order to now stated to give medication Tuesday, Thursday Saturday. During an interview on 3/24/22, at 4:30 p.m., Nurse Practitioner K stated Residents needed to get their medications administered as the physician ordered them. She stated Epoetin is prescribed for chronic kidney disease (A type of kidney disease that lasts for years and include symptoms of swelling, fatigue, and anemia; Anemia is when you do not have enough red blood cells to carry oxygen from your lungs to the rest of your body and resulted in shortness of breath and fatigue), to provide comfort since it is given when someone has anemia and felt tired. During a phone interview on 3/25/22, at 8:30 a.m., Pharmacist HH stated Resident #31 was prescribed Epoetin on 1/15/22 for anemia. She stated it is a medication for residents who suffer from Anemia and Renal (kidney) Disease. Pharmacist HH stated if Resident #31 did not receive the medication yesterday or today, she missed two doses of Epoetin. She stated the Pharmacy had delivered the Epoetin medication to the facility on 3/24/22, at 10 a.m. A review of the electronic medical record document for Resident #31, titled admission DOCUMENT, dated 3/28/22, indicated Orig.(original) Adm.(admission) Date 1/06/22. DIAGNOSIS INFORMATION Essential Hypertension, Anemia, Chronic Kidney Disease. A review of the electronic medical record document for Resident #31, titled Progress Notes, dated 3/29/22, indicated a Nurses's Note, dated 3/24/22 at 14:02 (2:02 p.m.), that indicated Licensed Staff G documented Pt (patient) received dose of epoetin at 1345 (1:45 p.m.) in upper left extremity. A review of a document titled Thomson Reuters Westlaw Baclays California Code of Regulations CCR § 76347, indicated Nursing Services -Administration of Medications and Treatments.(e) Medications shall be administered within two hours after dosages are prepared and shall be administered by the same person who prepared the dosages for administration. Dosages shall be administered within one hour of the prescribed time unless otherwise indicated by the prescriber. Based on observation, interview and record review, the facility did not ensure nursing staff utilized professional standards when providing resident care when: 1) Licensed Staff G did not verify placement of Resident 38's PEG tube (percutaneous endoscopic gastrostomy tube; a tube inserted through the wall of the abdomen directly into the stomach) per facility policy and procedure. This failure caused potential for injury when LN G did not ensure Resident 38's feeding tube was in his stomach immediately prior to administering medication. Feeding tubes can become displaced (for example: into the abdominal cavity or lungs) and delivery of tube feeding liquid into an area of the body other than the stomach can cause serious injury and death; and 2) The Director of Staff Development (DSD A) did not perform the medication rights (guide to clinical medication administration to ensure patient safety; right resident/medication/dose/route [oral, intravenous]/time) prior to administering Resident 120's IV (intravenous) antibiotic (medication used to treat infection) and did not document the antibiotic administration timely, per facility policy and procedure. This failure caused potential for a medication error and subsequent harm to Resident 120 [*]. [*Online review of the National Center for Biotechnology Information, U.S. National Library of Medicine website indicated medication errors were estimated to account for more than 7,000 deaths annually. https://www.ncbi.nlm.nih.gov/books/NBK2656/] 3) Facility staff did not assess and monitor the portable oxygen use for two (Resident 10, and Resident 48). This failure prevented Resident's 10 and 48 from receiving their oxygen as ordered by their physician when their oxygen tanks were not replaced when empty and caused Resident 10 to feel unimportant and worthless when staff did not check his oxygen tanks to make sure he had enough portable Oxygen. (Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air [20.9%] with the intent of treating or preventing the symptoms and manifestations of hypoxia.Hypoxia means decreased perfusion of oxygen to the tissues, resulting in cellular death, cardiac arrest and brain death.); 4) Facility staff did not ensure the availability of physician ordered medications (Epoetin; medication used to help stimulate the body's production of red blood cells, and treat anemia) for one resident (Resident 31). This failure resulted in Resident 31 missing two doses of Epoetin (EPO) and potentially impaired her treatment of anemia. Findings: 1) During a medication pass observation on 3/22/22 at 4:48 p.m., LN G gave Resident 38 his medications through his PEG tube. LN G crushed his medications, mixed them with water, and administered them into his PEG tube. LN G did not verify the tube's placement prior to the medication administration. During an interview on 3/22/22 at 5:15 p.m., LN G was asked how she verified PEG tube placement prior to medication administration. LN G stated she checked for residual and stated, I didn't do it. I didn't think of it. (Residual refers to fluid/contents that remain in the stomach; a nurse connects a syringe to the PEG tube and gently draw back the plunger of the syringe to withdraw stomach contents and ensure tube placement). During an interview on 3/25/22 at 5:20 p.m., the DON (Director of Nursing) was asked how nurses should assess PEG tube placement prior to medication administration. The DON stated nurses should use aspiration of gastric contents (checking residual) and auscultation (air injected into the tube using a syringe; this generates a whooshing sound used to determine tube placement in the gastrointestinal tract) [*]. [*According to the National Library of medicine, auscultation may not differentiate between respiratory (lungs) and gastrointestinal (stomach) tube placement. A similar sound can be heard over the epigastrium (area over the stomach) when the tube has been incorrectly placed into the tracheobronchial tree (lungs) , pleural space (lungs) or esophagus (tube connecting the throat with the stomach. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2871204/] Review of facility policy title, Enteral Tube Feeding via Syringe (Bolus), subtitled, Steps (revised 11/2018) indicated, 7. Verify placement of tube. 8. If anything suggests improper tube positioning, do not administer . medication. Notify the Charge Nurse or Physician . The policy did not contain verification steps or procedures for nurses to follow. Review of facility policy titled, Medication Administration General Guidelines, subtitled, Policy (dated 2007) indicated, Medications are administered . in accordance with . good nursing principles and practices . Under subtitle, Procedure, the policy indicated, 5. If it is safe to do so, medication tablets may be crushed . when a resident .is tube-fed, using the following guidelines . Neither the guidelines nor the policy contained instructions or procedures to follow when verifying tube placement prior to medication administration. 2) During a medication pass observation on 03/23/22 at 9:48 a.m., DSD A prepared and administered Resident 120's IV antibiotic. DSD A did not compare the label (that identified the resident, medication, dose, time, and route) on the antibiotic bag to Resident 120's MAR (medication administration report; medication orders are reflected here ) or the physician's order prior to hanging (attach and administer IV medication) the antibiotic. DSD A hung Resident 120's antibiotic at 9:48 a.m. Review of Resident 120's MAR on 03/23/22 at 9:59 a.m. revealed DSD A had not yet documented her administration of Resident 120's antibiotic (approximately eleven minutes earlier). During an observation on 3/23/22 at 10:27 a.m., DSD A disconnected Resident 120's IV antibiotic (the administration was completed). During an interview on 3/23/22 at 10:27 a.m., DSD A was asked if she had documented Resident 120's antibiotic administration (approximately thirty-nine minutes earlier) and she stated, no. DSD A stated she charted (documented) after hanging the medication (when the infusion was completed). When asked how she had verified the correct medication (and the five rights) prior to Resident 120's antibiotic administration, DSD stated she had checked earlier that morning when she came to the facility (between 7:30 a.m. and 7:45 a.m.) When asked if she had checked the dose of the antibiotic at approximately 7:30 a.m. or 7:45 a.m. (over two hours prior to medication administration ), DSD A stated, yes and stated she checked the physician order and the MAR and she talked to the nurses. DSD A was queried what would happen if the physician had come to the facility after 7:45 a.m., (when she checked the order) and had changed the order prior to her administering the medication. When asked how she would know if the order had been changed after 7:45 a.m., DSD A stated, the nurses would tell me and stated she communicated with the nurses and they knew she was hanging IV medications. When asked why she did not verify the medication rights by checking the physician order or MAR immediately prior to hanging the medication, DSD A stated, that's how I do it. During an interview on 3/25/22 at 5:20 p.m., the DON was asked to identify medication administration rights and he stated medication rights included right name (of the resident), right dose, right route, right time, right medication, and right documentation. The DON was asked how nurses should verify an IV antibiotic prior to it's administration. The DON stated the nurse should check the MAR prior to retrieving the medicine from the medication room, and after the nurse retrieved the IV medication, she should check it (again) against the MAR, immediately prior to administration. He stated the medication should not be verified one to two hours prior to the administration. When asked when the medication should be documented, the DON stated an IV medication should be documented after the medication is fully infused (not immediately after hanging the medication). Review of facility policy titled, Medication Administration General Guidelines, subtitled, Procedures (dated 2007) indicated, 3. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label . Review of facility policy titled, Administration of IV Fluids and Medications, subtitled, Intravenous Fluid and Drug Administration General Policies (dated 2011) indicated, 4. The nurse shall assess the following: . the dose, the route, the rate of the solution/medication ordered . 6. Prior to administration, the nurse will verify the patient's identity . 9. The nurse will verify that the container's label coincides with the prescriber's order. Verify content, dose, prescribed rate, and expiration date of the solution . Review of facility policy titled, Documentation of Medication Administration, subtitled, Policy Interpretation and Implementation (revised April 2007) indicated, 2. Administration of medication must be documented immediately after (never before) it is given.

Based on observation, interview and record review, the facility failed to recognize, evaluate and address 1 out of 25 residents (Resident 34) continued multiple meal refusals for the last 2 months. This failure had the potential for Resident 34 to have a decline in function, weakness, and unplanned weight changes. Findings: Review of Resident 34's face sheet (demographics)was diagnosed with Diabetes Mellitus Type 2 (a chronic condition that affects the way the body processes blood sugar), Dementia ( group of conditions characterized by impairment of at least 2 brain functions such as memory and judgement) and Major Depressive Disorder ( a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). During observation and interview with Resident 34 on 3/23/22 at 8:41a.m., was in bed, appears comfortable. Resident 34 stated he ate little breakfast today, was not sure if he finished it. Resident 34 stated he was unsure whether he ate dinner last night. Resident 34 stated feeling sad with little energy and depressed. During observation and interview with Resident 34 on 3/24/22 at 8:31 a.m., Resident 34 was still in bed, stated he did not eat his breakfast, and does not recall staff offering a meal alternative. There was no food tray noted at bedside. During interview and concurrent chart review on 3/24/22 at 10:11 a.m., Director of Dietary Services (DDS stated the facility process was for staff to offer a meal alternative when any resident refused meals. DDS verified Resident 34 had multiple meal refusals. DDS stated Resident 34's multiple meal refusals was only brought to her attention today, thus Resident 34 was not included on the facility's Nutrition at Risk (NAR-list of residents at risk for nutritional imbalance) list. DDS verified her last dietary assessment was conducted on 1/18/22 with upcoming quarterly assessment sometime in April. DDS confirmed Registered Dietician's (RD) last assessment was on 8/16/2021, and there was no new assessment done. DDS stated she will assess Resident 34 today and will contact RD based on her findings. During an interview with DON on 3/25/22 at 9:01a.m., stated he only became aware of resident continued meal refusals on 3/22/22 during the investigation. During an interview and meal record review with Director of Staff Development (DSD ) on 3/25/22 at 9:04 a.m., verified Resident 34 had multiple meal refusals beginning 2/24/22. DSD verified Resident 34 was not on any nutritional supplement. DSD verified that DDS wrote a dietary note on 3/24/22. DSD stated Resident 34 was at risk for weight loss and malnutrition for refusing multiple meals. During an interview and progress notes review on 3/29/22 at 1:53 p.m., DON verified physician was not notified of Resident 34's continued meal refusals. DON verified RD had assessed Resident 34 on 8/16/21 and no further assessment was done recently despite Resident 34's multiple meal refusals. DON verified Dietary Manager (DM) wrote a note on 3/24/22, stating Resident 34 was refusing meals due to depression, and that he prefers to eat hamburger from a preferred fast food chain. DON verified Interdisciplinary Team (IDT- core team responsible for coordinating and managing care across all settings) had not met yet to address Resident 34's continued meal/alternate meal refusals. Review of the facility's policy and procedure titled Requesting, Refusing and/or Discontinuing Care or Treatment not dated, the Interdisciplinary Team (IDT) should have met with resident or responsible party to determine why he was refusing his meals, to try and address his concerns and discuss alternative options and to discuss potential positive or negative outcomes of his decision.

Based on observation, interview and record review, the facility failed to ensure Resident 38 received appropriate nursing care to minimize potential complications associated with enteral feeding/nutrition (tube feeding; delivering nutrition directly into the stomach or small intestine as a liquid) when: 1) Licensed nurses failed to ensure administration of enteral nutrition was consistent and followed physicians orders and; 2) Licensed Staff G did not verify placement of Resident 38's PEG tube (percutaneous endoscopic gastrostomy tube; a tube inserted through the wall of the abdomen directly into the stomach) prior to medication administration per facility policy and procedure. These failures created 1) Potential for inadequate nutrition, calories, and hydration for Resident 38 when his tube feedings were not given as ordered and multiple meals were missed and 2) Potential for injury when LN G did not ensure Resident 38's feeding tube was in his stomach immediately prior to administering medication. Feeding tubes can become misplaced (for example: into the abdominal cavity or lungs) and delivery of tube feeding liquid into an area of the body other than the stomach can cause serious injury and death. Findings: 1) Review of Resident 38's face sheet indicated he had Dysphagia (difficulty swallowing foods/liquids) and Diabetes Mellitus Type 2 (a chronic condition that affects the way the body processes blood sugar). During an observation on 3/22/22 3:59 p.m., Resident 38 had a Percutaneous Endoscopic Gastrostomy ( PEG: a tube inserted through the wall of the abdomen directly into the stomach, that is used to give drugs, liquids and liquid food to the resident) in place and the PEG dressing was clean with a date of 3/22/22. During an interview and concurrent physician's order review on 3/23/22 8:45 a.m., Licensed Nurse D verified Resident 38 was Diabetic. Licensed Nurse D verified Resident 38 had an enteral feed order of Glucerna-1.2, 250 ml every four hours daily at 12:00 a.m., 4:00 a.m., 8:00 a.m.,12:00 p.m. 4:00 p.m., and 8:00 p.m. via PEG. Licensed Nurse D stated Resident 38 refused his tube feedings at 12:00 a.m. and 4:00 a.m. today. Licensed Nurse D stated facility policy was to notify the physician whenever Resident 38 refuses his tube feedings. Licensed Nurse D verified the feeding refusal this morning at 12:00 a.m. and 4:00 a.m. was not communicated to the physician. Licensed Nurse D stated if Resident 38 refused his tube feeding, staff would sometimes check Resident 38's blood sugar for hypoglycemia. Licensed Nurse D was unsure whether the doctor had ordered blood sugar checks as needed in relation to Resident 38's tube feeding refusals. During an interview on 03/24/22 at 9:29 a.m., Licensed Nurse E stated Resident 38 would sometimes refuse or say he only wanted to receive 3/4 or 1/2 of his formula. Licensed Nurse E stated Resident 38 only received 3/4 of his formula this morning. Licensed Nurse E stated Resident 38 not receiving his feeding formula as ordered placed him at risk for weakness and hypoglycemia. During an interview on 3/25/22 at 8:44 a.m., the DON stated physician's order was not being followed if Resident 38 is not receiving the full tube feeding as ordered. DON stated this was an error and the physician should have been notified. DON stated when Resident 38 refused his tube feedings, this placed him at risk for hypoglycemia and dehydration (loss of body fluid). During an interview and medication administration record review with Licensed Nurse B on 03/28/22 at 10:14 a.m., verified Resident 38 refused his tube feedings multiple times between February and March 2022. Licensed Nurse B confirmed there was no documentation to prove that the physician was notified. Licensed Nurse B stated Resident 38's tube feeding refusals placed him at risk for his blood sugar bottoming out, becoming hypoglycemic and dying. Review of the facility's Policy and Procedure (P/P) titled Requesting, Refusing and/or Discontinuing Care or Treatment, the physician must be notified of refusal of treatment. Interdisciplinary team should meet with resident or responsible party to determine why he was refusing his treatment (tube feedings), to try and address his concerns and discuss alternative options and to discuss potential positive or negative outcomes of his decision. 2) During a medication pass observation on 3/22/22 at 4:48 p.m., LN G gave Resident 38 his medications through his PEG tube. LN G crushed his medications (mixed them with water) and administered them into his PEG tube. LN G did not verify the tube's placement prior to medication administration. During an interview on 3/22/22 at 5:15 p.m., LN G was asked how she verified PEG tube placement prior to medication administration. LN G stated she checked for residual and stated, I didn't do it. I didn't think of it. (Residual refers to fluid/contents that remain in the stomach; a nurse connects a syringe to the PEG tube and gently draw back the plunger of the syringe to withdraw stomach contents and ensure tube placement). During an interview on 3/25/22 at 5:20 p.m., the DON (Director of Nursing) was asked how nurses should assess PEG tube placement prior to medication administration. The DON stated nurses should use auscultation (air injected into the tube using a syringe generates a whooshing sound used to determine tube placement in the gastrointestinal tract) [*] and and aspiration of gastric contents (checking residual). [*According to the National Library of medicine, auscultation may not differentiate between respiratory (lungs) and gastrointestinal (stomach) tube placement. A similar sound can be heard over the epigastrium (area over the stomach) when the tube has been incorrectly placed into the tracheobronchial tree (lungs) , pleural space (lungs) or esophagus (tube connecting the throat with the stomach.] (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2871204/) Review of facility policy title, Enteral Tube Feeding via Syringe (Bolus), subtitled, Steps (revised 11/2018) indicated, 7. Verify placement of tube. 8. If anything suggests improper tube positioning, do not administer .medication. Notify the Charge Nurse or Physician . The policy did not contain instructions or procedures to follow when verifying tube placement prior to medication administration. Review of facility policy titled, Medication Administration General Guidelines, subtitled, Policy (dated 2007) indicated, Medications are administered .in accordance with .good nursing principles and practices . Under subtitle, Procedure, the policy indicated, 5. If it is safe to do so, medication tablets may be crushed .when a resident .is tube-fed, using the following guidelines . Neither the guidelines nor the policy contained instructions or procedures to follow when verifying tube placement prior to medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure sufficient nursing staff when: 1. Consistent and accurate meals preferences were not honored for 5 sampled residents (Resident 59, Resident 48, Resident 31, Resident 58, Resident 55, Resident 219). 2. Call lights were not answered resulting in incontinence for 2 of 8 sampled residents (Resident 220 and Resident 58). 3. All residents did not have access to activities on weekends. 4. All residents did not have access to the RNA (Restorative Nursing Assistant) program (specially trained CNA's (Certified Nursing Assistant) who provide ongoing long-term physical and occupational care to improve patient's quality of life - physically, mentally and emotionally) because the RNA had been pulled to the floor to work as a CNA for the past five months. These failures resulted in: 1. Potential for weight loss from being served unpalatable food and choking from incorrect diets because staff were too busy to check for accuracy of resident meal trays. 2. Loss of dignity from incontinence. 3. Boredom, lack of socialization and decreased mobility by not having access to activities. 4. A disruption in the residents' RNA Care Program had the potential for residents to have a decline in ROM (Range of Motion), strength and endurance, an increase in joint pain and depression, and an overall decrease in activities in daily living (ADLs): bathing, eating, dressing), Reference Tags F-550, F-585, F-679, F802 and F804. 1. During an observation and interview on 3/21/22 at 1 p.m., Resident #219 was sitting up in her bed and finished her lunch. On her plate were approximately 1/2 cup bright green beans. Three green beans appeared to have been chewed and spit on the plate. The remaining green beans were observed to have been untouched. Resident #219 stated she loved green beans, but they were undercooked, and she could not chew them. She stated, they were too hard. During an observation and interview 3/21/22 at 2:56 p.m., Resident #48 stated he was a retired cook from the Navy. He stated the green beans served to him at lunch were just blanched and not cooked. He stated they were too hard to chew. He stated the pasta serving was overcooked and mushy. He stated when he tried to pick it up with his fork it was so soft it fell apart. He stated it was soggy and pretty bland. Resident #48 stated the facility consistently undercooked the vegetables. During an observation and interview on 3/21/22 at 3:42 p.m., Resident #55 stated the facility keeps refusing to give me two milks. She stated I have requested it; it was on my diet card and documented as my preference, but they keep either forgetting to get me milk or they give me only one milk. She stated I have also told them I do not like Thousand Island Dressing and now the facility does not give me any salad dressing at all. She stated the staff are too busy to even read what the likes and dislikes are on the food preference card that was on my tray. A review of the card on from her lunch tray indicated Diet Order: Regular, Thin Liquids Standing Orders .2 X fl oz Milk 2% (TWO GLASSES). During an interview with Resident #55 on 3/22/22 at 9:26 a.m., she stated the facility served green beans that were not even cooked yesterday, they were so hard you could not pick them up with your fork. During an observation and interview on 3/22/22 at 12:35 p.m., unlicensed staff were observed to start passing lunch trays. Director of Staff Development A at 12:37 was observed at the meal cart and start checking meal trays. She stated a licensed nurse must always check the meals to ensure residents are receiving the correct physician ordered diet. She stated she was unaware staff had started to pass the lunch trays to residents without a licensed nurse checking them first. She stated the danger was residents could possibly receive the incorrect diet and possibly choke. She stated the facility Policy and Procedure stated licensed nurses must check the food trays before serving them to residents. During an observation and interview on 3/23/22 at 1:15 p.m., Director of Staff Development A was observed to check resident meal trays before staff served them to residents. During an observation and interview on 3/23/22 at 1:20 p.m., an observation of Resident #31's lunch tray showed chicken covered with a dark brown sauce. An observation of the diet card on her lunch tray indicated Dislikes - Gravy. Resident #31 stated it happened every single time . It was like no one cared whether or not we get food we like. During an interview on 3/23/22 at 1:20 p.m., Resident #58 stated her lunch salad did not come with any salad dressing so Resident #31 shared her salad dressing with her. A review of her diet card indicated Dislikes, was empty and did not list salad dressing. During an observation and interview with Resident #55, on 3/23/22 at 1:30 p.m., she stated facility served me carrots when my dislikes on the diet card clearly has dislikes carrots. She stated they also did not bring his two milks today either. A review of Resident #55's diet card indicated Standing Orders: . 2 X 8 fl oz milk 2% (TWO GLASSES) Dislikes: .Carrots. She stated she did not ask for a substitution, but that it just does not make a difference. She stated her meals were never served correctly. 2. During an observation and interview on 3/21/22 at 10:34 a.m., Resident #58 was observed laying on her back, in her pajamas, with the curtains pulled in a dark room. She stated a couple nights ago, during the midnight to six a.m. shift a Certified Nursing Assistant (CNA), took her walker out of the room. She stated it had been located right next to her bed. An observation of the entire room and bathroom did not indicate her walker was in the room. Resident #58 stated one night (could not recall date) she had to go to the bathroom, and she pressed her call light for assistance. She stated after more than 15 minutes of waiting for someone to answer the call light to help her walk to the bathroom, she stood up, used her walker, and walked to the bathroom herself. She stated she had urinary urgency issues and when she had to go she could not wait. She stated the CNA came into her room and yelled at her that she needed to use the call light and ask for help because if Resident #58 fell she would sue the facility. Resident #58 stated the CNA removed her walker from the room and she had not seen it since. Resident #58 stated it was humiliating because when the staff do not answer the call lights when she had to use the bathroom and she could walk to the bathroom herself with her walker, she had to urinate in her incontinence brief. She stated she just wanted to go home and was unhappy with the night CNA taking away her walker and ability to use the bathroom. A review of Resident #58's medical record indicated she was admitted [DATE], with diagnoses that included lumbar fracture and pain. A review of Brief Interview of Mental Status (BIMS) (A screening tool used by facilities to determine how well a resident functioning cognitively. A core of 13-15 indicated someone was cognitively intact.), indicated a score of 13. During an interview on 3/22/22 at 9:35 a.m., Resident #58's roommate, Resident #31 stated The night CNA came in a took away Resident #58's walker. She stated happened every night. She stated the CNA would take a long time to answer the call light or come into the room and turn off the call light, leave and not help. She stated at the beginning of the night shift the CNA would come into the room and remove her walker and my wheelchair. She stated Resident #58, and she had told the licensed nurses, the day CNAs, and the Director of Nursing but nothing had been found or had changed. During an interview on 3/22/22 at 10:00 a.m., 4 out of 6 residents ( Anonymous 1, 2, 4 and 5) stated they had to wait for hours for staff to answer call lights. -Anonymous Resident 1 stated wait time for call light response was over the line, and he felt irritated when that occurs. Anonymous 1 stated call lights took around an hour before being attended to. -Anonymous Resident 2 stated needing to wait hours for call light to be answered and she ended up soiling herself. Anonymous Resident 2 stated she was embarrassed when this occurred. Anonymous Resident 2 stated staff told her to press call button during emergencies only. Anonymous Resident 2 stated staff did not come until an hour later when she pressed her call light. Anonymous Resident 2 stated staff got upset and made her feel like she was wasting their time whenever she pressed her call light. -Anonymous Resident 4 stated he had to wait 30 to 40 mins for his call light to be answered. Anonymous Resident 5 stated he was told by staff he was not the only resident being cared for when he presses his call light. Anonymous 5 stated facility had skeletal crew on Saturdays and Sundays. -Anonymous 5 stated Activity Director (AD) was off on weekends and there were no available activity staff to cover the weekend shift. Anonymous 5 stated having no activities on the weekends creates boredom making him want to leave the facility and wheel himself to the pub. During an interview on 3/23/22 at 8:19 a.m., Licensed Staff F stated the facility was short staffed. She stated we all work a lot of overtime. She stated I am work a lot of double shifts to cover missing licensed nurse shifts. She stated there was a big issue with resident care. Licensed Staff F stated, I do not want to stop working here but they told us two Licensed Nurses will have to cover the entire facility and it was the new normal. She stated things like answering call lights would not happen as fast and as a result there would be an increase in accidents when residents would try to get up and go to the bathroom. She stated they might fall or hurt themselves. She stated she would tell them to stay in bed and she would answer the call light but if they had an accident they had incontinence briefs on and she would make sure they get cleaned. She stated the staffing was making residents become less active and lose their ability to move around when they cannot get help to get up and go to bathroom. Licensed Nurse F stated low staffing was relying on residents using briefs instead of getting up and using bathroom. Licensed Nurse F stated it was worse on the evening and night shifts. She stated things do not get done, like resident's request for pain medications are late because we are answering call lights. She stated call lights don't get answered quickly enough. She stated staff become unable do the non-medical tasks in resident care plans for pain or for Activities of Daily Living (Bathing, Bathrooms, repositioning, going to activities). During an interview on 3/22/22 at 9:55 a.m., Unlicensed Staff V stated she did not know why the night shift would take walkers or wheelchairs out of resident's rooms. She stated if a resident needed to go to the bathroom, she had to ask staff for help and if no one answered the call light, and the resident would try to walk without a walker and there was ahigh risk of a fall, or the resident would experience incontinence waiting for help. During an observation and interview on 03/22/22 at 11:53 a.m., Resident #220 was observed to be dressed and well groomed, displayed no disorganized thinking, and was able to communicate effectively about his experience in the facility. He stated several nights ago he had experienced some bowel distress and had put on his call light to ask for assistance to go to the bathroom. He stated he waited more than 15 minutes and as a result he lost control of his bowels. Resident #220 stated when the CNA who worked the night shift came into his room she became angry with him and yelled at him to get up and go to the bathroom. He stated she yelled at him in a manner that felt disrespectful. He stated if he could get up and go to the bathroom himself he would not have to be in this facility. He stated he had Parkinson's (Long term degenerative neurological disorder that affects ambulation) and had trouble with walking. He stated she was disrespectful, and it felt undignified the way she spoke to him. During a review of Resident #220's medical record, it indicated he was admitted [DATE], with diagnoses that included Parkinson's Disease Tremors, Glaucoma and muscle weakness. A review of BIMS score indicated it had not been completed. During an observation on 3/23/22 at 8:43 a.m., call light bells were observed ringing. Eight staff were observed in the hallways and nurse's station, and no one was observed to go the rooms with a call light on. The call lights were answered at 8:53 a.m. During an observation on 3/23/22 at 9:19 a.m., the call light in room [ROOM NUMBER] was observed to start ringing. Unlicensed Staff R was observed to walk past room [ROOM NUMBER] without checking on the resident or answering the call light. Unlicensed Staff AA was then observed to answer the call light in room [ROOM NUMBER]. During an interview with Unlicensed Staff AA on 3/23/22 at 9:20 a.m. he stated everyone was supposed to answer lights within 5-6 minutes. He stated if staff did not answer call lights quickly a resident may have to use the bathroom and may experience incontinence. He stated that residents would feel embarrassed or undignified if they had to pee their pants. During an interview on 3/24/22 at 10 a.m., Resident #10 was observed seated in his wheelchair at the nurse's station with oxygen tubing connected to a portable oxygen tank on the back of his wheelchair. He stated he was responsible for checking the oxygen level himself. He stated, the staff say there are too busy, or they just don't get around to checking the oxygen level or provide him with a new oxygen tank. He stated if he does not check the O2 tank and runs out of oxygen, I get dizzy and lightheaded. He stated it made him feel like I'm not a priority and it made me feel worthless. A review of Resident #10's medical record indicated he was admitted [DATE] with diagnoses that included Congestive Heart Failure, Respiratory Failure and Major Depressive Disorder. A review of his Brief Interview for Mental Status (BIMS) (A screening tool used to determine how well a resident was functioning cognitively. A score of 13-15 indicated a resident was cognitively intact.) indicated a score of 15. During an interview on 3/25/22 at 11:50 a.m., the Director of Nursing stated his expectation was for all staff to answer call lights immediately. He stated if they were not answered residents would experience incontinence or might fall if they tried to get out of bed. During an interview on 3/29/22, at 10:30 a.m., the Administrator stated the facility was not short staffed. He stated he had discussed it with the Director of Nurses and the issue with staff was they were not working efficiently enough. During an observation on 3/21/22, at 10:15 a.m., Resident #58 was observed laying on her back in bed with her pajamas on, in a dark room with the curtains pulled. During an observation and interview on 3/21/22, at 10:34 a.m., Resident #58 was observed laying on her back in bed with her pajamas on, in a dark room with the curtains pulled. She stated she would prefer to have the curtains open and see outside but her roommate sleeps in late. She stated she does not have anything to do. She stated no one has come in to speak with her about what activities she liked to do. She stated she cannot get out of bed for long because her back pain prevented her from moving around a lot. She stated she enjoyed socializing with her daughter or anyone who would come to her bedside. During an observation on 3/22/22, at 8:30 a.m., Resident #58 was observed laying on her back with the lights off and the curtains closed. A review of Resident #58's document titled admission RECORD, indicated she was admitted [DATE], with diagnoses that included Wedge Compression Fracture of Lumbar Vertebra (Collapsing of the spinal vertebra, resulting in severe back pain.), muscle weakness, kidney disease. A review of Resident #58's Minimum Data Set (MDS) (A health status screening and assessment tool used for all Residents.) indicated a Brief Interview for Mental Status(BIMS), (A test used to get a quick snapshot of how well a resident is functioning cognitively at the moment. A score of 8-12 was considered to be mildly impaired. Residents were considered cognitively intact if they were able to complete the BIMS and scored between 13 and 15.) score of 13. No Activity Care Plan was implemented. During an observation and interview on 3/22/22 at 4:11 p.m., Resident #31 was observed was observed laying on her back in her bed with the lights on, reading a book. She stated there are no activities offered on the weekends. She stated it would be nice if she was offered a daily newspaper. She stated the activities that are offered do not interest her. She stated she has to entertain herself or she would be bored. A review of Resident #31's medical record document titled admission RECORD, indicated she was admitted [DATE], with diagnoses that included Pressure Ulcers right hip (Injury to skin and underlying tissue resulting from infection or prolonged pressure on the skin.), Muscle Weakness, Kidney Disease, Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.), Osteoarthritis (A degenerative joint disease that was a type of arthritis that occurs when flexible tissue at the ends of bones wears down. Symptoms include Joint pain in the hands, neck, lower back, knees, or hips and gradually worsens over time.), and Heart Failure (Heart failure occurs when the heart muscle doesn't pump blood as well as it should. Blood often backs up and causes fluid to build up in the lungs (congest) and in the legs. The fluid buildup can cause shortness of breath and swelling of the legs and feet.) A review of Resident #31's MDS indicated a BIMS score of 13. A review of Resident #31's medical record did not indicate a care plan for Activities. A review for her care plan titled Pain: resident at risk for pain/discomfort related to: Wound and osteoarthritis, not dated, indicated Encouragement mobility, physical activity as tolerate. Offer/provide diversional activities as desired, to distract from pain. During an interview on 3/23/22, at 8:21 a.m., Licensed Staff F stated, I worked a lot of overtime. Licensed Staff F stated the facility was short staffed and it occurred more on the weekends. Licensed Staff F stated,I was told by the Administration that two Licensed Staff for 77 residents was the new normal. She stated things do not get done, like call lights do not get answered fast enough. Licensed Staff F stated there was no activity staff on the weekends for resident activities. She stated the activity calendar does not accurately reflect what activities are provided for residents. She stated the result of not having activities on the weekend was that residents were bored. She stated, I would be bored if I did not have anything to do. 3. During an interview on 3/23/22, at 11:30 a.m., Unlicensed Staff O stated there are no activity assistants on the weekends. She stated none of the residents have access to activities on the weekends. During an observation on 3/28/22, at 8 a.m., the activity calendar was reviewed. It indicated 3/26/22 10 a.m. Coffee Klatch, 10:30 Weekend Puzzles, 12:00 Daily Chronicle, 2:00 [NAME] Off The Record, 3:30 Sensory & Music. 3/27/22 10 a.m. Coffee & Company, 10:45 Patio Hour, 12:00 Chronicle, 2:10 Sunday Matinee: Blue Miracle, 4:00 p.m. Sensory & Music. During an interview on 3/28/22, at 8:14 a.m., Director of Nursing stated he did not know what activities occur on the weekends. He stated he did not know how bed bound residents had access to activities on the weekends. During an interview with Activity Director N, on 3/28/22, at 8:36 a.m., she stated there were no weekend activities since January. She stated the television controller in the community room was provided to the nurses who are supposed to turn on the television. She stated she was unaware if bed bound residents were provided iPad to use in their rooms for music or entertainment. She stated she did not know if it was documented, and activity staff do not document in the medical record. Activity Director N reviewed her communication folder for the weekend and stated there was no documentation to indicate any activities had occurred during the weekend. She stated the risk to residents who do not have access to activities on the weekend was boredom and depression. She stated bed bound residents and cognitively impaired residents who were not provided activities had the potential to experience depression and an increase in behaviors like yelling, aggression or wandering. During an observation on 3/28/22, at 10 a.m., the current Activity Calendar had post-it notes on every weekend day that indicated No Activities. During an interview on 3/28/22, at 8:46 a.m., Resident #55, #31 and #58 stated no activities had occurred or been offered over the weekend. During an interview on 3/29/22 at 10:11 a.m., Activity Director (AD) verified no available Activity staff on the weekend since January 2022. AD stated she expects Certified Nursing Assistants (CNA) to help with activities on weekends. AD stated there was a risk of residents being left alone, unattended, in the activity room when CNAs gets busy. AD stated residents would be at risk for depressed mood when there were no available staff to conduct activities on weekends. During an interview on 3/29/22 at 10:37 a.m., Licensed Nurse D verified there were no Activity staff available on weekends. Licensed Nurse D stated this would place residents at risk for mood changes and resident getting upset because there's nothing to do on the weekends. During an interview and record review on 3/29/22 at 11:04 with Administrator, in his office, he stated resident activities are supposed to happen every day. He stated on the weekends, the licensed nurses are supposed to make sure residents are offered activities. He stated there are enough nursing staff on the weekends to make sure activities have been offered and have occurred. Administrator stated that he spoke with Director of Nursing about staffing, and he stated the nurses just are not working efficiently enough. Administrator stated all the nursing staff had been informed of the expectation to provide resident activities on the weekends. During a review of the Quality Indicator Performance Improvement (QAPI) Binder minutes, it indicated Activity Director N had submitted concerns about an activity staffing shortage. Administrator stated QAPI had no concerns about the shortage. He stated the two Activity Assistants were graduating from Certified Nursing Assistant (CNA) training in the future , and he would continue to schedule them as Activity Assistants. He stated that conversation must be in his private notes that he had transcribed into the QAPI minutes. During an interview on 3/29/22 at 12 p.m., Licensed Staff M stated she had not been told the expectation for nurses was to ensure resident participated in or were offered activities. She stated she did not know what the weekend activities were or how to ensure residents had offered them. She stated she did not know what [NAME] Off the Record was or what Sunday Matinee: Blue Miracle was. She stated she does not document the daily activities provided for residents. During an interview on 3/29/22 at 12:15, Licensed Staff D stated he had not been told he was supposed to ensure residents were offered opportunities to go to activities. He stated he did not know what the activities on the activity calendar for the weekend were. He stated she did not know what the weekend activities were or how to ensure residents had offered them. She stated she did not know what [NAME] Off the Record was or what Sunday Matinee: Blue Miracle was. During an interview on 3/29/22 at 12:30 p.m., Unlicensed Staff Q stated he worked on Saturday and did not observe any activities offered to residents in the activity room or in the resident rooms. During an interview on 3/29/22 at 12:45 p.m., Unlicensed Staff R stated there are no activities offered by staff on the weekends. He stated some of the residents know how to turn on the television in the activity room, but no one planned or offered resident activities. A review of a facility Policy and Procedure titled Residents Rights, revised December 2016, indicated Employees shall treat all residents with kindness, respect, and dignity. 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. A review of a document titled FACILITY ASSESSMENT TOOL, dated March 2022, indicated Resident support / care needs, Bowel/bladder toileting programs, incontinence prevention and care .responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. A review of a facility Policy and Procedure (P&P) titled Group Programs and Activities Calendar, not dated, indicated The activities calendar states all activities available for the entire month, which may also include schedule in-room activities. A review of a facility P&P titled Activity Program, revised June 2018, indicated Activities are scheduled 7 (seven) days a week .All activities are documented in the resident's medical record. A review of document titled Activities Staff, indicated no Activity Staff were scheduled for Saturdays or Sundays. 4. During an interview on 3/22/22 at 8:59 .a.m., Resident 6 stated he was back on Physical Therapy (PT) services. Resident 6 stated PT had been stopped for a while and he was never placed in the RNA program. Resident 6 stated he could not recall when he last walked but he could propel himself in his wheelchair. Resident 6 stated he was not as strong as he used to be and could only go from the dining room to his room. A review of Resident 6's admission Record, dated 3/23/22, indicated Resident 6 was admitted on [DATE], with a diagnosis including Parkinson's disease (progressive nervous system disorder that affects movement), unsteady on feet, lack of coordination, muscle weakness, amongst others. A review of Resident 6's Nurses Progress Notes, dated 9/7/21, indicated Resident 6 was transferred to the Emergency Department because of a possible stroke affecting his upper left extremity and left side facial drooling. Resident 6's acute hospital History and Physical, dated 9/7/22, indicated Resident 6 had Parkinson's disease, which has caused significant right sided tremors and stiffness and acute CVA (cerebrovascular accident, stroke) causing left facial droop, left lower extremity weakness, dysarthria (motor speech disorder), CVA caused flaccid (floppy or without muscle tone) hemiparesis on left side, requiring Resident 6 to require significant assistants with ADLs (Activities of Daily Living: fundamental skills required to independently care for oneself, such as eating, bathing, and mobility), and swallowing difficulty. A review of Resident 6's PT care plan, initiated 9/15/21, indicated: Goal: stand by assist for bed mobility and for all functional transfers. Interventions: resident to continue PT 5 x/week x 4 weeks due to left hemiparesis. A review of Resident 6's Occupational Therapy (OT) care plan, initiated 9/15/21, indicated: Goals: Resident will demonstrate grooming and hygiene with set-up, upper and lower body dressing and bathing with moderate assistance, and self-feeding skills, toileting with moderate assistance. Interventions: Skilled OT 5 x week/4 weeks. Resident 6's OT care plan indicated another initiation date, 11/1/21, interventions: OT 5 x week/4 weeks. During an interview on 3/22/22 at 4:17 p.m., Director of Staff Development (DSD) A stated there was no RNA program since 10/2021 when the COVID (Coronavirus) outbreak came about. The facility was short staffed, and the CNA had to be pulled to work on the floor. The Director of Nursing (DON) confirmed there was no RNA program in progress. The DON stated the Speech Therapist was doing evaluations to see if residents needed to be in physical therapy, since residents were not receiving RNA services. During an interview on 3/23/22 at 10:20 a.m., the Director of Rehab said, Yes, the RNA program was put on halt. The Director of Rehab stated the RNA had to be put back on the floor to work as a CNA. The Director of Rehab stated Resident 6 had a stroke a while ago and when he first returned from the hospital, he was able to receive two months of physical therapy. The Director of Rehab stated it was upsetting because insurance companies like to cut off rehab services to residents' way to early. The Director of Rehab stated after a person has a massive stroke, they usually need at least a year of rehab services. The Director of Rehab stated he was finally able to get an authorization for Resident 6 to be placed back on physical therapy (PT). A review of Resident 6's Order Summary Report, dated 3/2022, indicated Resident 6 had an order for PT, start date 2/16/22. During the time Resident 6 was discharged from rehab services and reinstated, Resident 6 was not placed in the RNA program because it was put on halt due to lack of staff. The facility policy/procedure titled, Restorative Nursing Services. revised 7/2017, indicated: Policy Statement: Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation. 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitation services (e.g. physical, occupational or speech therapists). 2. Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in resident's care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview and record review the facility failed to ensure all staff were competent and trained for: 1. Abuse Prevention Training. 2. Infection Prevention. This had to potential for resident harm when: 1. Staff were not trained to recognize and respond to family and resident complaints of abuse to ensure resident safety. 2. Staff were unable to prevent cross contamination during resident care and result in resident infection. Findings: 1. During an interview and record review on 3/29/22 at 8:50 a.m., at Director of Staff Development A's desk, four employee files were reviewed for current documentation for Abuse Prevention Training. Abuse Prevention training documentation for Licensed Staff C indicated it was completed on 3/5/19. Review of Licensed Staff B's employee file indicated Abuse Prevention Training documentation completed on 3/18/20. Review of Director of Nursing file did not indicate any documentation for Abuse Prevention Training since date of hire on 9/13/21. Review of Director of Staff Development A's employee field did not indicate any abuse training documentation. Director of Staff Development A stated she could not find documentation that Licensed Staff B, Licensed Staff C and Director of Staff Development A and Director of Nursing had completed Abuse Prevention Training. She stated the risk of staff not receiving training and education on Mandated Reporter and Abuse Prevention training was they might not be able to know what to do if a resident or family member was abused or witnessed abuse. 2. During an observation on 3/21/22, at 10 a.m., in the activity room, staff were observed wearing gloves and serving coffee and snacks to residents. Staff were not observed to change gloves and engage in hand hygiene between providing food and beverages to residents. During lunch service on 3/21/22, at 1:30 p.m., staff were observed taking lunch trays into resident rooms and not offering them hand hygiene before or after meal service. During an observation on 3/23/22 at 2:20 p.m., Unlicensed Staff Q was observed entering Resident room [ROOM NUMBER] with a blood pressure machine. He was observed to take apply the blood pressure cuff directly to the skin of both residents, take the blood pressure reading, and remove the blood pressure cuff. Unlicensed Staff Q was not observed to engage in hand hygiene or disinfection of the blood pressure cuff or machine. At 2:27 p.m., He was observed to leave room [ROOM NUMBER] , not engage in hand hygiene and enter room [ROOM NUMBER]. Unlicensed Staff Q was observed to take the blood pressure on the resident in room [ROOM NUMBER], leave the room, not engage in hand hygiene or disinfection of the blood pressure cuff or machine. At 2:32 p.m. he was observed to enter Resident room [ROOM NUMBER], proceed to take the blood pressure on the resident in bed B, then and assist the Resident in bed A with a bed pan, without wearing gloves and to not engage in hand hygiene after he emptied the bed pan. He was observed to exit Resident room [ROOM NUMBER] without completion of hand hygiene or disinfection of the blood pressure cuff and machine. During an interview on 3/23/22 at 2: 45 p.m., Unlicensed Staff Q stated it was the facility Policy and Procedure to use hand hygiene between resident care. He stated he forgot to engage in hand hygiene between taking blood pressures on the residents in room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. He stated the risk of no hand hygiene between residents was infection. He stated the blood pressure cuff, and the blood pressure machine were disinfected with a blue top container. He stated he wiped the surfaces and just let them dry. He could not state how long the surface was supposed to stay dry to disinfect completely. He was unable to show me any blue top disinfectant wipes in Resident room [ROOM NUMBER], room [ROOM NUMBER], or room [ROOM NUMBER]. He stated he did not disinfect the blood pressure cuff or the machine between each resident. He stated the risk was spread of infection. During an observation and interview on 3/23/22 at 2:55 p.m., Director of Staff Development A stated staff were supposed to engage in hand hygiene between every resident. She stated if staff did not engage in hand hygiene it had the potential to result in resident infection. She stated blood pressure equipment was supposed to be wiped with a blue top disinfectant wipe. Director of Staff Development A stated these disinfectant wipes were available in every room and staff would have cleaned the outside of the blood pressure machine with the blue top wipe for 1-4 minutes and then used the red top disinfectant wipe on the blood pressure cuff. She stated the surfaces should have stayed wet for 1-4 minutes. She stated the blood pressure cuff was supposed to be cleaned with the red top disinfectant wipe. She stated if the equipment was not cleaned between resident use it had the potential for cross contamination and spread of resident infection. She stated all staff were oriented upon hire and should know this. During a document review and interview on 3.23.22 at 4:11 p.m., a review of the blue top disinfectant wipe container label indicated These wipes are sporicidal, virucidal, bactericidal and fungicidal and can be used to clean deodorize and disinfect hard, non-porous healthcare and environmental patient care equipment. A review of the red top disinfectant wipe container indicated .Will clean and disinfect hard, non-porous surfaces.To disinfect hard, non-porous surfaces, thoroughly wet the surface to be treated, .allow the treated surge to remain wet for 10 minutes. Director of Staff Development A stated Wow, I guess these were not supposed to be used on the blood pressure cuffs since it only worked on non-porous surfaces. She stated she did not know what the manufacturer's recommendations for disinfection and cleaning of the blood pressure cuff, or the machine were. During a concurrent interview and record review on 3/29/22 at 9:45 a.m., Director of Staff Development A and Infection Preventionist reviewed employee files and Inservice records at the desk of Director of Staff Development A. Director of Staff Development A stated I provided that training for every employee upon hire and at least annually. Infection Preventionist stated he had provided in services for Personal Protective Equipment and asked if that was Transmission Based Precautions. He stated Hand Hygiene was not provided as a formal Inservice with documentation, but an informal training when he saw someone who was not doing it correctly. Review of Unlicensed Staff R, Unlicensed Staff Q, Occupational Therapist U, Director of Nursing, Licensed Staff C and Licensed Staff B and Unlicensed Staff CC did not indicate any documentation of a completed and validated new employee competencies, infection prevention competency validation, training, or Transmission Based Precaution training in their employee file. Director of Staff Development A stated there were around 84 employees she was responsible for providing training and competency validation. Review of Inservice documentation training for a Transmission Based Competency Inservice provided August 2021 and January 2022 indicated a total of 24 employee attended. A request for a copy of the documented in-services was not provided by the end of the survey. Review of a Policy and Procedure (P&P) titled Competency of Nursing Staff, revised May 2019, indicated Licensed nurses and nursing assistant employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program: and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents . Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: a. Preventing abuse, neglect and exploitation of resident property; .k. Infection control. Facility and resident-specific competency evaluations will include a. Lecture with return demonstration for physical activities; b. A pre-and post-test for documentation issues. Review of a P&P titled Handwashing/hand Hygiene, revised August 2019, indicated This facility considers hand hygiene the primary means to prevent the spread of infections.2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub . before and after direct contact with residents, after contact with a resident's intact skin, after removing gloves .8. Hand hygiene is the final step after removing and disposing of personal protective equipment. Review of a document titled FACILITY ASSESSMENT TOOL, dated March 2022, indicated Services and Care We Offer Based on our Residents' Needs .Infection prevention and control Identification and containment of infections, prevention of infections .Prevent abuse and neglect. Staff training/education and competencies Staff are consistently trained on the following training topics .Abuse, neglect and exploitation .Infection control.

Based on observation, interview and record review, the facility: 1) Failed to ensure the consulting Pharmacist's (Consultant L) review of medications identified and addressed irregularities with Resident 38's physician order for rapid-acting insulin (medication to treat high blood sugar in diabetics; onset of action is within 15 minutes). This failure resulted in Consultant L not addressing and potentially correcting the timing and administration of Resident 38's insulin (designed to be given with meals) and potentially impairing the control of his blood sugar; and, 2) Failed to ensure Pharmacy services provided physician ordered medications when Vitamin D was not onsite and available for one resident (Resident 14) . This failure caused Resident 14 to miss two days of Vitamin D ordered by her physician. Findings: 1) Review of Resident 38's MAR indicated Resident 38's nurses were to administer tube feedings (liquid nutrition delivered via a tube inserted through the wall of the abdomen directly into the stomach) at midnight, 4 a.m., 8 a.m., 12 noon, 4 p.m., and 8 p.m. Review of Resident 38's MAR (medication administration report; nurses document medications administration and other interventions here) indicated his physician ordered him to receive, Insulin Lispro (rapid-acting insulin) .subcutaneously (injection under the skin into the soft tissue) four times a day for DM (diabetes) . The MAR indicated the Insulin Lispro was timed to be given at midnight, 6 a.m., 12 noon, and 6 p.m. (The Insulin was not timed in conjunction with the tube feeding schedule at 8 a.m. and 8 p.m.). Online review of Insulin Lispro directions for use indicated, Insulin Lispro suspension .is usually injected within 15 minutes before a meal or immediately after a meal . (https://medlineplus.gov/druginfo/meds/a697021.html) During an interview on 3/25/22 at 10:34 a.m., the DON was asked about the schedule for rapid-acting insulin. The DON looked up rapid-acting insulin on the Internet and stated it should be given five to ten minutes prior to a meal and per manufacturer's guidelines. During a telephone interview on 3/25/22 at 3:30 p.m., Nurse Practitioner K (NP K) stated rapid-acting Insulin should be given approximately ten minutes prior to meals. NP K was asked about Resident 38's Insulin Lispro not aligning with his tube feedings. NP K stated she should have noticed that. When asked if nursing staff should have called her to question the order (to get clarification), NP K stated she would have liked to know this so she could have addressed it. During a telephone interview on 3/25/22 at 4:05 p.m., Pharmacy Consultant L stated he performed the monthly reviews of resident medications. Consultant L was asked why Resident 38's Insulin Lispro was not timed to coincide with his tube feedings. Consultant L stated he had not noticed that discrepancy. When asked what he would have done had he noticed it, Consultant L stated he would have notified the physician or spoken to nursing staff about re-timing (changing the times of administration) the Insulin. Consultant L sated he would recommend Lispro was timed closer to tube feeding administration. Review of facility policy titled, Pharmacy Services Overview, subtitled Policy Interpretation and Implementation (revised April, 2019) indicated, 1. Pharmaceutical services consists of: .c. The process of identifying, evaluating and addressing medication-related issues . 2) During a medication pass observation on 03/23/22 at 8 a.m., LN F administered Resident 14 her morning medications. LN F stated the Vitamin D 1000 IU (international units; the dose) was missing (the facility only had Vitamin D 800 IU). LN F called Residents 14's physician and stated the doctor instructed her to hold the Vitamin D until the correct dose was delivered to the facility. Review of Resident 14's medication administration report (MAR; location in the electronic medical record where medication administration is documented) indicated her physician ordered her to receive, Vitamin D Tablet 1000 unit .by mouth one time a day . The MAR indicated the medication was scheduled for 0900 (9 a.m.). On 3/23/2022, the licensed nurse documented the numbers 9 and 7 (indicating the medication was not given) and on 3/24/2022 and 3/25/2022, the nurse documented H (On hold by physician). During an interview in the DON's office on 3/25/22 at 5:20 p.m., the DON was queried about medication administration at the facility. When asked why Resident 14's Vitamin D was not available for two days (3/23/22 and 3/24/22), the DON stated a staff member called about it on Wednesday (3/23/2022) and a staff member called about it again yesterday (3/24/2022). The DON stated he expected the Vitamin D to be delivered that day (3/25/22), but it had not been delivered to the facility. The DON stated facility staff went to a local drugstore (prior to the interview) to purchase the Vitamin D and it was subsequently administered to Resident 14 (on 3/25/2022). At the time of the interview, the DON confirmed the Vitamin D had not yet been delivered (by their pharmacy vendor) to the facility. Review of facility policy titled, Pharmacy Services Overview, subtitled Policy Interpretation and Implementation (revised April, 2019) indicated, 4. Residents have sufficient supply of their prescribed medications and receive medications .in a timely manner. Review of facility policy titled, Medication and Treatment Orders, subtitled, Policy Interpretation and Implementation (Revised July 2016) indicated, 11. Drugs .that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Pharmacy Consultant L's recommendation to attempt a dose reduction for the antidepressant Mirtazapine for one of 25 sampled residents (Resident 59) was sent to Resident 59's physician. Pharmacy Consultant L identified Resident 59 had not had any reported instances of restlessness in the past five months, but Resident 59 continued on Mirtazapine 15 mg (milligrams). This failure had the potential for the Resident 59 to have adverse consequences such as increased sleepiness, increase hunger, weight gain, amongst other adverse side effect, which could have negatively impact Resident 59's physical, mental, and psychosocial well-being. Findings: A record review of Pharmacy Consultant L's Drug Regimen recommendations, Pharmacy Consultant L noted that Resident 59 had been on Mirtazapine 15 mg since 2/28/21. The drug regimen review titled, Note to the Attending Physician/Prescriber, dated 8/5/21, recommended Resident 59's attending physician attempt a dose reduction of Mirtazapine to 7.5 mg because Resident 59 had zero reported instances of restlessness since 2/2021. Resident 59's attending physician had not addressed the request. No box was checked Agree, Disagree, or Other, and the form was not dated and/or signed. There was no indication the Note to the Attending Physician/Prescribe was ever sent to Resident 59's attending physician. A review of Resident 59's admission Record indicated Resident 59 was admitted on [DATE], with a diagnosis including alcoholic cirrhosis (scarring) of the liver, alcohol abuse, skin cancer, anxiety disorder, liver cell carcinoma, major depression, amongst others. A review of Resident 59's MAR (Medication admission Record), dated 3/28/22, indicated Resident 59 was on Mirtazapine 15 mg, start date 2/18/21. A review of Resident 59's Mirtazapine care plan, revision date 7/7/21, indicated: Interventions: Give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness. Antidepressant side effects: dry mouth, dry eyes, constipation, urinary retention, suicidal ideations. During an interview on 3/28/22 at 12:45 p.m., the Director of Nursing (DON) described how he followed through with the pharmacy consultant's recommendation(s) as follows: I separate per Antibiotic Stewardship, Nursing, and Physician. [For] the pharmacy consultant's requests to the physician, I fax and keep a copy [of] fax verification. DON stated, This request looks as if the 'Note to the Attending Physician/Prescriber,' dated 8/5/21, was never sent to [Resident 59's] attending physician for review. During an interview on 3/28/22 at 12:55 p.m. the Administrator stated the facility did not have a DON in 8/2021 and the first week of 9/2021. There was a DON consultant available. During a interview on 3/28/22 at 2:12 p.m. Physician GG was asked about Pharmacy Consultant L's request for Resident 59's Mirtazapine 15 mg to be decreased to 7.5 mg. Physician GG stated if the pharmacy consultant had written a Note to the Attending Physician/Prescriber recommending a dose reduction, the document would have been faxed or placed in Physician G's binder whereby he would have addressed the request by checking a box, and then signed and dated the document. Physician GG stated he would then write a Progress Note, write a note on the resident's lab work, or make a change in the order. Physician GG stated if he did not sign the pharmacy consultant's request, indicating he agreed, disagreed, or other, and signed/dated the request form, then he did not receive the request. The facility policy/procedure, revised 5/2019, indicated: . Policy Interpretation and Implementation: 11. If the Physician does not provide a timely or adequate response, or the Consultant Pharmacist identifies that no action has been taken, he/she contacts the Medical Director or (Medical Director is the physician of record) the Administrator. 12. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it .

Based on observation, interview, and record review, the facility failed to ensure safe and accurate medication administration when the nursing medication error rate was 19.23%. Licensed nurse F (LN F) did not give Resident 14 her scheduled dose of Vitamin D (as it was not available) and LN D gave Resident 33 his morning medications, scheduled for 9 a.m., approximately 1 hour and 47 minutes late. These failures: 1) Caused Resident 14 to miss two days of Vitamin D ordered by her physician, and 2) Caused Resident 33 to receive his medications for blood pressure, seizures, and diabetes (to control blood sugar) almost 2 hours late, potentially impacting the control of his blood pressure, seizures and blood sugar. Findings: 1. During a medication pass observation on 03/23/22 at 8 a.m., LN F administered Resident 14 her morning medications. LN F stated the Vitamin D 1000 IU (international units; the dose) was missing (the facility only had Vitamin D 800 IU). LN F called Residents 14's physician and stated the doctor instructed her to hold the Vitamin D until the correct dose was delivered to the facility. Review of Resident 14's medication administration report (MAR; location in the electronic medical record where medication administration is documented) indicated her physician ordered her to receive, Vitamin D Tablet 1000 unit .by mouth one time a day . The MAR indicated the medication was scheduled for 0900 (9 a.m.). On 3/23/2022, the licensed nurse documented the numbers 9 and 7 (indicating the medication was not given) and on 3/24/2022 and 3/25/2022, the nurse documented H (On hold by physician). During an interview in the DON's office on 3/25/22 at 5:20 p.m., the DON was queried about medication administration at the facility. When asked why Resident 14's Vitamin D was not available for two days (3/23/22 and 3/24/22), the DON stated a staff member called about it on Wednesday (3/23/2022) and someone called about it again yesterday (3/24/2022). The DON stated he expected the Vitamin D to be delivered that day (3/25/22), but it had not been delivered to the facility. The DON stated facility staff went to a local drugstore (prior to the interview) to purchase the Vitamin D and it was subsequently administered to Resident 14 (on 3/25/22). At the time of the interview, the DON confirmed the Vitamin D had not yet been delivered (by their vendor) to the facility. Review of facility policy titled, Medication and Treatment Orders, subtitled, Policy Interpretation and Implementation (Revised July 2016) indicated, 11. Drugs .that are required to be refilled must be reordered from the issuing pharmacy not less than three (3) days prior to the last dosage being administered to ensure that refills are readily available. 2. During a medication pass observation on 03/23/22 at 10:47 a.m., LN D administered Resident 33 his morning medications including Lisinopril (used to treat high blood pressure/hypertension), Keppra (used to control seizures), Glipizide (used to treat high blood sugar levels caused by diabetes), and Metformin (used to treat high blood sugar levels). After the medications were given, LN D was asked if Resident 33's medications were scheduled for 9 a.m. and LN D stated, yes. When asked why they were given late, LN D stated the medications were late because, I got behind. LN D stated he was passing medications for twenty-two residents that morning, and he did not normally work in Resident 33's hall, therefore, he stated he did not know the residents well in this assigned hall, and it took longer to administer medications for residents he did not know. When asked when he last worked in Resident 33's hall, LN D stated it was approximately two weeks earlier. When asked if he passed medications late on that occasion, LN D stated he did not remember. Review of Resident 33's medical record revealed a document titled, Medication Admin (administration) Audit Report (dated 3/23/2022) indicated LN D documented administering Metformin, Glipizide, Keppra (Levetiracetam), and Lisinopril on 3/23/2022 at 10:59 a.m. (almost two hours late). During an interview on 03/25/22 at 10:34 a.m., the Director of Nursing (DON) was queried about late medication administration at the facility. The DON stated he was not aware specific medications were late. but stated he had seen (in the past) nurses administering medication late at 10:30 (a.m.). He stated these late medication administration incidents were related to an emergency situation that arose. During a telephone interview on 3/25/22 at 3:48 p.m., Nurse Practitioner K (NP K, who worked with the medical director) was queried about late medication administration at the facility. NP K was notified the medication error rate was over 19% and she stated she was not aware late medication administration was an issue at the facility and that it was contributing to medication errors. When asked, NP K stated she was not aware if the facility's Medical Director had been notified. During a telephone interview on 3/25/22 at 4:05 p.m., the Pharmacy Consultant (Consultant L) was queried about late medication administration. Consultant L stated Metformin should be taken with food and that late administration of Glipizide and Metformin could potentially cause impaired blood sugar control and they should be given on a regular schedule. During an interview in the DON's office on 3/25/22 at 5:20 p.m., the DON was asked to identify medication administration rights (guide to clinical medication administration to ensure patient safety) and he stated medication rights included right name (of the resident), right dose, right route (oral, injection, etc.) right time, right medication, and right documentation. Review of facility policy titled, Medication Administration Schedule, subtitled, Policy Interpretation and Implementation (Revised November 2020) indicated, 3. Scheduled medications are administered within one (1) hour of their prescribed time . 4. Scheduled medications designated as time-critical (medications that may cause harm or sub-therapeutic effect if administered before or after the scheduled time) are administered at the scheduled time .or within 30 minutes of the scheduled time . 5. Time critical medications are designated by the pharmacy and include: . e. medications that need to be administered before, with, or after meals. Review of the Mayo Clinic's online website indicated people taking Keppra, .should try to take this medicine at the same time each day. (https://www.mayoclinic.org/drugs-supplements/levetiracetam-oral-route/proper-use/drg-20068010) Review of the Mayo Clinic's online website indicated Metformin . should be taken with meals to help reduce stomach or bowel side effects . (https://www.mayoclinic.org/drugs-supplements/metformin-oral-route/proper-use/drg-20067074).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free from medication error for one out of 25 residents, when one resident (Resident 17) was administered a medication without a physician's order. Resident 17 had an antifungal powder in use at his bedside which did not have a physician's order. This failure had the potential for ineffective treatment, unwarranted side effects, or an allergic response from using an antifungal medication product without the physician's order. Findings: During an observation and concurrent interview on 3/23/22 at 2:20 p.m., with Licensed Nurse D and Resident 17, the presence of Miconazole 2% powder (an antifungal powder used to treat fungal skin infections), was verified to be on Resident 17's bedside table. Licensed Nurse D stated that staff applied it on Resident 1's7 abdomen and groin. Licensed Nurse D verified Resident 17 had redness on his abdominal pannus (area of excess skin and fat that hangs over the pubic region) and left groin. Resident 17 stated the redness on his groin and pannus were uncomfortable and smelly. During an interview and concurrent medication administration record (MAR dated 3/2022) review with Director of Staff Development (DSD) and Licensed Nurse B on 3/23/22 at 4:44 p.m., Licensed Nurse B verified Resident 17 had an active order for a Nystatin powder (medication used to treat fungal skin infections) to treat Resident 17's skin issues. Licensed Nurse B verified the presence of Miconazole 2% antifungal powder on his bedside table. Licensed Nurse B verified Miconazole 2% antifungal powder had no physician's order. Licensed Nurse B stated the risk of using an incorrect or unauthorized medication included ineffective treatment and inappropriate use of medication. Licensed Nurse B stated this was a safety risk. During an interview and concurrent Physician order review on 3/24/22 8:49 a.m., with Director of Nursing (DON), verified there was no physician's order for the Miconazole 2% antifungal powder. DON stated Resident 17 was at risk for non-healing and worsening of skin issues since he was not receiving the prescribed medication. During an interview on 3/24/22 at 8:53 a.m. with Licensed Nurse E, stated that administering medication without physician's order is considered a medication error. Licensed Nurse E stated the risks includes skin issues not resolving or worsening, and ineffective treatment Review of the facility's policy and procedure titled Medication Orders dated [DATE], stated it's purpose was to establish uniform guidelines in the receiving and recording of medication order. The policy stated treatment orders should specify the treatment frequency and duration of treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on food storage observation, dietary staff and resident interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by: 1. The facility did not ensure food temperature and palatability, 2. Penne pasta was being cooked 2 hours or longer prior to the beginning of meal service, 3. Recipes where not followed, and, 4. Broccoli mushy and grayish green, pureed spinach had a gluey texture causing pureed spinach hard to swallow, and the pureed meatloaf tasted like the added thickener (additive to pureed foods to make a pudding-like consistencies), no flavor. Failure to ensure food distribution and food production systems that ensured food palpability and nutritional content may result in decreased dietary intake, which may result in weight loss and further compromise resident medical status. Findings: 1. During an interview on 3/21/22 at 11:39 a.m. Resident 59 stated the soup was always cold. During interview on 3/29/22 at 12:38 p.m., Resident 59 stated the soup was always cold and tasted as if it came right out of a can. During an interview on 3/25/22 at 10:00 a.m., the DDS stated [NAME] S started working as a cook in 11/2021 but did not get checked off on kitchen competencies until 3/2022. The DDS stated dietary staff competencies should have been completed upon hire and annually. The DDS stated, Yes, there has been issues with the cooks taking and recording food temperatures once on the steam table and prior to plating residents' meal. The DDS stated food temperatures should be taken before plating residents' meal to make sure bacteria cannot grow to prevent residents from becoming ill and for palatability. The DDS stated food temperatures should be taken on the entrée, starch, vegetables, and soup. The DDS stated the cooks logged the food temperatures. The DSS stated she did remind the cooks to log the food temperatures, but she felt they forgot to document the temperatures. The DDS stated if the food temperatures were not documented, then the food temperatures were not taken. The DSS stated it was a safety factor for the residents if food temperatures were not taken. Foodborne illness could occur if meat, etc., was not cooked or chilled per guidelines. A review of the Food Temperature Logs, from 10/24/21 through 3/20/22, indicated the cooks were not taking the hot food temperatures of the meal entrees, starch, vegetables, and soup prior to plating the residents' meal. On 10/30/21, 12/19/21, 1/27/22, 2/25/22, and 3/18/22 food temperatures were not taken for breakfast. On 10/30/21, 11/5/21, 11/6/21, 11/11/21, 11/18/21, 11/20/21, 11/22/21, 12/9/21, 12/15/21, 12/19/21, 1/14/22, 1/27/22, 2/25/22, and 3/11/22 food temperatures were not taken for lunch. On 10/24/21, 10/30/21, 10/31/21, 11/5/21, 11/6/21, 11/15/21, 11/16/21, 11/20/21-11/22/21, 11/30/21, 12/1/21, 12/4/21-12/5/21, 12/14/21, 12/20/21, 12/27/21-12/28/21, 12/31/21, 1/4/22- 1/15/22, 1/18/22, 1/20/22-1/21/22, 1/25/22, 1/28/22-1/29/22, 2/1/22, 2/4/22-2/8/22, 2/11/22-2/12/22, 2/19/22-2/20/22, 2/26/22, and 3/9/22 food temperatures were not taken for dinner. This resulted in temperatures for soups, pasta, casseroles, turkey, pork, fish, ham, hamburger, beef, chicken, eggs amongst others not being taken. A review of the Food Temperature Logs, from 10/24/21 through 3/20/22, indicated dietary aides were not taking temperatures on residents' milk and juice prior to placing on the residents' meal tray. On 11/7/21, 11/8/21, 11/12/21-11/13/21, 11/21/21-11/22/21, 11/26/21-11/27/21, 12/18/21, 12/22/21, 12/24/21-12/25/21, 1/2/22, 1/7/22-1/8/22, 1/10/22-1/12/22, 1/14/22-1/16/22, 1/19/22, 1/21/22-1/23/22, 1/27/22, 1/29/22-1/31/22, 2/5/22-2/6/22, 2/17/22, 2/25/22-2/26/22, 3/5/22, and 3/9/22, milk and juice temperatures were not taken for breakfast. On 11/6/21, 11/8/21, 11/12/21-11/13/21, 11/20/21-11/22/21, 11/26/21-11/27/21, 12/18/21-12/20/21, 12/22/21, 12/24/21-12/25/21, 1/2/22, 1/6/22-1/8/22, 1/10/22-1/12/22, 1/14/22-1/15/22, 1/20/22-1/23/22, 1/27/22, 1/29/22-1/31/22, 2/5/22-2/6/22, 2/25/22-2/26/22, and 3/5/22, milk and juice temperatures were not taken for lunch. On 11/8/21, 11/12/21, 11/20/21-11/22/21, 11/26/21-11/27/21, 12/11/21, 12/18/21-12/19/21, 12/25/21, 1/2/22, 1/6/22-1/8/22, 1/10/22-1/15/22, 1/20/22-1/24/22, 1/26/22-1/31/22, 2/1/22, 2/5/22-2/6/22, 2/13/22-2/15/22, 2/19/22, 2/25/22-2/26/22, 3/5/22, and 3/7/22-3/8/22, milk and juice temperatures were not taken for dinner. A review of [NAME] S's personnel record indicated he was hired as a cook on 11/12/21. A review of [NAME] S's kitchen Employee Orientation Checklist, indicated he was not signed off on competency for Taking and Recording Temperatures for Trayline until 3/1/2022. During an interview on 3/24/22 at 8:47 a.m., [NAME] S stated he received three days of partial training as a cook, but was not trained on regulatory requirements. During an interview on 3/28/22 at 8:30 a.m. the DDS stated that training depended on how fast the new hire understood the kitchen/food processes. The DDS stated if soup was on the menu, the cook should have taken the temperature of the soup before sending the soup out to the residents. The DDS stated the temperature of hamburger patties should be taken before plating the hamburger patty. The facility policy/procedure titled, . 3. Meal Service, dated 2018, indicated: The food will be served on trayline at the recommended temperatures as below and recorded on the daily therapeutic menu in the temperature column of the regular food and next to the food item under therapeutic diet column of each food served. Hot food serving temperature must be at or above minimum holding temperature of 140º F. The temperatures may also be recorded on a temperature log. The temperature of the foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperatures. Soups and hot beverage service temperature: 170-190º F, Cream Soup: 160-170º F, Meat, casseroles, potatoes, rice, pastas, beans, vegetables, gravies, sauces, and hot cereal: 160-180º F, grilled cheese sandwich, omelets, scrambled eggs, bacon:150-170º F, pancakes, toasted items, French Toast (made with pasteurized eggs) 140º F or higher, milk, pudding, and salads: 41º or less, fruit juice: may be served at room temperature or chilled . 7. Temperatures of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot . The facility in-service titled, Food Preparation, dated 10/2018, indicated: Objectives: Participants will understand the importance of: Proper cooking techniques, which conserve nutritive value and produce eye appealing and palatable foods. Safe food handling to prevent foodborne illness . In-Service: . To prepare an attractive and palatable product, food must be handled carefully throughout receiving, storage preparation and service. Moreover, it is important that food is prepared by methods that conserve nutritive value, flavor, and appearance . General Food Preparation: . Food must be held at proper temperature (above 140º F, below 41º F) throughout tray line to avoid growth of harmful bacteria that can cause illness or even death . 2. & 3. During the initial tour of the kitchen on 3/23/2022 at 9:33 a.m., the Director of Dining Services (DDS) stated breakfast was at 7:30 a.m., lunch at 12 noon and dinner at 5 p.m. During the initial tour of the kitchen on 3/21/22 at 9:43 a.m., observed [NAME] S pouring Penne pasta into a colander (kitchen utensil to strain pasta) to drain the hot water. [NAME] S stated he was going to cool down the Penne pasta in the refrigerator for 2 hours to get the temperature down to 71º F and then the temperature of the Penne pasta needed to cool down to 40º F within 4 hours. [NAME] S stated he was going to place the Penne pasta in the steamer to reach 140º F before putting the Penne pasta on the steam table. During a concurrent interview and dining observation on 3/21/22 at 12:39 p.m., Resident 57, who was on a Chopped Meat/Chopped Vegetable Regular diet, did not like the Penne pasta. Resident 57 stated the pasta was tasteless and she did not like the green beans. Resident 57 did not eat any of the pasta. During an interview on 3/21/22 at 11:34 a.m., Resident 65 stated the food was horrible. The food did not go well together. During an interview on 3/21/22 at 12:54 p.m., Resident 65 stated she could not eat the green beans because they were to hard to stab with her fork to pick-up. Resident 65 stated the penne pasta had no flavor. Resident 65 stated she was not going to eat. Resident 65 ate 25% of her lunch. During a concurrent observation and interview 3/21/22 at 1:06 p.m., Resident 29 was upright in bed trying to feed herself. Resident 29 was on a Mechanical Soft, Regular diet with Thick Fluids-Nectar. Unlicensed Staff CC was asked to help Resident 29 with her green beans because Resident 29 could not stab the green beans, to hard. Unlicensed Staff CC stated all the residents' green beans were hard and the chicken was a little hard. Unlicensed Staff CC told Resident 29 not to eat the green beans because the green beans did not have a Mechanical Soft texture. During an observation and interview 3/21/22 at 2:56 p.m., Resident 48 stated he was a retired cook from the Navy. He stated the pasta serving was overcooked and mushy. He stated when he tried to pick it up with his fork it was so soft it fell apart. He stated it was soggy and pretty bland. During an interview on 3/23/22 at 8:45 a.m., [NAME] S stated he cooked the Penne pasta (starch on lunch menu) early on Mon, 3/21/22 to help him stay ahead of lunch preparation. [NAME] S stated he was the only cook and wanted to get the Penne pasta out of the way. [NAME] S stated he would cook the Penne pasta al [NAME] (tender but still firm to the bite), then before placing on steam table he would place the Penne pasta in the steamer for about 15 seconds. [NAME] S stated it was not impossible to cook the Penne pasta right before placing on the steam table, just a little difficult because he was the only cook. [NAME] S stated the green beans came out tough because he tried to separate textures: al [NAME] and mashable. [NAME] S stated he tried to prevent the green beans from looking brown, which could be caused from being on the steam table. The DDS stated she bought a different frozen brand of green beans and felt that had something to do with the outcome of the beans not cooking; turning out tough/hard. The dietary recipe titled, Parsley and Herb Penne, undated, indicated: Directions: 1. To add Penne to boiling water. Boil until tender, about 10-15 min. 2. Drain and rinse. 3. Add margarine, parsley, basil and pepper. Heat to temperature. 4. Serve on trayline at the recommended temperature of 160-180º F. Note: there was no mention of cooking the Penne pasta early, cooling the pasta down, and then steaming the pasta before placing the pasta dish on the steam table. The dietary recipe titled,Green Beans with Garlic, undated, indicated: . Special Diets: . Mechanical Soft: Soft. Chop if desired . Dysphagia (difficulty in swallowing): Cut green beans, chop to half-an-inch, mashable. During an interview on 3/23/22 at 10:10 a.m., [NAME] S stated he was cooking the meatloaf in the oven on 350º F for 45 minutes During an interview on 3/23/22 at 11:40 a.m., [NAME] S stated he pureed the meatloaf by adding hot water with a little bit of thickener (mixed with purees and other liquids in order to alter their consistency) to the meatloaf and then blended the meatloaf in the food processor. During an interview on 3/23/22 at 12:05 p.m., [NAME] S stated he did not cook the vegetables all the way through before mixing into the raw meatloaf and placing the meatloaf into the oven. [NAME] S stated he felt this caused the meatloaf to temp low when he pulled it out of the oven. He needed to return the meatloaf back into the oven two more times before the meatloaf temperature reached 155º F. The dietary recipe titled, Garden Fresh Meatloaf, undated, indicated: Cooking Time: one-and-half to two hours. Temperature: 325º F . 2. Heat margarine or oil in skillet and saute vegetables and Italian seasonings until vegetables are tender, approximate three to five minutes . 4. On 3/23/22 at 12:53 p.m. a lunch test tray it was noted by surveyors and the DDS, the broccoli was mush and grayish/green in color, the pureed spinach had a gluey texture, hard to swallow, and stuck to one's palate (roof of the mouth). The regular meatloaf had no flavor, did not crumble apart like hamburger and dry. The pureed meatloaf tasted like the thickener/no flavor. The DDS agreed and stated there was to much thickener used for the pureed spinach and meatloaf. The cook should have followed follow manufactures direction for adding the thickener. During an interview on 3/24/22 at 8:47 a.m., [NAME] S stated he pureed the meatloaf in the food processor. The temperature of the meatloaf was 160º F. [NAME] S stated he added one cup thickener and two cups of hot water plus a little gravy following the instructions on the thickener container. [NAME] S stated to puree the cooked spinach to have the texture of pudding, he added one-and-one half cups thickener and two cups hot water. A review of the resident's dietary cards indicated there were ten residents on a pureed diet (foods that do not need to be chewed, such as mashed potatoes, a pudding like texture). The dietary Therapeutic Spread Sheet, dated 3/23/22, indicated residents on a pureed diet received a half a cup of Garden Fresh Meatloaf, so for ten residents, five cups of meatloaf needed to be pureed. The dietary recipe titled, Pureed Meats, dated 4/2017, indicated: Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a pasted consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy). Recommended amounts of liquid for Twelve Servings: 1 1/2 to 3 cups of warm liquid to six to twelve tablespoons (3/8 to 3/4 cup) commercial instant food thickener. The dietary Therapeutic Spread Sheet, dated 3/23/22, indicated residents on a pureed diet received 1/3 cup of Spinach AuGratin, so for ten residents, three- and one-half cups if spinach needed to be pureed. The dietary recipe titled, Pureed Vegetables, undated, indicated: Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a pasted consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk). Recommended amounts of liquid for Twelve Servings: 1/4 to 3/4 cup of warm liquid to six to twelve tablespoons (3/8 to 3/4 cup) commercial instant food thickener. During an interview on 3/24/22 at 8:47 a.m., [NAME] S stated he received three days of partial training as a cook, but was not trained on regulatory requirements. A review of [NAME] S's kitchen Employee Orientation Checklist, indicated he was not signed off on competency for Food storage - Cold foods - Food temperature danger zone . Use of recipes, spreadsheet . Taking and Recording Temperatures for Trayline . until 3/1/2022. During an interview on 3/25/22 at 10:45 a.m., [NAME] BB stated if you use to much thickener for pureed food, the food loses its flavor. [NAME] BB stated if the cook followed the recipe, the meal should turn out good/palatable. [NAME] BB stated it was very important for the food to taste good/flavor important. [NAME] BB stated there was no point in cooking pasta, such as spaghetti, at 10 a.m., when residents' lunch was not plated until 12. [NAME] S should not have cooked the Penne pasta early. [NAME] BB stated she would have cooked the pasta around round 11 a.m., prepared the dish and kept the dish warm in the oven. [NAME] S stated if you cooked the pasta early, the pasta would become soggy/lose its texture. [NAME] BB stated the meatloaf should have been cooked for 1 to 1.5 hours, not 45 min. [NAME] BB stated she saw [NAME] S keep on pulling the meatloaf out of the oven to check the temperature. [NAME] BB stated [NAME] S should have left the meatloaf alone and just let the meatloaf cook per the recipe instructions. [NAME] BB stated [NAME] S was not following the Meatloaf recipe. [NAME] BB said, Why pull out 3 times to check temperature? The facility job descriptions titled, Position [NAME] A & Position [NAME] B, dated 2018, indicated: Qualifications: . 3. Ability to accurately measure food ingredients and portions . Duties and Responsibilities: .6. Check menu for thawing of meat . The dietary document titled, In-Service: Food Preparation, dated 10/2018, indicated: Objectives: Participants will understand the importance of: Proper cooking techniques, which conserve nutritive value and produce eye-appealing and palatable foods. Safe handling to prevent foodborne illness. In-service - Introduction: Residents in long-term care facilities may have poor appetite due to their disease stated or the medications they are taking. As the Food and Nutrition Cook, you have an important role in caring for the residents in your facility, by helping to prepare attractive food with good flavors. Eye-appealing and palatable foods help stimulate the appetite, which in turn help residents to eat well and be healthy. Definitions: Food palatability refers to the taste and/or flavor of the food . General Food Preparation: It is important to use a standard recipe, which specifies amounts and proportions or ingredients . The cook who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency . Do not serve poorly prepared food . Prepare foods as close as possible to serving time to preserve nutrition, freshness and to prevent overcooking .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare a meal tray with the individual diet consistency for two of 25 sampled residents (Resident 6 and Resident 29). when 1) Resident 6's physician order for a regular diet (example: sandwich) once a week, on Saturdays, did not reflect Resident 6 was receiving on Saturdays, and 2) Resident 29, who was on a Mechanical Soft Diet (texture-modified diet that restricts foods that are difficult to chew or swallow) was served green beans that were hard. A review of residents' lunch Meal Card, dated 3/23/22, indicated fourteen residents were on a Mechanical Soft diet and two residents were on a Dysphagia Mechanical diet. This failure for the dietary department to prepare vegetables with a soft texture had the potential to cause Resident 29 and all residents on a Mechanical Soft diet or on a Dysphagia Mechanical diet to choke, leading to airway being blocked and possible death. This failure could result in decreased dietary intake, leading to residents not meeting their individual resident nutritional requirement, which may result in weight loss and further compromise residents' medical status. Findings: 1) A review of Resident 6's admission Record indicated Resident 6 was admitted on [DATE], with a diagnosis including Parkinson's disease (progressive nervous system disorder that affects movement), unsteady on feet, lack of coordination, muscle weakness, amongst others. A review of Resident 6's Nurses Progress Notes, dated 9/7/21, indicated Resident 6 was transferred to the Emergency Department because of a possible stroke affecting his upper left extremity and left side facial drooling. Resident 6's acute hospital History and Physical, dated 9/7/22, indicated Resident 6 had Parkinson's disease, which has caused significant right sided tremors and stiffness and acute CVA (cerebrovascular accident, stroke) causing left facial droop, left lower extremity weakness, dysarthria (motor speech disorder), CVA caused flaccid (floppy or without muscle tone) hemiparesis on left side, requiring Resident 6 to require significant assistants with ADLs (Activities of Daily Living: fundamental skills required to independently care for oneself, such as eating, bathing, and mobility), and swallowing difficulty. A review of Resident 6's Order Summary Report, dated 3/2021, indicated Resident 6 was started on a regular pureed textured diet (foods have a soft, pudding-like consistency), start date 9/16/21. A review of Resident 6's Physician Orders, indicated: Patient may eat a regular diet, example, sandwich, once per week on Saturdays with 1:1 supervision, sitting up with aspiration (choking) precautions. Stop immediately if patient begins to choke, cough, order date 3/7/22. A review of Resident 6's Nutritional Risk care plan, initiated 2/23/21, interventions included: regular diet, mechanical soft texture (foods which can be pureed, finely chopped, blended, or ground to make them smaller, softer, and easier to chew, and thin liquids. Resident 6's Nutritional care plan was not updated to indicate Resident 6 was on a pureed diet, order date 9/16/21 nor was Resident 6's care plan updated to indicate he could have a regular diet once a week, on Saturdays, order dated 3/7/22. During an interview on 3/22/22 at 9:27 a.m., Resident 6 stated, The food was okay but always seems the same. I get potato, greens, and meat, but no flavor. I like when they have the pancakes so I can put syrup on it. I wish I could have that more often. Resident 6 stated he did not know about (food) choices, and that the facility slipped and gave me a sandwich once, which I liked. Resident 6 said, I cannot eat a regular diet and recently my soup was not pureed, it had potato in it. During an interview on 3/29/22 at 1:49 p.m., Licensed Nurse F stated she knew Resident 6 really well and stated he was on aspiration precautions and nurses needed to lemon swab Resident 6's mouth after meals. Licensed Nurse F stated she could see he could have a sandwich on Saturdays with assistance per doctor's orders, but she did not know if Resident 6 was receiving a Regular diet once a week, on Saturdays. Licensed Staff F stated nurses could have updated Resident 6's Nutritional care plan. During a review of Resident 6's MAR (Medical Administration Record), dated 3/2022, indicated: Patient may eat regular diet, example, sandwich once per week on Saturdays with 1:1 supervision, sitting up with aspiration precautions. Stop immediately if patient begins to choke, cough, every shift, start date 3/8/22. Resident 6's MAR indicated the order was being carried out by license nurses on the AM, PM and Night shift, from 3/8/22 through 3/25/22, AM shift, but Resident 6 was only to have a Regular diet once per week, on Saturdays. A review of Resident 6's Diet card indicated: Diet Order: Puree, Regular, Thick Fluids-Nectar texture, adaptive equipment: nosey cup (drinking cup with cut out for nose) and plate guard (curved to prevent food from falling off the plate and can be used as a barrier to push food against when scooping food onto a spoon or fork). Notes: Upright posture during intake, small sips/bites, alternate sips/bites, monitor for coughing and wet vocal quality. Oral care x 3 daily. Dislikes fish. There were no standing orders on Resident 6's meal card indicating a Regular diet once a week, on Saturdays. 2) A review of Resident 29's admission Record indicated Resident 29 was admitted on [DATE], with a diagnosis including [NAME] syndrome (are, acquired disorder characterized by abnormalities affecting the involuntary, rhythmic muscular contractions (peristalsis) within the colon), pseudobulbar affect (condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), cord compression (pressure on the spinal cord), major depression, anxiety, dysphagia (difficulty swallowing) amongst others. A review of Resident 29's lunch Meal Card, dated 3/23/22, indicate Resident 29 was on a Mechanical Soft, Regular , Thick Fluids-Nectar consistency. Resident 29 needed a plate-guard (curved to prevent food from falling off the plate and can be used as a barrier to push food against when scooping food onto a spoon or fork). During a concurrent observation and interview 3/21/22 at 1:06 p.m., Resident 29 was upright in bed trying to feed herself. Resident 29 was on a Mechanical Soft, Regular diet with Thick Fluids-Nectar. Unlicensed Staff CC was asked to help Resident 29 with her green beans because Resident 29 could not stab the green beans, too hard. Unlicensed Staff CC stated all the residents' green beans were hard and the chicken was a little hard. Unlicensed Staff CC told Resident 29 not to eat the green beans because the green beans did not have a Mechanical Soft texture. During an interview on 3/21/22 at 12:54 p.m., Resident 65 stated she could not eat the green beans because they were to hard to stab with her fork to pick-up. Resident 65 stated she was not going to eat. Resident 65 ate 25% of her lunch. During an interview on 3/23/22 at 8:45 a.m., [NAME] S stated the green beans came out tough because he tried to separate textures: al [NAME] (firm) and mashable. [NAME] S stated he tried to prevent the green beans from looking brown, which could be caused from being on the steam table. The DDS stated she bought a different frozen brand of green beans and felt that had something to do with the outcome of the beans not cooking, turning out tough/hard. The Therapeutic Spread Sheet, dated 3/21/22, indicated the Green Beans with Garlic served at lunch time, where to have a soft texture for Mechanical Soft diets and for Dysphagia Mechanical soft diet (texture-modified diet that restricts foods that are difficult to chew or swallow). The dietary recipe titled, Green Beans with Garlic, undated, indicated: . Special Diets: . Mechanical Soft: Soft. Chop if desired . Dysphagia (difficulty in swallowing): Cut green beans, chop to half-an-inch, mashable. The facility in-service titled, Food Preparation, dated 10/2018, indicated: Objectives: Participants will understand the importance of: Proper cooking techniques, which conserve nutritive value and produce eye appealing and palatable foods. Safe food handling to prevent foodborne illness . In-Service: . To prepare an attractive and palatable product, food must be handled carefully throughout receiving, storage preparation and service. Moreover, it is important that food is prepared by methods that conserve nutritive value, flavor, and appearance . General Food Preparation: . Food must be held at proper temperature (above 140º F, below 41º F) throughout tray line to avoid growth of harmful bacteria that can cause illness or even death . The policy/procedure titled, Therapeutic Diets, revised 10/2017, indicated: Policy Statement: Therapeutic diets are prescribed by Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. Policy Interpretation and Implementation: . 4. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet . 5. If a mechanically altered diet is ordered, the provider will specify the texture modification . The DDS was asked to provide the last Sanitation and Food Safety Checklist, completed by the RD. The latest Sanitation and Food Safety Checklist, signed and dated by the RD was completed on 9/24/21. The Sanitation and Food Safety Checklist, included the RD overseeing Food Preparation: . 13. Recipes are being followed . The facility job description titled, Dietary Manager, dated 1/2019, indicated: The primary purpose of your job position is to provide supervision for the Dietary Department ensuring quality food and Nutrition is meet in accordance with current federal, state and local standards, guidelines and regulations governing our facility. Supervise staff in the day-to-day facility operations of assigned areas. Direct and participate in food preparation and service of food that is safe, appetizing and is of the quality and quantity to meet each resident's needs in accordance with the physician's orders . Orient new staff . Communicate policies, assist and coach as needed. Monitor work assignments, provide feedback, and fulfill department head responsibilities. Maintains the proper temperature of food during preparation and service. Records food temperatures according to established policy . The facility job description titled, Registered Dietician, dated 9/2017, indicated: General Purpose: . Assist in coordination of nutrition care services with Dietary Supervisor . Essential Duties: Ability to meet all health, compliance, and competency requirements. Monitor food services operations to ensure conformance to nutritional, safety, sanitation, and quality standards, as well as state and federal regulations. Monitor food control systems such as food temperatures, portion control, preparation methods, garnishment, and preparation of food to ensure that food is prepared and presented in an acceptable manner . Note: there has not been a RD overseeing food services operations since 9/2021.

Based on observation, interview, and record review, the facility failed to ensure food preferences were honored for four of 25 sampled residents (Resident 31, 55, 57, and 58), when Resident 31's dislike for gravy was not being honored, Resident 57, who requested two packets of hot sauce with each meal, but was not receiving routinely, Resident 55 did not receive two glasses of milk on her meal tray per her diet card, and Resident 58 did not receive salad dressing for her salad. These failures could result in decreased dietary intake, leading to residents not meeting their individual resident nutritional requirement, which may result in weight loss and further compromise residents' medical status. Findings: During a concurrent trayline observation, interview, and meal card review on 3/23/22 at 12:15 p.m., Dietary Aide was observed placing Resident 57's plate on her meal tray. Resident 57's tray card indicated in capital letters: Standing Order: 2 x 2 tablespoons or 2 hot sauce packets. No hot sauce packets were placed on Resident 57's meal tray. When the dietary aide was asked what was missing from Resident 57's meal tray, she could not detect what was missing. The DSS then looked at Resident 57's meal tray and explained to the dietary aide Resident 57's hot sauce packets were missing. During an interview on 3/28/22 at 11:34 a.m., Resident 57 stated, Yes, often dietary forgets my hot sauce packets. I really like salsa on my food. A record review of Resident 57's weights indicated Resident 57's admission weight dated 2/18/21, was 97 pounds, and Resident 57's weight on 3/23/22 was 83.4 pounds, indicating Resident 57 was at risk for weight loss. A review of Resident 57's Nutrition care plan, Focus, initiated 2/18/21 and revised 3/2/21, indicated: Nutrition Status: At risk for nutritional problems related to new Admission, (paralysis of one side of the body) hemiplegia and hemiparesis (weakness or the inability to move one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (stroke), and dysphagia (difficulty swallowing). Goal, revised 3/10/2022, indicated: weight 100 - 110 pounds, no significant weight changes x 1, 3, 6 months, and maintain weight within an appropriate weight range. Interventions , initiated 2/18/21, indicated: offer meal alternatives, substitutes, supplements as appropriate. During an observation and interview on 3/21/22 at 3:42 p.m., Resident 55 stated the facility kept refusing to give her two milks. She stated she had requested it; it was on her diet card and documented as her preference. Resident 55 stated the facility staff kept either forgetting to get her milk or they gave her only one milk. She stated she had also told them she did not like Thousand Island Dressing and now the facility did not give her any salad dressing at all. She stated the staff were too busy to even read what the likes and dislikes were on the food preference card. A review of the meal card on her lunch tray indicated Diet Order: Regular, Thin Liquids Standing Orders . 2 X fl oz Milk 2% (TWO GLASSES). During an observation and interview on 3/22/22 at 12:35 p.m., unlicensed staff were observed to start passing lunch trays. Director of Staff Development A at 12:37 was observed at the meal cart and start checking meal trays. She stated a licensed nurse must always check the meals to ensure residents are receiving the correct physician ordered diet. She stated she was unaware staff had started to pass the lunch trays to residents without a licensed nurse checking them first. She stated the danger was residents could possibly receive the incorrect diet and possibly choke. She stated the facility Policy and Procedure stated licensed nurses must check the food trays before serving them to residents. During an observation and interview on 3/23/22 at 1:15 p.m., Director of Staff Development A was observed to check resident meal trays before staff served them to residents. During an observation and interview on 3/23/22 at 1:20 p.m., an observation of Resident 31's lunch tray showed chicken covered with a dark brown sauce. An observation of the diet card on her lunch tray indicated Dislikes - Gravy. Resident 31 stated it happened every single time, stating. It is like no one cared whether or not we get food we like. During an interview on 3/23/22 at 1:20 p.m., Resident 58 stated her lunch salad did not come with any salad dressing so Resident 31 shared her salad dressing with her. A review of her diet card indicated Dislikes, was empty and did not list salad dressing. During an observation and interview with Resident 55, on 3/23/22 at 1:30 p.m., she stated the facility served me carrots when my dislikes on the diet card clearly has 'dislikes carrots.' Resident 55 stated, they also did not bring me two milks today either. A review of Resident 55's diet card indicated Standing Orders: . 2 X 8 fl oz milk 2% (TWO GLASSES) Dislikes: . Carrots. She stated she did not ask for a substitution, but it just does not make a difference. She stated her meals are never served correctly. The Policy/Procedure titled, Resident Food Preferences, revised 7/2017, indicated: Policy Statement: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representatives consent. Policy Interpretation and Implementation: 1. Upon the resident's admission . the Dietician or nursing staff will identify a resident's food preferences. 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan . 11. The facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc.

Based on kitchen observations, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by 1) the facility did not follow its storage guidelines to store the bread, 2) the kitchen floor was dirty/sticky, and 3) garbage can lids were not on the garbage cans located underneath the cook's food prep counter. Failure to ensure effective dietetic services operations may result in placing residents at risk for foodborne illness as well as bacterial and foreign object contamination resulting in gastrointestinal (stomach and intestines) distress, weight loss and in severe instances may result in death. Findings: 1) During the initial tour of the kitchen on 3/21/22 at 9:33, the walk-in refrigerator was at 38º F. [NAME] bread, receive dated 3/17/22, and two large bags of hamburger buns, receive date 3/10/22, were being stored in the refrigerator. The Director of Dining Services (DDS) stated the bread was stored in the refrigerator because of limited space. The facility policy/procedure titled, Storage of Food and Supplies, dated 2020, Policy: Food and supplies will be stored properly and in a safe manner. Procedures for Dry Storage: . 13. Bread will be delivered frequently and used in the order that it is delivered to assure freshness. Bread products not used within five days can be frozen. Some breads do last five to seven days. Check manufactures recommendations. Do not store bread in the refrigerator. 2) During the initial tour of the kitchen on 3/21/22 at 9:33 a.m., the kitchen floor was sticky. During an observation on 3/21/22 at 10 a.m., the kitchen floor was sticky and black marks were throughout. During an interview on 3/23/22 at 8:50 a.m., the DDS (Director of Dining Services) stated the kitchen floor did feel sticky and looked dirty. The DDS stated the kitchen floor was old. The DDS stated the kitchen floor was mopped after the breakfast dishes were washed and after lunch, and before the P.M. aide went to lunch. The DDS stated the kitchen was deep cleaned every Friday. During an observation on 3/23/2022 at 9:45 a.m., debris from cutting carrots and celery were on floor around open garbage cans located under the cook's prep countertop, right of the steam table. 3) During an observation on 3/23/2022 at 9:45 a.m., two garbage cans under the cook's prep countertop, right of the steam table and left of the reach-in refrigerators, had no lids. During a concurrent observation and interview on 3/24/22 at 10:05 a.m., the two garbage cans underneath the cook's prep countertop, right of the steam table, were uncovered. The DDS stated the garbage can lids were left off while the cooks were prepping and cooking, while in use. During a concurrent interview and dietary record review on 3/28/22 at 8:30 a.m., the DDS stated the deep cleaning of kitchen took place on Fridays. The DDS stated the dietary staff was assigned tasks and by the end of the month all areas of the kitchen were deep cleaned. The DDS stated now that there was enough dietary staff, she was able to designate tasks weekly, which were assigned on the staff schedule. The DDS stated Dietary Staff were assigned cleaning tasks in corresponding to their position that day. The facility policy/procedure titled, Sanitization, revised 10/2008, indicated: Policy Statement: The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation: 1. All kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies and other insects . 13. Kitchen wastes that are not disposed by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily . 16. Kitchen and dining room services not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 76 out of 76 residents were provided activities on weekends, when no Activity Staff were available. This failure had the potential for all residents to experience isolation, decreased enjoyment of life and depression. Findings: During an observation and interview on 3/21/22, at 10:34 a.m., Resident 58 was observed laying on her back in bed with her pajamas on, in a dark room with the curtains pulled. She stated she would prefer to have the curtains open and see outside but her roommate sleeps in late. She stated she does not have anything to do. She stated no one had come in to speak with her about what activities she liked to do. She stated she cannot get out of bed for long because her back pain prevented her from moving around a lot. She stated she enjoyed socializing with her daughter or anyone who would come to her bedside. A review of Resident 58's document titled, admission Record, indicated she was admitted [DATE], with diagnoses that included Wedge Compression Fracture of Lumbar Vertebra (Collapsing of the spinal vertebra, resulting in severe back pain.), muscle weakness, kidney disease. A review of Resident 58's Minimum Data Set (MDS) (A health status screening and assessment tool used for all Residents.) indicated a Brief Interview for Mental Status (BIMS), (A test used to get a quick snapshot of how well a resident is functioning cognitively at that moment. A score of 8-12 was considered mildly impaired. Residents were considered cognitively intact if they were able to complete the BIMS and scored between 13 and 15.) score of 13. No Activity Care Plan was developed. During an interview on 3/21/22 at 4:12 p.m., Resident 57 stated she really liked the activities and went to all the activities. Resident 57 stated the facility used to have activities on the weekends and the activity staff would come into one's room. Resident 57 stated she really liked it when activities were offered on the weekends. A review of Resident 57's admission Record indicated Resident 57 was admitted on [DATE], with a diagnosis including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following a cerebral infarction (stroke) affecting the right side, aphasia (loss of ability to understand or express speech), unsteadiness on feet, muscle weakness, difficulty with walking, amongst others. A review of Resident 57's Activity care plan, indicated: Focus, revised 2/28/22, I would like to continue participating in the recreational activities I currently enjoy on the same level as well as keeping busy with my favorite independent activities . Goals, revised 3/10/22, I will continue to express my enjoyment and satisfaction with the activities I participate in thru my next review. Interventions, date initiated 2/28/22, Check in with me to make sure I can still do activities independently and have any supplies I need. Invite me to my favorite activities, such as pet visits, listening to my favorite music and morning socials as well as encouraging me to try new things that I might be interested in. Please give me more instructions or cuing (sic) if I need it. Please help me get music related to my favorite artists and styles. I love listening to 60's/70's music. Note: the facility did not follow Resident 57's Activity care plan by not offering the residents activities on the weekends, from 1/1/22 to 3/27/22. During an interview on 3/22/22 at 10:00 a.m., Anonymous Resident 5 stated facility had a skeletal crew on Saturdays and Sundays. Anonymous Resident 5 explained that Activity Director N was off on weekends and there were no available activity staff to cover the weekend shift. Anonymous Resident 5 stated having no activities on the weekends created boredom making him want to leave the facility and wheel himself to the pub. During a confidential interview on 3/22/22 at 10:00 a.m., multiple confidential residents were asked about their experience with activities at the facility. One resident stated the facility had no activities on Saturday and Sunday and he sometimes felt like wheeling himself, to the pub due to boredom. He stated Activity Director N was off on the weekends and no activity staff were available. Four out of six confidential residents indicated they would like to have activities on the weekends. Review of Resident Council Minutes (notes from monthly meetings with the facility and residents) between 10/2021 through 2/2022 indicated staffing and activities were an issue at the facility dating back to approximately October 2021. Resident Council Minutes (dated 10/21/21) indicated, 3) Weekend Activities are temporarily canceled until further notice due to not having the appropriate amount of staff . Minutes (dated 11/19/2021) indicated, 1) As mentioned last meeting, weekend activities was (sic) temporarily canceled (sic) [for 2-3 weeks] due to being short staffed. Good news! Weekend activities will begin on November 20th . Minutes (dated 12/16/2021) indicated residents, . would like to return to having bingo weekend afternoons. It was communicated that due to short staffing we will postpone, but will continue once we can recruit more staff for weekend position. Minutes (dated 2/17/22) indicated the facility had a , New activity assistant .starting on Friday (sic) 2/18/22 . She will be temporary unfortunately . starting April 1st she will be full time CNA at this facility . Activity Department will be short staffed, but we do not lose hope and are working hard in recruiting more staff and will continue to provide activity programs during the week. Currently looking for a stable weekend person. During a concurrent observation and interview on 3/22/22 at 11:25 a.m., Resident 29 was in her recliner wheelchair enjoying being in activities located in the Social Dining Room. Resident 29 stated activities were good except the residents were not offered activities on the weekends. A review of Resident 29's admission Record indicated Resident 29 was admitted on [DATE], with a diagnosis including Ogilvie syndrome (are, acquired disorder characterized by abnormalities affecting the involuntary, rhythmic muscular contractions (peristalsis) within the colon), pseudobulbar affect (condition that's characterized by episodes of sudden uncontrollable and inappropriate laughing or crying), cord compression (pressure on the spinal cord), major depression, anxiety, dysphagia (difficulty swallowing) amongst others. A review of Resident 29's Activities care plan indicated: Focus, revised 6/27/21, I require some assistance in participating in activities of my choice related to impaired motor skills and help maneuvering my wheelchair. Religious programs are important to me. I enjoy video chats and visits with family. I participate in social dining. Goals, revised 3/21/22, indicated: I will continue to participate in the small group socially distanced activities or 1:1 activities of my choice as independently as possible, especially spiritual practices and visiting with family. Interventions, revised 6/27/21, Ensure that resident and her family are accommodated when they request in person visits or video chats and intervention. Another Intervention, revised 6/20/20, indicated: Invite Resident 29 to small group, socially distanced activities such as Pet visits or patio based musical programs, weather permitting. Note: the facility did not follow Resident 29's Activity care plan by not offering the residents activities on the weekends, from 1/1/22 to 3/27/22. During an observation and interview on 3/22/22 at 4:11 p.m., Resident 31 was observed laying on her back in her bed with the lights on, reading a book. She stated there are no activities offered on the weekends. She stated it would be nice if she was offered a daily newspaper. She stated the activities that are offered do not interest her. She stated she had to entertain herself or she would be bored. A review of Resident 31's medical record document titled admission Record, indicated she was admitted [DATE], with diagnoses that included Pressure Ulcers right hip (Injury to skin and underlying tissue resulting from infection or prolonged pressure on the skin.), Muscle Weakness, Kidney Disease, Major Depressive Disorder (A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.), Osteoarthritis (A degenerative joint disease that is a type of arthritis that occurs when flexible tissue at the ends of bones wears down. Symptoms include Joint pain in the hands, neck, lower back, knees, or hips and gradually worsens over time.), and Heart Failure (Heart failure occurs when the heart muscle doesn't pump blood as well as it should. Blood often backs up and causes fluid to build up in the lungs (congest) and in the legs. The fluid buildup can cause shortness of breath and swelling of the legs and feet.) A review of Resident 31's Medical Data Sheet (MDS) indicated a BIMS score of 13. A concurrent review of Resident 31's medical record did not indicate a care plan for Activities. A review for her care plan titled Pain: resident at risk for pain/discomfort related to: Wound and osteoarthritis, undated, indicated Encouragement mobility, physical activity as tolerate. Offer/provide diversional activities as desired, to distract from pain. During an interview on 3/23/22, at 8:21 a.m., Licensed Staff F stated she worked a lot of overtime. She stated the facility was short staffed, and it occurred more on the weekends. She stated she was told by the Administration that two Licensed Staff for 77 residents was the new normal. She stated things do not get done, like call lights do not get answered fast enough. Licensed Staff F stated there was no activity staff on the weekends for resident activities. She stated the activity calendar did not accurately reflect what activities are provided for residents. She stated the result of not having activities on the weekend is that residents were bored. She stated I would be bored if I did not have anything to do. During an interview on 3/23/22, at 11:30 a.m., Unlicensed Staff O stated there were no activity assistants on the weekends. She stated none of the residents have access to activities on the weekends. During an interview on 3/24/22 at 9:13 a.m., Activity Director N stated there were activities offered to the residents Monday through Friday, but none offered on the weekends because there was no activity staff for the weekends. Activity Director stated there has not been any activities offered on the weekends since the start of 1/2022. Activity Director N stated an Activity Assistant was hired last month but did not show up and currently there has been no luck in finding activity staff for the weekends. Activity Director N expressed concern for weekday activity staff, too, because two Activities Assistants were in the Certified Nursing Assistant (CNA) program and would be graduating from the program soon. Activity Director N stated the two Activities Assistants would be looking for a CNA position leading to the facility being short staffed two Activity Assistants on the weekdays as well. During an interview on 3/28/22, at 8:14 a.m., Director of Nursing stated he did not know what activities occur on the weekends. He stated he did not know how bed bound residents had access to activities on the weekends. During an interview with Activity Director N, on 3/28/22, at 8:36 a.m., she stated there were no weekend activities since January. She stated the television controller in the community room was provided to the nurses who are supposed to turn on the television. She stated she was unaware if bed bound residents were provided iPad to use in their rooms for music or entertainment. She stated she did not know if it was documented, and activity staff do not document in the medical record. Activity Director N reviewed her communication folder for the weekend and stated there was no documentation to indicate any activities had occurred during the weekend. She stated the risk to residents who do not have access to activities on the weekend was boredom and depression. She stated bed bound residents and cognitively impaired residents who were not provided activities had the potential to experience depression and an increase in behaviors like yelling, aggression or wandering. During an observation on 3/28/22, at 10 a.m., the current Activity Calendar had post-it notes on every weekend day that indicated No Activities. During a concurrent interview on 3/28/22, at 8:46 a.m., Resident 55, 31 and 58 stated no activities had occurred or been offered over the weekends since they had been admitted to the facility. During an interview on 3/29/22 at 10:11 a.m., Activity Director N verified no available Activity staff on the weekend since January 2022. Activity Director N stated she expected Certified Nursing Assistants (CNAs) to help with activities on weekends. Activity Director N stated there was a risk of residents being left alone and unattended in the activity room when CNAs got busy. Activity Director N stated residents would be at risk for depressed mood when there were no available staff to conduct activities on weekends. During an interview on 3/29/22 at 10:37 a.m., Licensed Nurse D verified there were no Activity staff available on weekends. Licensed Nurse D stated this would place residents at risk for mood changes and residents getting upset because there was nothing to do on the weekends. During an interview and record review on 3/29/22 at 11:04 with Administrator, in his office, he stated resident activities are supposed to happen every day. He stated on the weekends the licensed nurses are supposed to make sure residents are offered activities. He stated there are enough nursing staff on the weekends to make sure activities have been offered and have occurred. Administrator stated that he spoke with Director of Nursing about staffing, and he stated the nurses just are not working efficiently enough. Administrator stated all the nursing staff had been informed of the expectation to provide resident activities on the weekends. During a review of the Quality Indicator Performance Improvement (QAPI) Binder minutes, it indicated Activity Director N had submitted concerns about an activity staffing shortage. Administrator stated QAPI had no concerns about the shortage. He stated the two Activity Assistants were graduating from Certified Nursing Assistant (CNA) training in the future, but he would continue to schedule them as Activity Assistants. During an interview on 3/29/22 at 12 p.m., Licensed Staff M stated she had not been told the expectation for nurses was to ensure residents participated in or were offered activities. She stated she did not know what the weekend activities were or how to ensure residents were offered them. She stated she did not know what [proper name] Off the Record was or what Sunday Matinee: Blue Miracle was. She stated she does not document the daily activities provided for residents. During an interview on 3/29/22 at 12:15, Licensed Staff D stated he had not been told he was supposed to ensure residents were offered opportunities to go to activities. He stated he did not know what the activities on the activity calendar for the weekend were. Licensed Staff D stated he did not know what the weekend activities were or how to ensure residents had offered them. He stated he did not know what [proper name] Off the Record was or what Sunday Matinee: Blue Miracle was. During an interview on 3/29/22 at 12:30 p.m., Unlicensed Staff Q stated he worked on Saturday, 3/26/22, and did not observe any activities offered to residents in the activity room or in the resident rooms. During an interview on 3/29/22 at 12:45 p.m., Unlicensed Staff R stated there were no activities offered by staff on the weekends. He stated some of the residents know how to turn on the television in the activity room, but no one planned or offered resident activities. A review of a facility Policy and Procedure (P&P) titled Group Programs and Activities Calendar, undated, indicated The activities calendar states all activities available for the entire month, which may also include schedule in-room activities. A review of a facility P&P titled Activity Program, revised June 2018, indicated Activities are scheduled 7 (seven) days a week .All activities are documented in the resident's medical record. A review of document titled Activities Staff, undated, indicated no Activity Staff were scheduled for Saturdays or Sundays. The facility policy/procedure titled, Care Plans, Comprehensive Person-Centered, revised 12/2016, indicated: . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being . Note: the facility did not offer the residents activities per their care plans on the weekends.

Based on food production observation, dietary staff interview, and dietary document review, the facility failed to ensure a Registered Dietician (RD) was overseeing the operations of the facility's Food Service Department, resulting in issues with safe and effective food storage, meal production, infection control, and a clean kitchen. Failure to ensure adequate oversight may result in compromising the nutritional status of all residents and cross contamination of resident food and foodborne illness. Findings: During the course of the survey from 3/21/22-3/29/21 through observations, interviews and dietary record reviews related to deficient practices in food service systems were noted, affecting all residents. These included: 1. Failure to ensure that resident meals were prepared and distributed in a manner that met resident preferences and maintained palatability (Cross Reference F804), 2. Failure to ensure physician ordered diets were followed (Cross Reference F805), 3. Failure to ensure safe dietetic services as evidence dietary staff not: 1.) thawing meat according to the facility's policy and procedure, 2) using the correct Cool Down Process for cooked meats and ambient food items like tuna for tuna salad, 3) Following recipes, and 4) Taking hot and cold food temperatures prior to food service. Failure to ensure staff competency could: (Cross Reference F802 & F804). 4. Failure to ensure the kitchen floor was clean, not dirty/sticky, and garbage can lids were on garbage cans underneath food prep countertops (Cross Reference F812). During the initial tour of the kitchen on 3/21/22 at 9:33 a.m., the DDS (Director of Dining Services) stated the Registered Dietician (RD) moved to another state and was only working virtual the past three months. The DDS stated herself, the RD, and the Administrator. When the DDS was asked how the RD saw residents, the DDS stated the RD reviewed the resident's chart on admission, annual and change of condition including the resident's weight. The DDS stated the RD did not visit residents and oversee kitchen. During an interview on 3/22/22 at 5:09 p.m., the Director of Nursing (DON) stated, Yes, the RD had moved to another state and was teleworking for the past three months. The DON stated the RD did not see residents. The RD reviewed the resident's clinical record, and the DDS would go over nutritional issues with the RD During an interview on 3/25/22 at 2:25 p.m., Regional Consultant I and the Administrator both stated the RD was last onsite in 12/2021, the RD was employed by their corporation and was working between their buildings fulltime up until 12/2021. The RD did virtual meetings a couple times a week now. Regional Consultant I stated the RD reviews weight loss. The Administrator stated he did the Sanitation and Food Safety Checklist for the kitchen. When the Administrator was asked if he was qualified to oversee the kitchen, he stated he was not, but he was still checking to see if things were being done in the kitchen since there was no RD to oversee the kitchen. Regional Consultant I and the Administrator stated the RD should oversee the kitchen. During an interview on 3/25/22 at 2:53 p.m., the RD stated he left the facility mid-September. The RD said, Yes, ultimately the RD oversees the kitchen. No, I am not overseeing the kitchen. Monthly inspection of kitchen is the RD's responsibility top to bottom. The RD stated dietary staff should be taking food temperatures of all food/drinks prior to plating/preparing meal trays. The RD stated he would check the dietary staffs' competencies. The RD said, I am not there in-person at all. I am helping the facility out as a favor. I meet weekly by virtual with the DDS and DON for the Nutrition at Risk meeting. The RD stated he did the resident's Nutritional admission Assessment, Annual Assessments and Change of Condition Assessments when he was able to. The RD stated he reviewed as many residents' records as he had time for. The RD stated he helped in the small way he could help. The RD stated the RD was ultimately responsible for the kitchen and making sure staff was following best practices for preparing food and keeping the kitchen clean. The DDS was asked to provide the last Sanitation and Food Safety Checklist, completed by the RD. The latest Sanitation and Food Safety Checklist, signed and dated by the RD was completed on 9/24/21. The Sanitation and Food Safety Checklist, included the RD overseeing General Sanitation and Safety: . 6. All floors and mats are clean, free from greasy, film and food debris . 19 Garbage cans are covered at all times . Food Preparation: 1. Temperatures of the food to be served are taken and recorded prior to service. 2. Food at temperatures not in compliance with the food safety policy is not served or temp. is corrected before food service . 8. Proper thawing methods used, 9. Proper cooling methods of cooked foods are used and recorded on Cool Down Log per policy . 13. Recipes are being followed, 14. Spreadsheets are being used properly . The facility job description titled, Registered Dietician, dated 9/2017, indicated: General Purpose: . Assist in coordination of nutrition care services with Dietary Supervisor . Essential Duties: Ability to meet all health, compliance, and competency requirements. Attends and participates in morning/stand up to facilitate communications with the team. Assess nutritional needs, diet restrictions and current health plans to develop and implement dietary care plans and provides nutritional counseling as needed. Monitor food services operations to ensure conformance to nutritional, safety, sanitation, and quality standards, as well as state and federal regulations. Monitor food control systems such as food temperatures, potion control, preparation methods, garnishment, and preparation of food to ensure that food is prepared and presented in an acceptable manner . Note: there has not been a RD overseeing food services operations since 9/2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on dietary staff observation, interview, and dietary record review, the facility failed to ensure staff possessed required competency as evidenced by dietary staff members not: 1) thawing meat according to the facility's policy and procedure, 2) using the correct Cool Down Process for cooked meats and ambient (room temperature) foods like tuna for tuna salad, 3) Following recipes, and 4) Taking food temperatures prior to food service. Failure to ensure staff competency could: 1) put residents at risk for foodborne illness, 2) result in decreased food distribution and food production systems to ensure food palpability and nutritional content, which could result in decreased dietary intake that did not meet individual resident nutritional requirement. This could result in weight loss and further compromise resident medical status, and 3) not cooking green beans at a mechanical soft texture (easier to chew foods) could have led to the residents having trouble chewing and/or swallowing, which could have led to aspiration (choking or breathing in food particles) compromising residents' health. Findings 1. During an interview on 3/23/22 at 9:45 a.m., [NAME] S stated he thawed the hamburger for today's vegetable meatloaf two days ago (Monday, 3/21/22) under continuous running water. [NAME] S stated he started at 9:30 to 10 a.m. to 1 p.m. and placed the frozen hamburger in a bucket and placed the bucket in the double sink. [NAME] S stated the frozen hamburger was submerged in the bucket of water at first because the hamburger was frozen, but the hamburger did not stay submerged all the time because the hamburger started floating above the water. [NAME] S stated he did not take the temperature of the running water to know how cold/warm the water was. [NAME] S stated he then placed he hamburger in the refrigerator until today. During a concurrent interview and record review on 3/23/22 at 11:10 a.m., DDS (Director of Dining Services) stated she found the Special Cool Down Log showing the temperature of the hamburger while thawing under running water. The DDS stated the meat never went above 40º F degrees when it was thawing under running water. The DDS stated the meat then went into the refrigerator to continue thawing. When asked if this was the the facility's process for thawing hamburger, the DDS stated it was okay because the meat stayed at 40º F. The dietary document titled, Special Cool Down Log: Use for potential hazardous foods prepared from ingredients at ambient temperature such as canned tuna, dated 3/20/22 at 9:30 a.m., indicated the temperature of the hamburger was 32º F and at 1 p.m., the temperature of the hamburger was 40º F. Note: There was no documentation of the running water temperature and the log was a Cool Down Log for an ambient cool down process (potential hazardous foods shall be cooled within four hours to 41º F). During an interview on 3/23/22 at 11:20 a.m., the DDS stated [NAME] S had indicated to the DDS there was word confusion and [NAME] S did not know he had to tell surveyor the temperature of the hamburger after thawing the meat under running water and before placing the meat in the refrigerator. During an interview on 3/24/22 at 8:47 a.m., [NAME] S stated he learned how to cook working at a lodge for three years and a senior living center for five years. [NAME] S stated he did not fill out the Special Cool Down Log for the Ambient cool down process. [NAME] S stated he did not check the temperature of the hamburger when it was thawing under the running water. [NAME] S stated the meat was not fully defrosted after thawing the meat under running water. Cooks S stated the normal process to thaw meat was to pull the meat from the freezer three days prior to using and placing in the refrigerator to thaw, but the hamburger was not pulled on Sunday, 3/20/22. [NAME] S stated the hamburger was not pulled until 3/21/22 (two days before using the hamburger to make the meatloaf for lunch), which was why he partially thawed the meat under flowing water and then placed the meat in the refrigerator to thaw the rest of the way. [NAME] S stated he never took temperatures of the hamburger at any time during the various thawing processes. [NAME] S stated thawing the hamburger under running water and then placing the partially thawed hamburger in the refrigerator to thaw the rest of the way was no a normal process. During an interview on 3/24/22 at 10:05 a.m., the DDS stated normally the cooks would pull the meat out of the freezer two to three days prior to using the meat and place the meat in the refrigerator to thaw. The meat would be labeled with a date indicating when the meat was pulled from the freezer and when the meat needed to be used by. During a interview on 3/25/22 at 10:45 a.m., [NAME] BB stated she cooked three days a week and had been cooking at the facility for seventeen years. Meat/fresh beef needs to reach 160º F showing the meat was fully cooked through. She stated how she thawed meat was to pull the meat out of the freezer three days before using and thaw the meat in the refrigerator. [NAME] BB stated it was not a normal process to thaw the meat under running and then place in the meat in the refrigerator for two days. The facility policy/procedure titled, Inservice: Thawing and Storage of Raw Meats, undated, indicated: . Inservice: Thawing meat properly can be done in these four ways: 1. In refrigerator at 41º F or colder. Allow two to three days to defrost depending on the quantity and total weight of meat . 3. Submerge under running water at a temperature of 70º F or lower, with a pressure sufficient to flush away loose particles. The food product cannot remain in the temperature danger zone (40º F to 140º F) for more than four hours, which includes the time the food is thawed. The facility policy/procedure titled, Food Preparation and Service, revised 4/2019, indicated: Policy Statement: Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Policy Interpretations and Implementation: . Thawing Frozen Food: 1. Thawing procedures include: a. Thawing in the refrigerator in a drip-proof container, b. Completely submerging the item in cold running water (70º F or below) that is running fast enough to agitate and remove loose ice particles . 2. During a concurrent interview and dietary record review of cool down logs on 3/25/22 at 10 a.m., , indicated the dietary log titled, Special Cool Down Log used for the Ambient Temperature Foods Cool Down Process was being used for cooked meats (chicken, bacon, sausage, beef rice, and potato, pasta and macaroni salad. When the DDS was questioned about using the wrong cool down process for cooling down the hot cooked foods, the DDS stated if the meat was cooled down to 41º F within four hours, why did it matter what process was used? It was pointed out to the DDS that such hot foods as beef, chicken, and potatoes to make potato salad needed to be cold down from 140º F to 70º F within 2 hours or less and then cold down to 41º F within 4 hours, but the Ambient Cool Down Log only showed the hot foods being cooled down to 41º F within four hours. During an interview on 3/25/22 at 10:45 a.m., [NAME] BB stated how she did the cool down process was as follow: the cooked meat needed to reached room temperature, which took around two hours or until the temperature dropped to 140º F, then the meat would be place in the refrigerator and the temperature was taken every two hours until the meat reached 41º F. [NAME] BB stated she cooled down the hot potatoes used to make potato salad by placed the covered bowl of potatoes in a ben of ice and placed ice on top of the bowl too. [NAME] BB stated she cold down the potatoes to 41º F within 4 hours, checking the potatoes every 2 hours. [NAME] BB stated she was concerned about the Cool Down form the facility was using because the form was not following the right cool down process for cooked meat, hot potatoes, amongst other hot foods. Note: [NAME] BB did not state the meat had to be cooled down from 140º F to 70º F within 2 hours or less and then cold down to 41ºF within 4 hours, During an interview on 3/25/22 at 3:25 p.m., the DDS stated she figured out herself and the dietary staff were using the wrong logs to cool down the cooked food such as meat, bacon, chicken, potatoes, pasta amongst others. The DDS stated the dietary staff were doing cool down processes wrong. The facility policy/procedure titled, Cooling and Reheating Potentially Hazardous Foods also called Time/Temperature Control for Safety, dated 2018, indicated: Policy: Cooked potentially hazardous foods shall be cooled and reheated in a method to ensure food safety. Potentially hazardous foods include: a food of animal origin that is raw or heat-treated: a food of plant origin that is heat treated or consists of raw seed sprouts; cut melons: garlic and oil mixtures. This list includes . meat, fish, poultry, cooked rice, beans, pasta, potatoes Procedure: When potentially hazardous cooked food will not be served right away it must be cooled as quickly as possible. The method is The Two-Stage Method, Cool cooked food from 140º F to 70º F within two hours. Then cool from 70º F to 41º F or less in an additional four hours for a total cooling time of six hours . Once the food items have cooled to 41º F or less, they can be covered tightly, remember to label . When cooling down food, use the Cool Down Log to document proper procedure. Ambient Temperature Foods: Potentially hazardous food shall be cooled within four hours of 41º F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Use cool down log. The facility recipe titled, Pasta Salad, undated, indicated: Use Cool Down Log. Combine all ingredients. Utilize cool down log. Note the macaroni is a cooked food needing the Two-Stage Method. The facility has two types of cool down logs: 1. Special Cool Down Log, used for ambient temperature, such as canned tuna and 2. Cool Down Log for the Two Stage Method. Note: Ambient cool down log, the dietary staff was using the Ambient cool down method for the cooked meat (beef, bacon, chicken, sausage .), rice, and pasta and potato salad amongst others . 3. (a) During the initial tour of the kitchen on 3/21/2022 at 9:33 a.m., the Director of Dining Services (DDS) stated breakfast was at 7:30 a.m., lunch at 12 noon and dinner at 5 p.m. During the inital tour of the kitchen on 3/21/22 at 9:333 a.m., the Dietary observed [NAME] S pouring Penne pasta into a colander (kitchen utensil to strain pasta) to drain the hot water. [NAME] S stated he was going to cool down the Penne pasta in the refrigerator for 2 hours to get the temperature down to 71º F and then the temperature of the Penne pasta needed to cool down to 40º F within 4 hours. [NAME] S stated he was going to place the Penne pasta in the steamer to reach 140º F before putting the Penne pasta on the steam table. During a concurrent interview and dining observation on 3/21/22 at 12:39 p.m., Resident 57, who was on a Chopped Meat/Chopped Vegetable Regular diet, did not like the Penne pasta. Resident 57 stated the pasta was tasteless and she did not like the green beans. Resident 57 did not eat any of the pasta. During an interview on 3/21/22 at 12:54 p.m., Resident 65 stated she could not eat the green beans because they were to hard to stab with her fork to pick-up. Resident 65 stated the penne pasta had no flavor. Resident 65 stated she was not going to eat. Resident 65 ate 25% of her lunch. During a concurrent observation and interview 3/21/22 at 1:06 p.m., Resident 29 was upright in bed trying to feed herself. Resident 29 was on a Mechanical Soft, Regular diet with Thick Fluids-Nectar. Unlicensed Staff CC was asked to help Resident 29 with her green beans because Resident 29 could not stab the green beans, to hard. Unlicensed Staff CC stated all the residents' green beans were hard and the chicken was a little hard. Unlicensed Staff CC told Resident 29 not to eat the green beans because the green beans did not have a Mechanical Soft texture. During an observation and interview on 3/21/22 at 2:56 p.m., Resident 48 stated he was a retired cook from the Navy. He stated the pasta serving was overcooked and mushy. He stated when he tried to pick it up with his fork it was so soft it fell apart. He stated it was soggy and pretty bland. During an interview on 3/23/22 at 8:45 a.m., [NAME] S stated he cooked the Penne pasta (starch on lunch menu) early on Mon, 3/21/22 to help him stay ahead of lunch preparation. [NAME] S stated he was the only cook and wanted to get the Penne pasta out of the way. [NAME] S stated he would cook the Penne pasta al [NAME] (tender but still firm to the bite), then before placing on steam table he would place the Penne pasta in the steamer for about 15 seconds. [NAME] S stated it was not impossible to cook the Penne pasta right before placing on the steam table, just a little difficult because he was the only cook. [NAME] S stated the green beans came out tough because he tried to separate textures: al [NAME] and mashable. [NAME] S stated he tried to prevent the green beans from looking brown, which could be caused from being on the steam table. The DDS stated she bought a different frozen brand of green beans and felt that had something to do with the outcome of the beans not cooking, turning out tough/hard. The dietary recipe titled, Parsley and Herb Penne, undated, indicated: Directions: 1. To add Penne to boiling water. Boil until tender, about 10-15 min. 2. Drain and rinse. 3. Add margarine, parsley, basil and pepper. Heat to temperature. 4. Serve on trayline at the recommended temperature of 160-180º F. There was no mention of cooking the Penne pasta early, cooling the pasta down, and then steaming the pasta before placing the pasta dish on the steam table. The dietary recipe titled,Green Beans with Garlic, undated, indicated: . Special Diets: . Mechanical Soft: Soft. Chop if desired . Dysphagia (difficulty in swallowing): Cut green beans, chop to half-an-inch, mashable. (b) During an interview on 3/23/22 at 10:10 a.m., [NAME] S stated he was cooking the meatloaf in the oven on 350º F for 45 minutes During an interview on 3/23/22 at 11:40 a.m., [NAME] S stated he pureed the meatloaf by adding hot water with a little bit of thickener (mixed with purees and other liquids in order to alter their consistency) to the meatloaf and then blended the meatloaf in the food processor. During an interview on 3/23/22 at 12:05 p.m., [NAME] S stated he did not cook the vegetables all the way through before mixing into the raw meatloaf and placing the meatloaf into the oven. [NAME] S stated he felt this caused the meatloaf to temp low when he pulled it out of the oven. He needed to return the meatloaf back into the oven two more times before the meatloaf temperature reached 155º F. The dietary recipe titled, Garden Fresh Meatloaf, undated, indicated: Cooking Time: one-and-half to two hours. Temperature: 325º F . 2. Heat margarine or oil in skillet and saute vegetables and Italian seasonings until vegetables are tender, approximate three to five minutes . On 3/23/22 at 12:53 p.m. during a lunch tray testing, it was noted by surveyors and the DDS, the broccoli was mush and grayish/green in color, the pureed spinach had a gluey texture, hard to swallow, and stuck to one's palate (roof of the mouth). The regular meatloaf had no flavor, did not crumble apart like hamburger and dry. The pureed meatloaf tasted like the thickener/no flavor. The DDS agreed and stated there was to much thickener used for the pureed spinach and meatloaf. The cook should have followed manufactures direction for adding the thickener. During an interview on 3/24/22 at 8:47 a.m., [NAME] S stated he pureed the meatloaf in the food processor. The temperature of the meatloaf was 160º F. [NAME] S stated he added one cup of thickener and two cups of hot water plus a little gravy following the instructions on the thickener container. [NAME] S stated to puree the cooked spinach to have the texture of pudding, he added one-and-one half cups thickener and two cups hot water. A review of the resident's dietary cards indicated there were ten residents on a pureed diet (foods that do not need to be chewed, such as mashed potatoes, a pudding like texture). The dietary Therapeutic Spread Sheet, dated 3/23/22, indicated residents on a pureed diet received a half a cup of Garden Fresh Meatloaf, so for ten residents, five cups of meatloaf needed to be pureed. The dietary recipe titled, Pureed Meats, dated 4/2017, indicated: Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a pasted consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy). Recommended amounts of liquid for Twelve Servings: 1 1/2 to 3 cups of warm liquid to six to twelve tablespoons (3/8 to 3/4 cup) commercial instant food thickener. The dietary Therapeutic Spread Sheet, dated 3/23/22, indicated residents on a pureed diet received 1/3 cup of Spinach AuGratin, so for ten residents, three-and-one- half cups of spinach needed to be pureed. The dietary recipe titled, Pureed Vegetables, undated, indicated: Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a pasted consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk). Recommended amounts of liquid for Twelve Servings: 1/4 to 3/4 cup of warm liquid to six to twelve tablespoons (3/8 to 3/4 cup) commercial instant food thickener. During an interview on 3/25/22 at 10:45 a.m., [NAME] BB stated if you use to much thickener for pureed food, the food loses its flavor. [NAME] BB stated if the cook followed the recipe, the meal should turn out good/palatable. [NAME] BB stated it was very important for the food to taste good/flavor important. [NAME] BB stated there was no point in cooking pasta, such as spaghetti, at 10 a.m., when residents' lunch was not plated until 12. [NAME] S should not have cooked the Penne pasta early. [NAME] BB stated she would have cooked the pasta around round 11 a.m., prepared the dish and kept the dish warm in the oven. [NAME] S stated if you cooked the pasta early, the pasta would become soggy/lose its texture. [NAME] BB stated the meatloaf should have been cooked for 1 to 1.5 hours, not 45 min. [NAME] BB stated she saw [NAME] S keep on pulling the meatloaf out of the oven to check the temperature. [NAME] BB stated [NAME] S should have left the meatloaf alone and just let the meatloaf cook per the recipe instructions. [NAME] BB stated [NAME] S was not following the Meatloaf recipe. [NAME] BB said, Why pull out 3 times to check temperature? The facility job descriptions titled, Position [NAME] A & Position [NAME] B, dated 2018, indicated: Qualifications: . 3. Ability to accurately measure food ingredients and portions . Duties and Responsibilities: .6. Check menu for thawing of meat . The dietary document titled, In-Service: Food Preparation, dated 10/2018, indicated: Objectives: Participants will understand the importance of: Proper cooking techniques, which conserve nutritive value and produce eye-appealing and palatable foods. Safe handling to prevent foodborne illness. In-service - Introduction: Residents in long-term care facilities may have poor appetite due to their disease stated or the medications they are taking. As the Food and Nutrition Cook, you have an important role in caring for the residents in your facility, by helping to prepare attractive food with good flavors. Eye-appealing and palatable foods help stimulate the appetite, which in turn help residents to eat well and be healthy. Definitions: Food palatability refers to the taste and/or flavor of the food . General Food Preparation: It is important to use a standard recipe, which specifies amounts and proportions or ingredients . The cook who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency . Do not serve poorly prepared food . Prepare foods as close as possible to serving time to preserve nutrition, freshness and to prevent overcooking . 4. A review of the Food Temperature Logs, from 10/24/21 through 3/20/22, indicated the cooks were not taking the hot food temperatures of the meal entrees, starch, vegetables, and soup prior to plating the residents' meal. On 10/30/21, 12/19/21, 1/27/22, 2/25/22, and 3/18/22 food temperatures were not taken for breakfast. On 10/30/21, 11/5/21, 11/6/21, 11/11/21, 11/18/21, 11/20/21, 11/22/21, 12/9/21, 12/15/21, 12/19/21, 1/14/22, 1/27/22, 2/25/22, and 3/11/22 food temperatures were not taken for lunch. On 10/24/21, 10/30/21, 10/31/21, 11/5/21, 11/6/21, 11/15/21, 11/16/21, 11/20/21-11/22/21, 11/30/21, 12/1/21, 12/4/21-12/5/21, 12/14/21, 12/20/21, 12/27/21-12/28/21, 12/31/21, 1/4/22- 1/15/22, 1/18/22, 1/20/22-1/21/22, 1/25/22, 1/28/22-1/29/22, 2/1/22, 2/4/22-2/8/22, 2/11/22-2/12/22, 2/19/22-2/20/22, 2/26/22, and 3/9/22 food temperatures were not taken for dinner. This resulted in temperatures for soups, pasta, casseroles, turkey, pork, fish, ham, hamburger, beef, chicken, eggs amongst others not being taken. A review of the Food Temperature Logs, from 10/24/21 through 3/20/22, indicated dietary aides were not taking temperatures on residents' milk and juice prior to placing on the residents' meal tray. On 11/7/21, 11/8/21, 11/12/21-11/13/21, 11/21/21-11/22/21, 11/26/21-11/27/21, 12/18/21, 12/22/21, 12/24/21-12/25/21, 1/2/22, 1/7/22-1/8/22, 1/10/22-1/12/22, 1/14/22-1/16/22, 1/19/22, 1/21/22-1/23/22, 1/27/22, 1/29/22-1/31/22, 2/5/22-2/6/22, 2/17/22, 2/25/22-2/26/22, 3/5/22, and 3/9/22, milk and juice temperatures were not taken for breakfast. On 11/6/21, 11/8/21, 11/12/21-11/13/21, 11/20/21-11/22/21, 11/26/21-11/27/21, 12/18/21-12/20/21, 12/22/21, 12/24/21-12/25/21, 1/2/22, 1/6/22-1/8/22, 1/10/22-1/12/22, 1/14/22-1/15/22, 1/20/22-1/23/22, 1/27/22, 1/29/22-1/31/22, 2/5/22-2/6/22, 2/25/22-2/26/22, and 3/5/22, milk and juice temperatures were not taken for lunch. On 11/8/21, 11/12/21, 11/20/21-11/22/21, 11/26/21-11/27/21, 12/11/21, 12/18/21-12/19/21, 12/25/21, 1/2/22, 1/6/22-1/8/22, 1/10/22-1/15/22, 1/20/22-1/24/22, 1/26/22-1/31/22, 2/1/22, 2/5/22-2/6/22, 2/13/22-2/15/22, 2/19/22, 2/25/22-2/26/22, 3/5/22, and 3/7/22-3/8/22, milk and juice temperatures were not taken for dinner. During an interview on 3/21/22 at 11:39 a.m. Resident 59 stated the soup was always cold. During interview on 3/29/22 at 12:38 p.m., Resident 59 stated the soup was always cold and tasted as if it came right out of a can. During an interview on 3/25/22 at 10:00 a.m., the DDS stated [NAME] S started working as a cook in 11/2021 but did not get checked off on kitchen competencies until 3/2022. The DDS stated dietary staff competencies should have been completed upon hire and annually. The DDS stated, Yes, there has been issues with the cooks taking and recording food temperatures once on the steam table and prior to plating residents' meal. The DDS stated food temperatures should be taken before plating residents' meal to make sure bacteria cannot grow to prevent residents from becoming ill and for palatability. The DDS stated food temperatures should be taken on the entrée, starch, vegetables, and soup. The DDS stated the cooks logged the food temperatures. The DSS stated she did remind the cooks to log the food temperatures, but she felt they forgot to document the temperatures. The DDS stated if the food temperatures were not documented, then the food temperatures were not taken. The DSS stated it was a safety factor for the residents if food temperatures were not taken. Foodborne illness could occur if meat, etc., was not cooked or chilled per guidelines. A review of [NAME] S's personnel record indicated he was hired as a cook on 11/12/21. A review of [NAME] S's kitchen Employee Orientation Checklist, indicated he was not signed off on competency for Taking and Recording Temperatures for Trayline until 3/1/2022. During an interview on 3/24/22 at 8:47 a.m., [NAME] S stated he received three days of partial training as a cook, but was not trained on regulatory requirements. During an interview on 3/28/22 at 8:30 a.m. the DDS stated that training depended on how fast the new hire understood the kitchen/food processes. The DDS stated if soup was on the menu, the cook should have taken the temperature of the soup before sending the soup out to the residents. The DDS stated the temperature of hamburger patties should be taken before plating the hamburger patty. The facility policy/procedure titled, . 3. Meal Service, dated 2018, indicated: The food will be served on trayline at the recommended temperatures as below and recorded on the daily therapeutic menu in the temperature column of the regular food and next to the food item under therapeutic diet column of each food served. Hot food serving temperature must be at or above minimum holding temperature of 140º F. The temperatures may also be recorded on a temperature log. The temperature of the foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperatures. Soups and hot beverage service temperature: 170-190º F, Cream Soup: 160-170º F, Meat, casseroles, potatoes, rice, pastas, beans, vegetables, gravies, sauces, and hot cereal: 160-180º F, grilled cheese sandwich, omelets, scrambled eggs, bacon:150-170º F, pancakes, toasted items, French Toast (made with pasteurized eggs) 140º F or higher, milk, pudding, and salads: 41º or less, fruit juice: may be served at room temperature or chilled . 7. Temperatures of the food when the resident receives it is based on palatability. The goal is to serve cold food cold and hot food hot . The facility in-service titled, Food Preparation, dated 10/2018, indicated: Objectives: Participants will understand the importance of: Proper cooking techniques, which conserve nutritive value and produce eye appealing and palatable foods. Safe food handling to prevent foodborne illness . In-Service: . To prepare an attractive and palatable product, food must be handled carefully throughout receiving, storage preparation and service. Moreover, it is important that food is prepared by methods that conserve nutritive value, flavor, and appearance . General Food Preparation: . Food must be held at proper temperature (above 140º F, below 41º F) throughout tray line to avoid growth of harmful bacteria that can cause illness or even death .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure the baseline care plan for one of 32 residents (R) 177 included risk of elopement and wandering as an area of concern for her plan of care. This failure could have led to R177 leaving the building without the facility knowing. Findings include: Review of R177's admission Record located in the profile tab of the electronic medical record (EMR) revealed she was admitted to the facility from the hospital on [DATE]. Her admitting diagnoses included alcohol abuse, uncomplicated; and alcohol use, unspecified with intoxication, unspecified. Review of the hospital History and Physical (H&P), located in R177's hard record, dated 07/31/19 indicated the following, .Patient is still intoxicated but not going through withdrawal versus septic . In the History of present illness, located in the H&P, the doctor documented, .Patient was at home she was feeling depressed and wanted to change her feelings into something better. She took two Ativan which are 1 mg (milligram) each per patient which she gets from a friend's house then drank three, 80-ounce beers .Patient drinks every day she drinks beer various kinds .and does go through withdrawal when she does not drink . Review of a Hospitalist Progress Note dated 08/06/19 under the section titled Comprehensive Assessment/Plan the doctor documented .Due to short-term memory deficits, intermittent difficult with balance . Under the doctor's Subjective review of 08/06/19 at 1:50 PM he wrote, .She was able to answer questions appropriately this morning, however on evaluation by nursing later this morning, she was disoriented to time and place . Review of a Case Manager Note located in the clinical record provided to the facility on admission, dated 08/06/19 at 11:49 AM a case manager wrote, .Pt (patient) appears to continue to display short term memory loss . In a Case Manager Note located in the clinical record provided to the facility on admission, dated 08/02/19 at 11:53 AM a case manager documented, .patient is talking about leaving AMA (against medical advice) when her husband arrives . Review of the nursing home History and Physical, located in the R177's clinical record, completed by her attending physician on 08/08/19 revealed he documented, .found trying to leave . Review of the Nursing-Wandering Risk Observation/Assessment, located in R177's clinical record, dated 08/08/19 and timed at 3:02 PM, R177 was assessed to be at risk of wandering due to a .history of wandering (past hospitalization or history from resident/family) .medical diagnosis of dementia/cognitive impairment . Review of a Nurse's Note located in the Progress Note tab of the EMR dated 08/07/19 at 7:23 PM said her husband asked if he could take her next door to the church for an hour, the nurse explained she did not have an order to go out on pass and that if they went it would be considered an against medical advice (AMA) discharge. The nurse documented, .MD (Medical Doctor) was notified and said no to go out on pass because he has not seen patient yet. CNA (certified nursing assistant) brought to my attention that resident stated she would like to leave. Stated 'I thought this was a hotel.' .Resident upset she is not able to leave facility whenever she likes then stated (sic) 'I want to leave, I want to pack all my belongings.' . At 7:45 PM the same evening nursing documented, .explained again what the risks were if she decided to AMA . On 08/08/19 at 10:49 PM nursing documented, .Resident attempted to leave facility to go to 7/11. Discussed need for pass to leave the facility or AMA . R177's Baseline Care Plan Person-Centered Care Planning with an effective date of 08/08/19 at 11:56 AM was entered into the EMR system. Review of the Baseline Care Plan revealed the nursing section did not identify a potential elopement risk but indicated she was .here for conditioning s/p (status post) ETOH (ethyl alcohol) withdrawal and rehab . The social services section was completed through resident interview. The social services director (SSD) documented .no mood or bx (behavior) issues . On 08/11/19 at 3:10 PM nursing documented, .Continues to ask if she can go across the street to CVS to get money from her brother in law through western union . 08/12/19 at 10:25 PM a Behavior Note documented, .Husband asked if he could say goodnight and agreed to leave afterwards .was leaving and stated he heard his wife say that she might try to go the store later in the night . On 08/14/19 at 3:30 PM a Skilled Nursing Note documented, Resident was found by CNA attempting to leave facility through the outside gate on the south end of the building. CNA directed her to return to her room . The admission minimum data set (MDS) with an assessment review date (ARD) of 08/13/19 was incomplete in the EMR. The Brief Interview Mental Status (BIMS) to identify her cognitive level of functioning was not completed. The Behavior section of the MDS was completed and signed as complete on 08/14/19 by the SSD and it indicated, .no episodes of wandering . An interview was conducted with the director of nursing (DON) on 08/15/19 at 4:50 PM. The DON was not aware of any of R177's statements or attempts to leave to leave the facility. During an interview with the SSD and DON on 08/15/19 at 5:04 PM the SSD stated she was not aware of any of R177's statements or attempts to leave the facility. She stated she had not read the notes in the EMR regarding R177. The DON spoke up and said, We haven't had any of our meetings this week because survey is in the building. She also confirmed she had not reviewed the notes for R177. Normally at stand up we review the notes, any incidents and such but haven't this week. The DON when asked if she should have been notified stated, I was on leave last week. Then stated, The DSD (director of staff development) was covering for me during that time. She finally confirmed nursing should have notified her or the SSD of the statements and attempts to leave the facility by R177. Interview with Licensed Vocational Nurse (LVN) on 08/15/19 at 5:45 PM the 3-11 shift nurse for R177, stated she had not worked with her (R177) before but if a resident were discovered trying to exit one of the courtyards she stated, I would assist in redirecting (the resident) back into the facility, then contact the responsible party, DON and administrator. During an interview on 08/15/19 at 6:00 PM with the Administrator In Training (AIT) in the building he stated the Administrator had to leave early for the day. When asked what his expectations were about being notified of a resident making multiple statements of wanting to leave or attempting to leave the facility, he confirmed he would expect to be told of the concern. Interview with a Senior Administrator assisting with survey on 08/15/19 at 6:15 PM stated, .I would expect to be told but also went on to state it wasn't an elopement and her (R177) cognition and if she was her own responsible party would have to be taken into account. The surveyor explained the resident had not had a full MDS yet, the BIMS was not complete and she was here for safety reasons related to ETOH withdrawal and strengthening. Review of the undated policy Individual and Interdisciplinary Plan of Care (IPOC) stated, .An initial Baseline plan of care will be implemented by the nursing department upon admission (not to exceed 48 hours) and reviewed by the IPOC team within 72 hours . Under the section titled, Procedure it stated, .Review new admissions in the daily Interdisciplinary Plan of Care (IPOC) meeting following the day of admission .Review the following documents from the last 24 hours for all patients .24-hour Report .Incident Reports .Other related information essential to planning the care for a patient . Facility policies reviewed included Elopements with a revision date of 2007 and Discharging a Resident without a Physician's Approval last revised in October 2012.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to maintain and properly store respiratory care equipment for one (Resident (R) 64) of 12 residents receiving oxygen therapy. Findings Include: R64 was admitted on [DATE] with diagnoses of but not limited to, acute respiratory failure with hypoxia, asthma, chronic obstructive pulmonary disease, pneumonia, muscle weakness, dementia and need for assistance with personal care. Observations on 08/14/19 at 11:00 AM, R64 was lying in bed. Oxygen was being delivered via nasal cannula (through the nose) connected to a bedside oxygen concentrator. At the foot of her bed was her wheelchair (w/c) with a portable oxygen concentrator (a device that delivers oxygen) located hanging off the back with a nasal cannula (n/c) oxygen tubing connected to the air flow port. The n/c oxygen tubing was draped over the back and seat cushion of the w/c with the n/c part of the tubing touching the seat cushion. The n/c oxygen tubing was not dated, initialed or stored in a plastic bag for sanitation. Interview with the Licensed Vocational Nurse (LVN) 5 in R64's room at the time of the findings, revealed, she stated, the n/c oxygen tubing located on the portable tank on the w/c, should have been stored in a protective bag and the date should have been labeled on the tubing, as it was policy. She stated, the tubing should not have been lying over the seat cushion because it could become contaminated and cause the resident to become ill. She stated, she would replace it prior to R64 getting up to her w/c. Observation on 08/15/19 at 10:07 AM, R64 was in bed. Her n/c oxygen was in place and on via bedside concentrator. At the foot of her bed, her w/c had a portable oxygen concentrator hanging off the back with an attached n/c oxygen tubing connected to the air flow port. The tubing was draped over the back cushion of the w/c with the n/c part touching the floor. There was no date labeled on the tubing, or a storage bag to contain the tubing to keep it clean and sanitary when not in use. In an interview with the LVN (6) taking care of R64 at 10:10 AM, she stated, R64 had recently required around the clock oxygen use. She stated, the facilities policy was to change the oxygen tubing once a week on Saturdays on the night shift. She stated, the nurse was responsible for changing the oxygen tubing and was supposed to place a label with the date and the nurse's initials on the tubing. She stated the purpose of this was to know how long the tubing had been in use. She stated, when the oxygen was not in use, the tubing should be stored in a plastic bag to keep it clean. She stated, she would replace the oxygen tubing connected to the portable concentrator located on R64's w/c. Review of R64's Physician Orders (PO) for the month of August 2019, revealed the resident had an order for, .Oxygen 2 L/min (liters per minute) prn (as needed) for SOB (short of breath), chest pain, oxygen saturation less than 90% and notify MD [for oxygen saturations less than 90%]; Check O2 (oxygen) saturation daily every day . Review of R64's Medication Administration Record (MAR) for the month of August 2019, revealed R64 had been receiving oxygen therapy daily on a routine basis since 08/05/19, to maintain her oxygen saturation above 90%. A Review of the facility's policy titled, Oxygen Administration dated revised October 2010, was completed. The policy purpose stated, .To provide guidelines for safe oxygen administration . and under the Infection Control section of the policy, it stated, . Universal precautions will be observed at all times. Disposable cannulas and humification bottles, are to be changed weekly and as indicated. Tubing and humidification bottles should be dated/labeled when changed . In an interview with the Director of Nursing (DON) in the conference room on 08/15/19 10:20 AM, she stated, it was nursing policy to label oxygen tubing with the date/initials of the nurse at the time it was changed. She stated, the tubing should be stored in a plastic bag when not in use, even when attached to a portable concentrator on the w/c. She stated, nurses were trained on respiratory care and were responsible for properly maintaining the resident's respiratory equipment. She stated, it was her expectation and the facility's policy, only nurses were to handle oxygen tubing changes. She stated, she was unaware of any resident's oxygen tubing not being labeled with the date and initialed by the nurse when changed. She stated, she was unaware R64's n/c oxygen tubing connected to the portable w/c concentrator was not labeled or stored properly when not in use. In an interview with the Director of Staff Development (DSD) on 08/15/19 at 11:30 AM in the conference room, she stated the nursing staff had a general facility orientation, then after, they received nursing orientation and were given a skill competency check off sheet that was to be turned back in to her when completed. She stated, nursing skill competency check off sheets covered respiratory care and maintaining equipment such as oxygen tubing. She stated, the facility recently completed training for respiratory care. She stated, the care and maintenance of respiratory equipment, specifically, when to change oxygen tubing and to label the tubing with the date/nurse's initials were covered in the training.