**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls, and who had Care Plan interventions indicating Resident 1's bed to be in a low position, did not fall. This failure resulted in Resident 1 having an unwitnessed fall from her bed on 7/13/2025 and because of the fall, Resident 1 sustained an abrasion (wound caused by rubbing or scraping the skin against a rough surface) and redness to her forehead, and bilateral knee. Resident 1's bed was found at medium height level (approximately three feet from the floor) per the facility's Post Fall Evaluation dated 7/13/2025, upon her fall. Resident 1 was subsequently transferred to a General Acute Hospital (GACH) for evaluation of her injuries on 7/13/2025 via 911 (emergency transportation). This failure had the potential for Resident 1 to sustain greater injuries.Findings:During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental activities), muscle weakness and encephalopathy (brain disease, damage, or malfunction).During a review of Resident 1's History and Physical (H&P) dated 1/18/2025, the H&P indicated Resident 1 did not have the capacity to understand and make medical decisions.During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 4/23/2025, the MDS indicated Resident 1's cognition (ability to register and recall information) was severely impaired and was sometimes understood and was sometimes able to be understood by others. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half of the effort) from staff for rolling left to right (ability to roll from lying on back to left and right side, and return to lying on back on the bed), sit to lying (ability to move from sitting on side of the bed to lying flat on the bed), lying to sitting on the side of the bed (ability to move from lying on the back to sitting on the side of the bed with no back support), and sit to stand (ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed). The MDS indicated Resident 1 was incontinent (involuntary voiding of urine and stool) in both her bowel and bladder functions). During a review of Resident 1's Fall Risk Evaluation, dated 1/17/2025, the Fall Risk Evaluation indicated Resident 1 was at risk for falls. During a review of Resident 1's Care Plan, revised 1/18/2025, the Care Plan indicated Resident 1 is at risk for falls related to gait and balance problems. The Care Plan interventions included always keep the environment clear of clutter and hazards and position Resident 1's bed in a low position.During a review of Resident 1's Change of Condition (COC) Evaluation, dated 7/13/2025, the COC Evaluation indicated Resident 1 had an unwitnessed fall and was found by Certified Nursing Assistant (CNA) 1, next to her bed, face down on the floor, with her knees on the floor. The COC Evaluation indicated Resident 1 hit her forehead on the floor and had a small abrasion (measurement unknown) and redness on her forehead, and redness on both of her knees.During a review of Resident 1's Order Summary Report (Physician's Orders), dated 7/13/2025, the Physician's Orders indicated to transfer Resident 1 to a GACH via 911 due to an unwitnessed fall with head trauma (an injury to the head, including the scalp, skull, brain and underlying tissues). During a review of Resident 1's Post Fall Evaluation, dated 7/13/2025, the Post Fall Evaluation indicated Resident 1 sustained an unwitnessed fall in her room on 7/13/2025 at 5:40 p.m. The Post Fall Evaluation indicated Resident 1's activity at the time of the fall was unknown, and her bed was found at medium height at the time of her fall. During a review of the Emergency Department (ED) documents dated 7/13/2025, the ED documents indicated Resident 1 was transferred to the ED on 7/13/2025 at 6:42 p.m.During a review of Resident 1's GACH History and Physical (H&P), dated 7/14/2025, the H&P indicated Resident 1 was found to have forehead abrasions (unknown measurement). During an interview on 7/22/2025 at 3:05 p.m., Registered Nurse (RN) 1 stated she was called into Resident 1's room on 7/13/2025 at approximately 5 p.m. by Licensed Vocational Nurse (LVN) 1. RN 1 stated when she entered Resident 1's room she (RN 1) saw Resident 1 on the floor next to her bed. RN 1 stated Resident 1 appeared to be kneeling face down with her forehead on the floor. RN 1 stated she assessed Resident 1 and observed redness on Resident 1's forehead and bilateral knees and an abrasion (unknown measurement) to Resident 1's forehead. RN 1 stated she observed Resident's 1 bed being at a medium height, measuring approximately three feet from the ground. RN 1 stated Resident 1's bed height should have been positioned at the lowest level, as Resident 1 was at risk for falls. RN 1 stated the bed positioned at medium height placed Resident 1 at risk for injuries.During an interview on 7/22/2025 at 3:20 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she was called into Resident 1's room by Certified Nurse Assistant (CNA) 1 on 7/13/2025 at approximately 5 p.m. LVN 1 stated she saw Resident 1 on the floor next to her (Resident 1's) bed. LVN 1 stated Resident 1 was face down, with her knees bent under her and her hands to her side. Resident 1's bed was not at the lowest level. LVN 1 stated the bed must be at the lowest level due to Resident 1 being at risk for falls and injury.During an interview on 7/23/2025 at 1:30 p.m., the Director of Nursing (DON) stated the nursing staff should have implemented safety measures as indicated in Resident 1's Care Plan which was to position Resident 1's bed height at a low position. The DON stated failure to ensure Resident 1's bed was positioned to the lowest level placed Resident 1 at risk for falls which could lead to severe injuries, including death. During a review of the facility's policy and procedure (P&P) titled, Free of Accident Hazards/Supervision/Devices, revised 1/2025, the P&P indicated the facility provides an environment that is free from accident hazards over which the facility had control, and each resident receives adequate supervision and assistive devices for each resident to prevent avoidable accidents. The P&P indicated factors which may result in resident falls include but are not limited to incorrect bed height or width.During a review of the facility's P/P titled Quality of Care, revised 1/2025, the P&P indicated the facility ensures that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person -centered care plan and resident's choices based on the comprehensive assessment of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain right to privacy for one of six sampled residents (Resident 25) by failing to ensure privacy curtains was long enough to cover the resident's room during wound care dressing change. This failure violated Resident 25's right to privacy and had the potential for Resident 25 feeling of embarrassment. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease stage 3 (kidneys are moderately damaged and are not filtering waste and fluid from the blood as it should be), pulmonary hypertension( condition that affects the blood vessels in the lungs that makes the heart work harder than normal to pump). On 7/14/2020 Resident 25 had a diagnosis of moderate protein -calorie malnutrition (state of inadequate intake of food- during resident stay in the facility). During a review of Resident 25's Minimum Dat Set (MDS- resident assessment tool) dated 11/2/2024, the MDS indicated Resident 25 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent (helper does all of the effort) on staff with bed mobility, bathing, toileting hygiene, personal hygiene, dressing, and transfer to and from the bed to chair. The MDS indicated Resident 25 was always incontinent of urine and stool. The MDS indicated the resident was at risk of developing pressure injury and had a Stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). During an observation 11/21/1014 at 9:49 a.m., in Resident 25's room, privacy curtains was pulled by a staff before changing the wound dressing located in the coccyx (small bone at the bottom of the spine) area and left buttock of Resident 25. Observed the privacy curtains were not long enough to cover the room of Resident 25 and only covered the area in between Resident 25 and Resident 25's roommate. During an interview on 11/21/2024, at 10:02 a.m., with Certified Nursing Assistant (CNA 3), CNA 3 stated he noticed the privacy curtains had been short since he started working in the facility a month ago. CNA 3 stated the privacy curtains should be able to cover the resident's care area because the resident will not have privacy, and someone could walk in during the middle of provision of personal care where the resident was being cleaned or bathed. During an interview on 11/21/2024, at 10:14 a.m., with Treatment Nurse (TN 1), TN 1 stated the privacy curtains for Resident 25 had been short for a long time and was not sure if someone knew about it. TN 1 stated the privacy curtains should be completely cover the resident's care area to ensure privacy and maintain resident's dignity. During an interview on 11/23/2024, at 2:51 p.m., with Director of Nursing (DON), the DON stated privacy curtains need to cover the whole resident care area during provision of personal care to provide privacy and maintain resident's dignity. During a review of facility's policy and procedure (P&P) titled Dignity and respect dated 6/2018, the P&P indicated Residents' private space and property shall be always respected. The P&P indicated all residents will be always treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure two of 27 sampled residents (Resident 1 and Resident 49), was provided a safe, clean and homelike environment by failing to provide a room that did not have peeling paint and exposed wall on the bedroom walls. This deficient practice had the potential for Resident 1 and Resident 49 to affect the residents' dignity, mood, and violation of residents' rights to have a homelike environment. Findings: During a review of Resident 1's admission record, the admission Record indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and hemiparesis (a condition that causes weakness or an inability to move on one side of the body). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/4/2024, the MDS indicated Resident 1 had severe cognitive impairment (ability to think and reason) and was dependent on staff for activities of daily living (ADLs) such as oral hygiene, toileting, dressing, showering, and positioning. During a review of Resident 49's admission record, the admission Record indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a brain dysfunction due to an underlying condition that can cause confusion, memory loss and loss of consciousness) and dementia. During a review of Resident 49's MDS dated [DATE], the MDS indicated Resident 49 had severe cognitive impairment and was dependent on staff for activities of daily living (ADLs) such as oral hygiene, toileting, dressing, showering, and positioning. During an observation on 11/19/2024 at 9:35 a.m., in Resident 1 and Resident 49's room, observed peeling yellow paint and cracked wall on the wall facing the residents above the baseboards. During a concurrent observation and interview on 11/23/2024 at 12:19 p.m., with Certified Nurse Assistant (CNA) 6 in Resident 1 and Resident 49's room, CNA 6 stated the chipped paint and exposed wall did not reflect a homelike environment. CNA 6 stated maintenance should have been notified. During a concurrent observation and interview on 11/23/2024 at 12:24 p.m., with the Maintenance Supervisor/Account Manager (MS) in Resident 1 and Resident 49's room, the MS stated the wall was not intact, and the facility was working on repainting the room. The MS stated the peeling paint and exposed wall does not reflect a homelike environment. During an interview on 11/23/24 2:51 p.m., with the Director of Nursing (DON), the DON stated, Resident 1 and Resident 49's room should be a homelike environment. The DON stated there should not be paint that has chipped or dirty bedroom walls. The DON stated this could potentially affect the residents' dignity, the residents' mood, and violate residents' rights to have a homelike environment. During a review of the facility's policy and procedure (P&P), titled Homelike Environment, last revised 3/2023, The P&P indicated It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of 18 sampled residents (Resident 39) unwitnessed fall that caused a right hip fracture (a break or crack in a bone), required surgical repair and hospitalization at a General Acute Care Hospital (GACH) for four days (9/10/2024 to 9/14/2024) was reported to the state agency (California Department of Public Health [CDPH]). This failure resulted in a delay of an onsite investigation by CDPH to ensure Resident 39's fall was investigated and prevent further falls. Findings: During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including to fracture (broken bone) of the right femur (thigh bone), legal blindness ( a term used to describe a person's visual field of vision that is so limited that they are unable to see as well as most people), Alzheimer's disease, (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 39's History and Physical (H&P), dated 9/14/2024, the H&P indicated Resident 39 had fluctuating capacity to understand and make decisions due to dementia. The H&P indicated Resident 39 had a diagnosis of a right hip fracture and was status post (a patient's condition after a significant event such as surgery) intramedullary nailing (a surgical procedure that involves inserting a metal rod into the center of a bone to treat a fracture). During a review of Resident 39's Minimum Data Set (MDS -resident assessment tool) dated 9/19/2024, the MDS indicated Resident 39 had severely impaired cognition (ability to think, understand, learn, and remember) and never and or rarely made decisions. The MDS indicated Resident 39 needed substantial to maximal assistance (helper does more than half the effort) with eating, oral hygiene, upper body dressing, personal hygiene, rolling from left to right, moving from a sitting to lying position, the ability to stand from a sitting position, and transferring from the bed to a chair. The MDS indicated Resident 39 was dependent on staff (helper does all of the effort to complete the activity) for toileting, lower body dressing, and putting on and taking of footwear. The MDS indicated Resident 39 did not attempt to transfer on and off the toilet, transferring in and out the shower, and walking due to medical condition or safety concerns. During an interview on 11/23/2024 at 9:58 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 39 was blind in both eyes and dependent on nursing staff for feeding, bathing, and toileting. RN 1 stated Resident 39 had two falls in the past (5/2023 and 4/17/2024). RN 1 stated Resident 39 was found on the floor the morning of 9/10/2024. RN 1 stated Resident 39 was transferred to a GACH for a right hip fracture. During an interview on 11/23/2024 at 10:34 a.m., with RN 4, RN 4 stated on 9/10/2024 during the change of shift he was informed that Resident 39 was found on the floor at 6 a.m. and complained of right hip pain. RN 4 stated Resident 39 was found by a certified nursing assistant (CNA-unknown) sitting on the floor in between the bed of her roommate facing the wall. RN 4 stated Resident 39 had pain in the right leg and a right hip x-ray (create images of the inside of the body) was done. RN 4 stated the x-ray showed Resident 39 had a right hip fracture and Resident 39 was transferred to GACH on 9/10/2024 at 12:10 p.m., RN 4 stated Resident 39 had right hip surgery and returned to the facility on 9/14/2024. RN 4 stated Resident 39 had an unwitnessed fall that resulted in a fracture of the right hip. RN 4 stated Resident 39's fall was witnessed by a confused resident who was only alert and oriented to name and place. RN 4 stated an unwitnessed fall was when the staff or resident does not know what happened. RN 4 stated Resident 39's roommate was not a reliable witness because she was confused and cannot tell the details of the fall. RN 4 stated if a resident had an unwitnessed fall the resident should be assessed for any injury, the doctor and family notified. RN 4 stated if there was an injury like a fracture it should be reported to the California Department of Public Health. RN 4 stated an unusual occurrence should be reported as soon as possible and needs to be investigated right away. During a concurrent interview and record review on 11/23/2024 at 11:38 a.m., with the Program Manager (PM), Resident 39's roommate MDS was reviewed. The PM stated Resident 39's roommate's MDS dated [DATE], indicated Resident 39's roommate had a BIMS (Brief Interview for Mental Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of nine. PM stated a BIM score of nine means moderate cognitive (thinking, reasoning, or remembering) impairment (a stage of cognitive decline where the ability to think, learn, and remember is significantly affected, interfering with daily activities). PM stated when she spoke to Resident 39's roommate after the fall the roommate stated she was in a dream like state when she was awakened by Resident 39 and does not remember seeing Resident 39's fall. During an interview on 11/23/2024 at 4:06 p.m., with the Director of Nursing (DON), the DON stated if a fall was unwitnessed, and after the investigation it does not make sense why and how the resident fell, then the fall was reportable to CDPH. The DON stated an unwitnessed fall was when nobody sees what happen and the resident was found on the floor. The DON stated she does not know exactly what happened and did not report the fall based on Resident 39's roommate's interview at the time of the fall. During a review of the facility's Fall Incident report, dated 9/10/2024, the Fall Incident report indicated, at 6 am the charge nurse was summoned by a certified nurse assistant to Resident 39's room. Resident 39 was found on the floor in a sitting position facing the wall in between the residents' bed and Resident 39's roommate. Resident 39 was assisted back to bed and complained of pain on the right hip. Resident 39's roommate was interviewed and stated Resident 39 came to Resident 39's roommate bedside while she was asleep and held her hand and both residents were startled possibly causing Resident 39 to fall. During a review of Resident 39's Change in condition Evaluation, dated 9/10/2024, the Change in condition Evaluation indicated, an x-ray was done on the right hip and resulted in an acute right hip fracture. During a review of the GACH records, titled History & Physical, dated 9/10/2024, the History & Physical indicated an intertrochanteric fracture of the right femur. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, date revised 3/2023, the P&P indicated, Following comprehensive evaluation of the resident, notification of the appropriate persons, and after the resident is stable, the facility staff member in charge will complete applicable report and forward to management as indicated; or required by State law. During a review of the facility's policy and procedure (P&P) titled, Reporting Unusual Occurrences, date revised 3/2023, the P&P indicated, The facility asserts there are no requirements in the California Code of Regulations, Title 22, for facilities to report events, such as falls, or residents wandering outside of the building, unless the circumstances are unusual, as with suspected abuse or neglect. This remains true when the event results in an injury to the resident, unless the injury is unusual for the resident given the resident's current health status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Minimum Data Set Coordinator (MDSC) completed a significant change in status assessment (SCSA- a comprehensive assessment that must be completed when the Interdisciplinary Team [IDT- team of healthcare professionals who discuss and manage resident's care] has determined that a resident meets the significant change guidelines to either major improvement or decline) to one of six sampled residents (Resident 25). This failure had the potential for not providing appropriate care and services to Resident 25. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease stage 3 (kidneys are moderately damaged and are not filtering waste and fluid from the blood as it should be), pulmonary hypertension( condition that affects the blood vessels in the lungs that makes the heart work harder than normal to pump). On 7/14/2020 Resident 25 had a diagnosis of moderate protein -calorie malnutrition (state of inadequate intake of food- during resident stay in the facility). During a review of Resident 25's Minimum Dat Set (MDS- resident assessment tool) dated 11/2/2024, the MDS indicated Resident 25 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent (helper does all of the effort) on staff with bed mobility, bathing, toileting hygiene, personal hygiene, dressing, and transfer to and from the bed to chair. The MDS indicated Resident 25 was always incontinent of urine and stool. The MDS indicated the resident was at risk of developing pressure injury and had a Stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). During a review of Resident 25's COC Evaluation dated 11/11/2024, timed at 3:58 p.m., the COC indicated there was a small opening in the coccyx area where the redness was observed on 10/30/2024. During a review of Resident 25's Pressure Sore Management Record dated 11/11/2024, the Pressure Sore Management Record indicated Stage II pressure injury on the coccyx measured two and half (2.5) cm. in length and two (2) cm. in width. During an interview on 11/22/2024, at 3:03 p.m., with Minimum Data Set Coordinator (MDSC), MDSC stated significant change in status assessment (SCSA- a comprehensive assessment that must be completed when the Interdisciplinary Team (IDT- team of healthcare professionals who discuss and manage resident's care) has determined that a resident meets the significant change guidelines to either major improvement or decline) was triggered by two major areas like weight loss and pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). MDSC stated when she conducted her assessment the pressure injury was Stage 1 and weight loss. MDSC stated she will review Resident 25's medical records, talk to Treatment Nurse (TN1) and will do a significant change in status assessment. MDSC stated MDS should be accurate because the information was submitted to Center of Medicare (CMS) and wrong resident's information will affect the resident's care by not receiving the proper care and treatment. During an interview on11/23/2024, at 3:40 p.m., with Director of Nursing (DON), the DON stated SCSA was triggered if a resident had two major changes in their condition. The DON stated it was important to complete SCSA to target a specific action for an identified problem. During a review of facility's policy and procedure (P&P) titled Comprehensive Assessments Timing revised 3/2023, the P&P indicated a SCSA is appropriate if there are either two or more MDS areas of decline or two or more areas of improvements or if the IDT determines that the resident would benefit from the SCSA assessment and subsequent care plan revision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b.During a review of Resident 68's admission record, the admission Record indicated Resident 68 was admitted to the facility on [DATE] with diagnoses including wedge compression fractures (type of spine fracture [broken bone] that occurs when the front of a vertebra collapses or compresses, giving it a wedge shape) of the thoracic (middle section of spine) and lumbar (lower section of spine) vertebrae (bones of the spine), fracture of the sacrum (a bony structure at the base of the lumbar vertebrae that is connected to the pelvis-hip bone), and repeated falls. The face sheet indicated Resident 68 was discharged on 10/31/2024 to a private home with home health services. During a review of Resident 68's History and Physical (H&P), dated 10/23/2024, the H&P indicated Resident 68 did not have the capacity to understand and make decisions. During a review of Resident 68's Interdisciplinary Discharge summary, dated [DATE], the document indicated Resident 68 was discharge to home on [DATE] with arranged home health services including physical therapy, occupational therapy, and registered nurse visits. During a concurrent interview and record review on 11/22/2024 at 10:03 a.m., with the MDS Coordinator (MDSC), Resident 68's MDS dated [DATE] was reviewed. The MDSC indicated Resident 68 had an unplanned discharge to a Short-Term General hospital on [DATE]. The MDS nurse stated the MDS was incorrect, and the MDS should have reflected that Resident 68 was discharged home. The MDS nurse stated they will submit a correction. During an interview on 11/23/2024 at 2:51 p.m. with the Director of Nursing Services (DON), the DON stated it is important for the MDS to be accurate and reflect the resident to be able provide accurate care and services for the residents. During a review of the facility's policy and procedure (P&P) titled, Accuracy of Assessments, date revised 3/2023, the P&P indicated, The assessment must represent an accurate picture of the resident's status during the observation period of the MDS .When the MDS is completed, only those occurrences during the observation period will be captured on the assessment. In other words, if it did not occur during the observation period, it is not coded on the MDS. Based on interview and record review the facility failed to ensure two of 18 sampled Residents (Resident 39 and 68 ) entry on the Minimum Data Set (MDS -resident assessment tool) assessment entries were accurate. The facility failed to: a. Ensure Section M in the MDS titled Skin Conditions was accurately documented to reflect Resident 39's current skin condition. b. Ensure Resident 68 discharge status was accurately documented to reflect Resident 68 was discharged home. This failure had the potential to result in a negative effect of Resident 39 and 68's plan of care and delivery of necessary care and services. Findings: a.During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of the right femur (thigh bone), legal blindness, Alzheimer's disease, (a disease characterized by a progressive decline in mental abilities) and dementia (a progressive state of decline in mental abilities). During a review of Resident 39's History and Physical (H&P), dated 9/14/2024, the H&P indicated Resident 39 had fluctuating capacity to understand and make decisions due to dementia. The H&P indicated Resident 39 had a diagnosis of a right hip fracture and was status post (a patient's condition after a significant event such as surgery) intramedullary nailing (a surgical procedure that involves inserting a metal rod into the center of a bone to treat a fracture). During a review of Resident 39's MDS dated [DATE], the MDS indicated Resident 39 had severely impaired cognition and never and or rarely made decisions. The MDS indicated Resident 39 needed substantial to maximal assistance with eating, oral hygiene, upper body dressing, personal hygiene, rolling from left to right, moving from a sitting to lying position, the ability to stand from a sitting position, and transferring from the bed to a chair. The MDS indicated Resident 39 was dependent on staff for toileting, lower body dressing, and putting on and taking of footwear. The MDS indicated Resident 39 did not attempt to transfer on and off the toilet, transferring in and out the shower, and walking due to medical condition or safety concerns. The MDS indicated Resident 39 had a Stage II (partial-thickness loss of skin, presenting as a shallow open sore or wound) and stage III (a full-thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are not exposed) pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During an interview on 11/22/2024 at 2:05 p.m., with Treatment Nurse (TN) 1, TN 1 stated Resident 39 was re-admitted to the facility after surgery with Stage II pressure ulcer located at coccyx (the last bone at the bottom of the spine) on 9/14/2024. TN 1 stated Resident 39 has not developed Stage III pressure ulcer or Stage IV (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) pressure ulcer and was not receiving any wound care. TN 1 stated the Stage II pressure ulcer is resolved. During an interview on 11/22/2024 at 3:38 p.m., with Minimum Data Set Coordinator (MDSC), MDSC stated Resident 39 came to the facility with a Stage II pressure ulcer. MDSC stated the MDS was miscoded inaccurately by documenting Resident 39 had a Stage III pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 46's admission record, the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteomyelitis (inflammation of bone, usually due to infection). During a review of Resident 46's History and Physical (H&P), dated 9/13/2024, the H&P indicated Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 46 was able to understand and be understood by others. The MDS indicated Resident 46 required setup or clean up assistance for eating and oral hygiene and partial assistance (helper performs less than half of the effort) for toileting and dressing. During a review of Resident 46's Medication Administration Record (MAR) for July 2024, the MAR indicated the following orders: a.Basagalar KwikPen subcutaneous solution pen-injector 100 unit/ml (milliliter) (Insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) Glargine ((long acting type of insulin that works slowly over time] ) Inject 64 unit subcutaneously (administered in the fatty tissue just under the skin layer) one time a day for DM , Start Date: 5/23/2024. b.Farxiga oral tablet five mg (milligrams) (Dapagliflozin Propandediol) Give 1 tablet by mouth one time a day for Type 2 DM, Start Date: 1/17/2024. c.NovoLin R FlexPen Injection Solution Pen-Injector 100 unit/ml (Insulin Regular (Human)) (a short acting type of insulin usually given 30 minutes prior to meal based on sliding scale parameters (the amount of insulin to be administered changes or slides up or down based on the person's blood sugar.) Inject as per sliding scale subcutaneously before meals for DM2, Start date 4/10/2024, Schedule times: 6:30 a.m., 11:30 a.m., and 4:30 p.m. d.NovoLin R FlexPen Injection Solution Pen-Injector 100 unit/ml (Insulin Regular (Human)) Inject as per sliding scale subcutaneously at bedtime for DM2, scale Start date 4/10/2024 During a review of Resident 46's Situation, Background, Assessment, Recommendation [SBAR]a communication tool used by healthcare workers when there is a change of condition among the residents) Summary dated 7/18/2024 at 8:00 a.m., the SBAR indicated Resident 46: a.Experienced confusion and skin were cold and clammy (common symptoms of hypoglycemia). b.Blood glucose (sugar) was 42 milligrams per deciliter (mg/dL -unit of measurement). c.Resident 46 was given two glasses of orange juice and 3 packets of sugar. d.One hour after orange juice administration, Resident 46's blood sugar was 80 mg/dL and was back to baseline mentation. During a review of Resident 46's Physician Order Summary dated 11/23/2024, the Order Summary indicated on 7/19/2024 at 9:38 a.m., the physician decreased Resident 46's scheduled Insulin Glargine from 64 units to 30 units. During a review of Resident 46's care plans, the care plan indicated Registered Nurse (RN) 4 initiated a care plan on 7/19/2024 regarding Resident 46's episode of hypoglycemia. The Care plan was cancelled on 8/29/2024 when Resident 46 was transferred to the acute care hospital. During a concurrent interview and record review on 11/23/2024 at 10:08 a.m., with Licensed Vocational Nurse (LVN) 3, Resident 46's SBAR Summary dated 8/18/2024 at 4:04 p.m. was reviewed. The SBAR indicated Resident 46: a.Experienced symptoms of increased confusion, feeling cold and clammy b.Blood glucose was checked by an LVN (TN1) and was 34 mg/dL. c.TN 1 attempted to give a glass of apple juice with 3 packs of sugar, but Resident 46 was unable to swallow. TN 1 administered glucagon (medication to increase blood glucose) 1 mg intramuscular (IM-given in the muscle). d.Blood glucose was rechecked 10 minutes after glucagon administration and was 49mg/dL e.30 minutes after glucagon administration, Resident 46 was not verbally responsive and blood glucose was 61 mg/dL. f.TN 1 gave Resident 46 a glass of orange juice with 3 packets of sugar. g.15 minutes after orange juice administration, Resident 46 became verbally responsive and blood sugar was 106. During an interview on 11/23/2024 at 10:08 a.m., with LVN 3, LVN 3 stated any situation that the resident experiences a change of condition, a care plan should be initiated or revised. During a review of Resident 46's Physician Order Summary dated 11/23/2024, the Physician Order Summary indicated on 8/18/2024 at 7:14 p.m , the physician discontinued Resident 46's scheduled Insulin Glargine 30 units. During an interview on 11/23/2024 at 10:50 a.m., with the Minimum Data Set Coordinator (MDSC), the MDSC stated Resident 46's care plans were not revised after the hypoglycemic event on 8/18/2024. The MDSC stated it was important that the care plan was revised to prevent continued hypoglycemic events. During a concurrent interview and record review on 11/23/2024 at 2:51 p.m., with the Director of Nursing Services (DON), Resident 46's electronic health record (EHR) was reviewed. The DON stated care plans should always be initiated or revised when there was a change of condition to have a clear picture of what the interventions are and what needs to be monitored. During a review of the facility's policy and procedure (P&P), titled Comprehensive Care Plans-Timing, last revised March 2023, The P&P indicated Each resident shall have a person-centered, comprehensive care plan, developed, reviewed and revised by the facility interdisciplinary team. Based on interview and record review, the facility failed to review and revise the comprehensive care plan for two of five sampled residents (Resident 2 and Resident 46). The facility failed to: a. Update the Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) plan of care when OT services were discontinued. This deficient practice had the potential to negatively affect the delivery of necessary care and services for Residents 2. b. Review and revise the care plan after the Resident 46 experienced a change of condition. This failure had the potential to result in Resident 46 experiencing repeated hypoglycemic (low blood sugar) events, diabetic coma (a life-threatening condition that occurs when someone with diabetes [ DM a disorder characterized by difficulty in blood sugar control and poor wound healing] has dangerously high or low blood sugar and becomes unconscious), or death. Findings: a.During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right sided hemiplegia (weakness to the right side of the body) and hemiparesis (inability to move one side of the body) following a non-traumatic intracerebral hemorrhage (bleeding in the brain) and contractures (loss of motion of a joint associated with stiffness and joint deformity) of both hands and the lower leg. During a review of Resident 2's Physician Order Summary Report, the Physician Order Summary Report indicated a physician's order, dated 6/28/2024, for OT to discontinue OT services for exercises, neuromuscular re-education (rehabilitation techniques to restore muscle function and movement), and splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) management. During a review of Resident 2's Care Plan titled Resident 2 had decreased balance, coordination, safety, endurance, and range of motion (ROM, full movement potential of a joint) in both hands, initiated on 6/26/2024, the Care Plan indicated interventions to address Resident 2's impairments were for OT services, three times a week for four weeks, for exercises, neuromuscular re-education (rehabilitation techniques to restore muscle function and movement), and splint management. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 2 had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 2 was dependent in eating, hygiene, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 2 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During a concurrent interview and record review on 11/21/2024 at 1:06 p.m., with the Director of Rehabilitation (DOR), the DOR stated the licensed therapists which included the OTs, Physical Therapists (PT, licensed professional aimed in the restoration, maintenance, and promotion of optimal physical function), and Speech Therapists (ST, licensed professional aimed in the prevention, assessment, and treatment of speech, language, communicative, and swallowing disorders) were responsible for developing, reviewing, and revising the section of a resident's care plans related to therapy services. The DOR stated everything related to therapy should be care planned. The DOR reviewed Resident 2's care plans, physician's orders, and therapy notes. The DOR confirmed Resident 2's care plans indicated Resident 2 was receiving OT services but was not. The DOR confirmed Resident 2's care plan was not updated and stated the OT interventions should have been discontinued when Resident 2 was discharged from OT services on 6/28/2024. The DOR stated it was important care plans were revised and updated to avoid confusion and to ensure the facility was addressing the resident's care appropriately. During an interview on 11/22/2024 at 9:15 am, the Minimum Data Set Coordinator (MDSC) stated the Rehabilitation Department was responsible for developing and updating all the care plans related to therapy services. The MDSC stated it was important for care plans to be accurate and updated to ensure the resident was receiving the appropriate type of care. During an interview on 11/22/2023 at 10:14 am, the Director of Nursing (DON) stated the comprehensive care plan was a guide used by staff to identify a resident's goals and problem areas and create interventions to address those concerns. The DON stated the care plan should be updated for any change of condition, upon discovery of any new concern, quarterly, and as needed. The DON stated it was important for care plans to be accurate and updated to ensure staff knew how to provide the appropriate care to the residents. During a review of the facility's Policy and Procedure (P&P), revised 3/2023, titled Comprehensive Care Plans - Timing, the P&P indicated the residents shall have a person-centered, comprehensive care plan, developed, reviewed, and revised by the facility interdisciplinary team including the resident and resident representative, if applicable. The P&P indicated the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, one of one sampled resident (Resident 46) received treatment and care when Resident 46 experienced two hypoglycemic (low blood sugar) events (7/18/2024 and 8/18/2024). The facility failed to: a.Conduct and Interdisciplinary Team (IDT- team of health care professionals that work together toward and prioritize the resident's needs) meeting after Resident 46 experienced two hypoglycemic (low blood sugar) events (7/18/2024 and 8/18/2024). b.Activate the emergency response system on 8/18/2024 when Resident 46's continues to be unresponsive after interventions. This failure had the potential to result in Resident 46 experiencing repeated hypoglycemic events, diabetic coma (a life-threatening condition that occurs when someone with diabetes [ DM a disorder characterized by difficulty in blood sugar control and poor wound healing]), including death. Findings: During a review of Resident 46's admission record, the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteomyelitis (inflammation of bone, usually due to infection). During a review of Resident 46's History and Physical (H&P), dated 9/13/2024, the H&P indicated Resident 46 had the capacity to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 46 was able to understand and be understood by others. The MDS indicated Resident 46 required setup or clean up assistance for eating and oral hygiene and partial assistance (helper performs less than half of the effort) for toileting and dressing. During a review of Resident 46's Medication Administration Record (MAR) for July 2024, the MAR indicated the following orders: a.Basagalar KwikPen subcutaneous solution pen-injector 100 unit/ milliliter (mg-unit of measurement) (Insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) Glargine (long acting type of insulin that works slowly over time ) inject 64 unit subcutaneously (administered in the fatty tissue just under the skin layer) one time a day for DM , with a start date of 5/23/2024. b.Farxiga oral tablet five milligrams (mg-unit of measurement ) (Dapagliflozin Propandediol) give one tablet by mouth one time a day for type 2 DM, with a start date of 1/17/2024. c.NovoLin R FlexPen Injection Solution Pen-Injector 100 unit/ml (Insulin Regular (Human)) (a short acting type of insulin usually given 30 minutes prior to meal based on sliding scale parameters (the amount of insulin to be administered changes or slides up or down based on the person's blood sugar.) inject as per sliding scale subcutaneously before meals for type 2 DM, with a start date of 4/10/2024, and schedule times: 6:30 a.m., 11:30 a.m., and 4:30 p.m. d.NovoLin R FlexPen Injection Solution Pen-Injector 100 unit/ml (Insulin Regular (Human)) inject as per sliding scale subcutaneously at bedtime for type 2 DM, scale with a start date of 4/10/2024. During a review of Resident 46's Situation, Background, Assessment, Recommendation [SBAR]a communication tool used by healthcare workers when there is a change of condition among the residents) Summary dated 7/18/2024 at 8:00 a.m., the SBAR indicated Resident 46: a.Experienced confusion and skin were cold and clammy (common symptoms of hypoglycemia). b.Blood glucose (sugar) was 42 milligrams per deciliter (mg/dL -unit of measurement). c.Resident 46 was given two glasses of orange juice and 3 packets of sugar. d.One hour after orange juice administration, Resident 46's blood sugar was 80 mg/dL and was back to baseline mentation. During a review of Resident 46's Laboratory (Lab) Results Report dated 7/19/2024, the Lab results report indicated Resident 46's blood glucose collected on 7/19/2024 at 4:30 a.m. was 34 mg/dL. The report indicated the results were communicated from the laboratory to registered nurse (RN) 3 on 7/19/2024 at 8:04 p.m. During a review of Resident 46's Medication Administration Record (MAR) for July 2024, the MAR indicated Resident 46's blood sugar was: a.7/19/2024 at 9:00 p.m. was 283 mg/dL b.7/20/2024 at 6:30 a.m. was 128 mg/dL. During a review of Resident 46's Physician Order Summary dated 11/23/2024, the Order Summary indicated on 7/19/2024 at 9:38 a.m., the physician decreased Resident 46's scheduled Insulin Glargine from 64 units to 30 units. During a review of Review of Resident 46's Nurse Progress Note dated 7/20/2024, the note indicated Resident 46's blood glucose level of 34 mg/dL (collected by the laboratory) was reported to the physician on 7/20/2024 at 8:42 a.m. The note indicated the physician did not provide new orders as the Insulin Glargine was decreased on 7/19/2024. During a concurrent interview and record review on 11/23/2024 at 10:08 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 46's SBAR Summary dated 8/18/2024 at 4:04 p.m., Resident 46's Meal Nutrition-Meal Percentages for August 2024, and Resident 46's MAR for August 2024 were reviewed. The SBAR indicated Resident 46: a. Experienced symptoms of increased confusion, feeling cold and clammy b. Blood glucose was checked by an LVN (TN1) and was 34 mg/dL. c. TN1 attempted to give a glass of apple juice with 3 packs of sugar, but Resident 46 was unable to swallow. TN 1 administered glucagon (Medication to increase blood glucose) 1 mg intramuscular (IM-given in the muscle). d. Blood glucose was rechecked 10 minutes after glucagon administration and was 49mg/dL e. 30 minutes after glucagon administration, Resident 46 was not verbally responsive and blood glucose was 61 mg/dL. f. TN 1 gave Resident 46 a glass of orange juice with 3 packets of sugar. g. 15 minutes after orange juice administration, Resident 46 became verbally responsive and blood sugar was 106. The Nutrition-Meal Percentages for August 2024 indicated on 8/18/2024, Resident 46 ate 0% of meal during lunch time (12:15 p.m.) and 0% of meal during dinner (5:15 p.m.). The MAR for 2024 indicated on 8/18/2024 at 4:45 p.m., Resident 46 received 1 unit of Insulin Regular. LVN 3 stated if the resident's blood sugar was still under 70 and the resident was symptomatic or had a decline in mentation after the administration of glucagon, the emergency response system should have been activated and 911 should have been called. LVN 3 stated because Resident 46 experienced the hypoglycemic event, the Insulin Regular scheduled to be given at 4:30 p.m. should have been clarified with the physician prior to administering even the blood glucose was within range to administer. During a review of Resident 46's Physician Order Summary dated 11/23/2024, the Physician Order Summary indicated on 8/18/2024 at 7:14 p.m , the physician discontinued Resident 46's scheduled Insulin Glargine 30 units. During an interview on 11/23/2024 at 10:50 a.m. with the Minimum Data Set Coordinator (MDSC), the MDSC stated IDT meetings did not occur after the hypoglycemic events and was not discussed during the scheduled quarterly IDT meetings. During a concurrent interview and record review on 11/23/2024 at 2:51 p.m. with the Director of Nursing Services (DON), Resident 46's chart was reviewed. The DON stated the emergency response system should have been initiated after Resident 46 experienced a decline in mentation on 8/18/2024 to prevent any delay in care. The DON stated IDT meetings should have been conducted after the hypoglycemic events to discuss the possible causes and to ensure care plan and interventions were revised to prevent reoccurrence of the hypoglycemic events. The DON stated the nurse should have clarified the insulin orders with the physician on 8/18/2024 prior to administering scheduled insulin after the hypoglycemic event. During a review of the facility's policy and procedure (P&P), titled Care and Services Residents Rights, dated November 2024, The P&P indicated The facility strives to provide residents with the necessary care and services to maintain his or her highest level of practicable functioning in an environment that enhances each resident's quality of life in the scope of a long-term care facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident, who was assessed at a moderate risk (a scoring tool used to predict residents' risk of developing a pressure injury, total scores range from six to 23. A lower score indicating a higher risk of developing a pressure injury) for developing a pressure injury and had an intact skin upon admission, did not develop a Stage I ( intact skin with a localized area of redness and/ or changes in sensation, temperature , or firmness) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on coccyx area and progressed into Stage II ( partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury measuring two and half centimeter (cm-unit of measurement) in length by two cm in width and shearing (type of injury where different layers of skin or tissue slide against each other in opposite directions, causing damage to the deeper tissue layers) in the coccyx (small bone at the bottom of the spine) area to one of five sampled residents (Resident 25). The facility failed to: 1. Implement Resident 25's care plan titled Altered Skin Integrity due to actual pressure injury related to immobility and compromised nutritional status, initiated on 10/30/2024 with interventions to turn and reposition the resident to offload (minimizing or removing weight placed on the affected area to help and prevent pressure injury) the coccyx area and buttocks and low air loss mattress (designed to distribute the patient's body over a broad surface area and help prevent skin breakdown) with bolsters ( a long pillow or cushion) for skin maintenance (not initiated until 11/11/2024 [11 days after Resident 25 developed a Stage I pressure injury]) to prevent Resident 25 from developing a pressure injury by relieving the pressure from the coccyx area. 2. Ensure bath towels were not used in replacement of incontinence pads (diaper) to keep Resident 25 clean and dry from incontinence of urine and stool. These failures had the potential for Resident 25's Stage II pressure injury on the left buttock delayed in healing and to progress to size and wound stage. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease stage 3 (kidneys are moderately damaged and are not filtering waste and fluid from the blood as it should be), pulmonary hypertension( condition that affects the blood vessels in the lungs that makes the heart work harder than normal to pump). On 7/14/2020 Resident 25 had a diagnosis of moderate protein -calorie malnutrition (state of inadequate intake of food- during resident stay in the facility). During a review of Resident 25's Minimum Dat Set (MDS- resident assessment tool) dated 11/2/2024, the MDS indicated Resident 25 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent (helper does all of the effort) on staff with bed mobility, bathing, toileting hygiene, personal hygiene, dressing, and transfer to and from the bed to chair. The MDS indicated Resident 25 was always incontinent of urine and stool. The MDS indicated the resident was at risk of developing pressure injury and had a Stage 1 pressure injury (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness). During a review of Resident 25's Care plan titled Resident is at risk for Alteration in Skin Integrity related to diabetes, fragile skin , incontinence, anemia (low blood count), hypothyroidism, muscle weakness, moderate calorie protein malnutrition and resident refuses to turn, high risk for pressure injuries initiated on 1/28/2019, with Care plan goal included Resident 25 will remain free of avoidable altered skin integrity dated 1/28/2024 and revision on 8/8/2024. The Care plan interventions included monitoring for signs and symptoms of skin breakdown (initiated 4/20/2020), and notify the physician if present, apply skin moisturizers to dry skin, encourage and assist to offload, encourage to turn, and reposition at least every two hours while in bed and keeping Resident 25 clean and dry. During a review of Resident 25's Braden Scale (a scoring tool used to predict residents' risk of developing a pressure injury, total scores range from six to 23. A lower score indicating a higher risk of developing a pressure injury) dated 2/2/2024 the Braden Scale indicated Resident 25's score was 13 (score of 13 means moderate risk of developing pressure injury). During a review of Resident 25's Change of Condition Evaluation (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional condition) dated 10/30/2024 timed at 4:42 p.m., the COC indicated Resident 25 had developed redness on the coccyx area. During a review of Resident 25's Care Plan titled Altered Skin Integrity due to actual pressure injury related to immobility and compromised nutritional status, initiated 10/30/2024. The Care Plan indicated on 11/11/2024 the pressure injury progressed to Stage II and on 11/12/2024 the wound specialist physician clarified wound site as located in the left buttock. The Care Plan goal indicated Resident 25's pressure injury will show signs of healing and remain free of infection. The Care Plan interventions included encourage Resident 25 to turn and reposition every two hours and as needed due to resident's preference to lay on her back, low air loss mattress with bolsters for skin maintenance, provide supplemental proteins, vitamins, minerals as ordered, provide diet and supplements and Registered Dietician to assess nutritional needs to promote wound healing. The Care Interventions indicated to provide perineal care (the practice of cleaning the genital and anal area) with each incontinence episode, and monitor wound dressing to ensure it was intact, adhering in the affected area and change dressing as needed. During a review of Resident 25's Weekly Pressure Injury dated 10/30/24 indicated a Stage 1 in the coccyx measuring two centimeter (cm-unit of measurement) in length and two cm. in width. During a review of Resident 25's Pressure Sore Management Record dated 11/11/2024, the Pressure Sore Management Record indicated Stage II pressure injury on the coccyx measured two and half (2.5) cm. in length and two (2) cm. in width. During a review of Resident 25's COC Evaluation dated 11/11/2024, timed at 3:58 p.m., the COC indicated there was a small opening in the coccyx area where the redness was observed on 10/30/2024. During a review of Resident 25's Weekly Pressure Injury Skin Problem assessment dated [DATE], the Weekly Pressure Injury Skin Problem Assessment indicated the Stage II pressure injury was clarified and reclassified as left buttock from coccyx on 11/11/2024, measuring two and half (2.5) cm. in length and two (2) cm. in width by the physician. During a review of Resident 25's COC Evaluation, dated 11/19/2024, the COC indicated Wound Specialist physician observed a shearing on the sacral (bottom of the spine) area. During a review of Resident 25's Wound Assessment Report dated 11/19/2024, the Wound assessment Report indicated Stage II pressure injury on the sacrum. The Wound Assessment Report indicated shearing and described the wound as dry flaking epithelium (peeling skin) with hyperpigmentation (darkened area of skin discoloration that develops around the pressure wound). The Wound Assessment Report indicated to clean wound with soap and water, pat dry, apply zinc oxide paste (medicated paste that treats or prevents and protect skin from irritation) and dry foam dressing daily. During a review of Resident 25's Physician Order Summary Report dated 11/19/2024, the Order Summary Report indicated to cleanse pressure injury with normal saline (cleaning solution), pat dry, apply zinc oxide and cover with foam dressing daily for 14 days for Stage II on the left buttock. During a review of Resident 25's Physician Order Summary Report, the Physician Order Summary Report indicated the following orders: 1. On 11/11/2024, low air loss mattress with bolster for skin maintenance was ordered 2.On 11/21/2024, Prostat (liquid protein) 30 milliliters (ml- unit of measurement) daily protein supplementation. During a review of Resident 25's Weekly Pressure Injury dated 11/19/2024, the Weekly Pressure Injury indicated shearing and hyperpigmentation on the sacrum measuring 1.5 cm. in length and 1.5 cm. in width. During a concurrent interview and record review on 11/20/2024 at 4:11 p.m., with RN 4, reviewed Resident 25's electronic health record (EHR). RN 4 stated Resident 25 developed pressure injury due to poor food intake. RN 4 stated there was no added nutritional supplements or diet modification. RN 4 stated Resident 25 was not eating well and was refusing mechanical soft diet (diet of soft and moist food that are easy to swallow) so speech therapy consultation was ordered on 8/9/2024. During a concurrent observation and interview on 11/21/2024, at 8:49 a.m., with Treatment Nurse (TN 1) in Resident 25's room, observed Resident 25 was tuned to her right side by Certified Nursing Assistant (CNA 3) and CNA 4. Observed dressing was absent on the left buttock and coccyx area where the Stage II pressure injury was located. Observed darkened skin discoloration, dry, flaky skin in the coccyx area and left buttock. TN 1 stated wound dressing was not in place because Resident 25 had a large bowel movement (process by which the body eliminate waste from the digestive tract) that occurred closed to breakfast and the dressing will be change by TN 1. TN 1 stated the charge nurse should have changed the wound dressing as needed if it gets soiled by urine and stool if the treatment nurse was not in the facility or unavailable. TN 1 stated the Stage II pressure injury was closed but not resolved per Wound Specialist Physician and remained a Stage II pressure injury. During an observation on 11/21/2024, at 9:45 a.m. during wound care dressing of Resident 25's pressure injury, observe Resident 25 was turned towards the left side of the bed by CNA 3 and CNA 4 after wound care dressing provided by TN 1. Observed a pillow positioned on the right upper side of resident's body and another pillow was placed on the left side on the upper body. Observed Resident 25's coccyx area was not offloaded because of the position of the two pillows on the right side and left side of her upper body. During a concurrent observation on 11/21/2024, at 12:00 p.m., and 1:30 p.m. Resident 25 was positioned on her back with pillows on both right and left side of the resident's body. During an interview on 11/20/2024, at 3:12 p.m. and subsequent interview on 11/21/2024, at 2:49 p.m. with CNA 3, CNA 3 stated Resident 25 was incontinent (inability to control the flow of urine or stool) of urine and stool. CNA3 stated Resident 25 does not wear an incontinence pad because of the type of mattress Resident 25 was using. CNA 3 stated they put a bath towel in between the legs and under the buttocks to help with the incontinence of stool or urine. During a concurrent interview and record review on 11/20/2024, at 4:35 p.m. and subsequent interview on 11/22/2024, at 12:43 p.m. with TN 1, reviewed Resident 25's EHR. TN 1 stated she found out Resident 25's pressure injury on the left buttock progressed to Stage 2 during her skin rounds on 11/11/2024. TN 1 stated the staff did not notify her about the progression of Resident 25's Stage 1 pressure injury to Stage 2 on the left buttock. TN 1 stated on 11/12/2024, wound specialist came and evaluated the Resident 25's wound and labeled the wound's location to be left buttock and not coccyx. TN 1 stated on 11/19/2024 wound specialist examined Resident 25's left buttock which showed shearing in the sacrum and change the treatment order to application of zinc oxide paste on the left buttock and sacrum then apply foam dressing. TN 1 stated Resident 25 was incontinent of stool and urine and the CNAs place bath towels right under and in between her legs to catch stool and urine as to not run down to the mattress. TN 1 stated Resident 25 needs to be repositioned every two hours to offload the left buttock and sacral area. TN 1 stated the facility used only pillow to turn and position resident and pointed out an observation made that the resident was positioned to left but the CNAs also placed a pillow on the right side of resident's body to turn resident to the left then placed a pillow on the right side of the body. TN 1 agreed Resident 25 was not properly repositioned and not offloading the sacrum and buttock when CNAs positioned Resident 25 on the back with pillows on both right and left side of the resident's body. TN 1 stated the facility should positioned resident properly to offload the buttock and sacrum. TN 1 stated CNAs should not use bath towels to catch urine or stool as it causes shearing to Resident 25 skin. TN 1 stated the bath towel are not designed to fit snugly around Resident 25's body like diapers, which can lead to increased friction and shearing when Resident 25 moves. TN1 does not absorb moisture effectively compared to diapers, prolonged exposure to moisture can lead to skin breakdown.TN 1 stated bath towels could cause skin breakdown because the texture of the material was rough. During an interview on 11/22/2024, at 3:03 p.m. with Director of Staff Development (DSD), DSD stated residents who are on low air loss mattress should use diapers and not bath towels for incontinence episodes because bath towels soaked with urine or stool that could lead to skin irritation and skin breakdown. DSD stated the resident (in general) should be turned every two hours and ideally residents should be provided incontinence or personal care every two hours. DSD stated the staff should not place pillow on both sides because the back was not being offloaded. DSD stated when Resident 25 was turned to the left, pillow should be placed on the right side of the resident's body, pillow under the legs for support and no pillow on the left side of the body to offload. During a concurrent interview and record review on 11/23/2024 at 2:51 p.m., with the Director of Nursing (DON), reviewed Resident 25's EHR. The DON stated all licensed staff and CNAs are responsible in monitoring the food intake of all residents. The DON stated if the resident was eating poorly the CNA should notify the charge nurses. The DON stated Resident 25 was eating poorly and confirmed there was no change of condition documented nor documentation the physician was notified about the weight loss on her EHR. The DON stated weight loss and pressure injury go together and Resident 25 was vulnerable to develop pressure injury because of Resident 25's poor food intake, immobility, incontinence of urine and stools and skin condition. The DON stated using of bath towels to prevent urine and stool to run down the air loss mattress should not be practiced because bath towel texture was rough and can cause skin breakdown. The DON stated using bath towels to absorb urine and stool and improper turning or positioning contributed to the development of Resident 25's pressure injury. During a review of facility's Position Description of a Treatment Nurse, the Position Description of a Treatment Nurse indicated The Treatment Nurse will provide primary skin care to residents under the medical direction and supervision of the resident's attending physician, the Director of Nursing Services, or the Medical Director of the facility, with an emphasis on the treatment and therapy of skin disorders. During a review of facility's policy and procedure (P&P) titled Skin Assessment revised 3/2023, the P&P indicated the licensed nurse completes routine monitoring of the resident's existing and potential risk factor for developing a pressure injury through the completion of a weekly assessment. The P&P indicated the sacrum and heels should be inspected and assessed for skin discoloration and pressure related concerns and are the areas of great vulnerability. The P&P indicated skin integrity should be assessed for pressure related discoloration or breakdown from positioning or use of medical devices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) were provided a resting hand splint (splint [rigid material or apparatus used to support and immobilize a broken bone or impaired joint] secured from the hand to the forearm to position the hand in a functional position) to Resident 2's left arm and a hand roll splint (splint placed in the palm of the hand used to position the hand in a functional position) to Resident 2's right hand in accordance with Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) recommendations on 6/28/2024. This failure had the potential to cause Resident 2 to have further range of motion (ROM, full movement potential of a joint) decline in both arms, contracture (loss of motion of a joint associated with stiffness and joint deformity) development, decreased mobility (ability to move) and a decline in activities of daily living (ADLs, basic activities such as eating, dressing, and hygiene). Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right sided hemiplegia (weakness to the right side of the body) and hemiparesis (inability to move one side of the body) following a non-traumatic intracerebral hemorrhage (bleeding in the brain) and contractures (loss of motion of a joint associated with stiffness and joint deformity) of both hands and the lower leg. During a review of Resident 2's Physician Order Summary Report, the Physician Order Summary Report indicated a physician's order, dated 6/26/2024, for OT to evaluate Resident 2 to prevent further contractures of both hands. During a review of Resident 2's OT Evaluation and Plan of Treatment (OT Eval), initiated 6/26/2024, the OT eval indicated the reason for referral was due to a decline in ROM of Resident 2's both hands. The OT Eval indicated Resident 2 had impaired ROM in both shoulders and both hands and had rigid muscle tone (the amount of tension or resistance to movement in muscles) in both arms. The OT Eval indicated the OT recommended Resident 2 to wear a resting hand splint on the left hand and a hand roll on the right hand for four hours to maintain joint integrity and manage muscle tone. During a review of Resident 2's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 2 was discharged from OT services due to transfer to Hospice care (care focused on comfort and quality of life of a person with a serious illness who is approaching the end of life). The OT Discharge Summary indicated the OT recommended Resident 2 to wear a resting hand splint on the left hand and a hand roll on the right hand for four hours on and four hours off (removed) to maintain joint integrity and manage muscle tone. The OT Discharge Summary indicated OT recommended an RNA program for splint or brace care and passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 2 had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 2 was dependent in eating, hygiene, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 2 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation on 11/19/2024 at 2:31 p.m., in Resident 2's room, Resident 2 was lying in bed with both elbows slightly bent with rolled up towels positioned in both hands. During a concurrent observation and interview on 11/21/2024 at 9:51 am, with Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) 1 in Resident 2's room, observed RNA 1session. Resident 2 was lying in bed with both elbows bent and both hands held in fists. RNA 1 provided PROM exercises to Resident 2's both shoulders, elbows, wrists, and hands for ten repetitions each at every joint (where two bones meet) at a very fast speed. Resident 2 bent both elbows and tightened both fists when RNA 1 tried to quickly straighten both elbows and all the fingers on both hands. Resident 2 moaned, grimaced, and appeared to be in pain during PROM exercises of both elbows and both hands. RNA 1 continuously told Resident 2 to relax and stop closing her hands so tightly during PROM exercises because it was hurting RNA 1's hands. After providing PROM to Resident 2's both arms, RNA 1 applied lotion to Resident'2 both hands and applied rolled up towels into the palm of Resident 2's hands. RNA 1 stated she worked with Resident 2 for a long time and never had orders to apply splints to both hands. RNA 1 stated she applied towel rolls to Resident 2 both hands to keep both hands open and to prevent the nails from digging into her palms because she always positioned her hands in fists. During a concurrent interview and record review on 11/21/2024 at 1:10 pm, the Director of Rehabilitation (DOR) who was the OT who evaluated Resident 2 reviewed Resident 2's OT therapy notes and confirmed OT recommended Resident 2 wear a left resting hand splint and a right-hand roll splint upon discharge from OT services on 6/28/2024. The DOR stated the physician referred OT to evaluate Resident 2 on 6/26/2024 for contracture management of both hands. The DOR stated Resident 2 did not have contractures of both hands but was at high risk for contracture development because she had increased muscle tone and always held both hands in a fists. The DOR stated he recommended a left resting hand splint and a right-hand roll splint because Resident 2 was at high risk for contracture development and could have benefitted from splinting. The DOR stated hand roll splints were not the same as the towel rolls placed in Resident 2's hands. The DOR stated the Rehabilitation Department was not involved in the placement of towel rolls in both hands since it was an intervention done by nursing. The DOR confirmed he recommended RNA for application of splints to Resident 2's both hands at the time of discharge from OT services but did not endorse the left-hand splint and right- hand roll to RNA for application since both hand splints were never issued to Resident 2. The DOR stated both splints were never issued to Resident 2 as recommended because he did not have time to assess Resident 2 for the appropriate splint wear time (length of time and frequency a person can tolerate wearing the splint for safety, comfort, and maximal benefits) since she was discharged from OT services so quickly. The DOR stated OT should have continued to follow up on the issuance and trialing of both hand splints because Resident 2 could have benefitted from both splints since she was at high risk for contracture development. The DOR stated if a resident needed a splint and did not receive it, it could potentially result in ROM decline and contracture development. During an interview on 11/22/2024 at 10:14 am, the Director of Nursing (DON) stated the Rehabilitation Department (Rehab) was responsible for assessment and issuance of splints to the residents in the facility. The DON stated it was important recommendations for splinting be carried out to prevent the residents from having a ROM decline and developing contractures. The DON stated if a resident needed a splint and did not receive it as recommended by Rehab, it could potentially result in a decline in ROM, overall function, and contracture development. During a review of the facility's undated OT Job Description, titled Registered OT Job responsibilities, the Job Description indicated the OT assured continuation of the therapy plan following discharge by designing and instructing patients, families, and caregivers in home exercises programs and recommending and/or providing assistive equipment. During a review of the facility's Policy and Procedure (P&P), titled Increase/Prevent Decline in ROM mobility, revised 3/2023, the P&P indicated the facility provided treatment and services to maintain or improve each resident's ROM and reduced further decline in ROM unless the resident's clinical condition demonstrated an unavoidable reduction in ROM. During a review of the facility's P&P, titled Splinting, revised 3/2023, the P&P indicated splints helped protect the skin from breaking down and contractures from becoming worse. The P&P indicated the therapist could assist in determining if a resident would benefit from splinting or other types of supportive care such as strengthening or positioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent the resident's unplanned weight loss of 9.2 percent (%) in three months and greater than 10 % in six months for one of two sampled residents (Resident 25). The facility failed to: a1 Ensure staff identified Resident 25's decrease oral intake (amount of food and water consumed), reassess, and monitor interventions to prevent a weight loss when Resident 25 had a weight loss of 15 pounds (lbs. unit of weight) from 5/7/2024 to 9/7/2024. 2. Ensure the nursing staff reported a decrease in Resident 25's oral intake to Resident 25's physician (MD1), in accordance with the Care Plan titled, Altered Nutrition/Hydration Status and Unplanned/ Unexpected weight loss of 4.8 percent (%) in one month on 9/7/2024, 9.2 % loss in three months and 10.5 % in six months on 11/11/2024. 3. Ensure licensed staff followed the facility's policy and procedure (P&P) titled, Nutrition (Impaired)/ Unplanned Weight Loss- Clinical Protocol and immediately notified physician of any abrupt or persistent change from Resident 25's food intake. These failures had the potential for Resident 25's continued weight loss and placed the resident at risk for malnutrition (lack of proper nutrition, caused by not eating enough), and dehydration (dangerous loss of body fluid). Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease Stage III (kidneys are moderately damaged and are not filtering waste and fluid from the blood as it should be), pulmonary hypertension (condition that affects the blood vessels in the lungs that makes the heart work harder than normal to pump). On 7/14/2020 Resident 25 had a diagnosis of moderate protein -calorie malnutrition (state of inadequate intake of food- during resident stay in the facility). During a review of Resident 25's Minimum Dat Set (MDS- resident assessment tool) dated 11/2/2024, the MDS indicated Resident 25 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent (helper does all of the effort) on staff with bed mobility, bathing, toileting hygiene, personal hygiene, dressing, and transfer to and from the bed to chair. The MDS indicated Resident 25 weigh was 120 lbs. and height were 65 inches. The MDS indicated Resident 25 was not on a physician's prescribed weight loss regimen. During a review of Resident 25's Physician's Orders Summary Report from 1/28/2019 to 11/14/2024, the Physician's Orders Summary Report indicated the following orders: 1. On 1/28/2019, Multivitamin with minerals to give one tablet by mouth one time a day for supplement. 2.On 1/28/2019, Vitamin C tablet 500 milligram (mg- unit of measurement) to give one tablet by mouth one time a day for supplement. 3.On 2/6/2024, Glucerna (replacement shake to help manage blood sugar with people with diabetes) 80 milliliters (ml- unit of measurement) three times a day. 4.On 5/10/2024, Remeron (medicine used to treat depression and can increase appetite) 15 mg to give one tablet by mouth at bedtime for depression manifested by poor oral intake. 5. On 8/9/2024, Regular Pureed (food that had been mashed, ground, crushed until it is smooth and has the consistency of a creamy paste) texture diet, thin liquid consistency, eight ounces super milk ( type of milk that is higher in protein and fat than regular milk) three times a day with meals; four ounces (oz-unit of measurement) of prune juice at breakfast, super cereal (fortified wheat, soy, milk that is processed and packed). 6. On 11/14/2024, Remeron was decreased to 7.5 mg to give one tablet by mouth at bedtime for depression as manifested by poor oral intake. During a review of Resident 25's care plan titled Altered Nutrition/Hydration Status initiated on 5/18/2024 and revised on 8/8/2024 the care plan indicated the goal for Resident 25 was to consume 68 percent (%) of meal served daily and to have no significant weight loss through review date of 1/31/2025. The Care plan interventions included to monitor Resident 25 weight at every month or as ordered, provide 4.0 oz of prune juice at breakfast, 8.0oz whole milk with meals, fortified (foods with nutrients added to them) cereal at breakfast, provide nutritional supplements, peanut butter and jelly with lunch and dinner, and notify the physician and Registered Dietician (RD) of significant weight loss/ gain. During a review of Resident 25's Care Plan titled, Unplanned/ Unexpected weight loss on 9/7/2024 of 4.8 % in one month, 9.2 % weight loss in three months and 10.5 % weight loss in six months, initiated on 9/10/2024 and revised on 11/12/2024, the Care Plan indicated the goal for Resident 25 was not to have further weight loss through review date and the resident will consume at least 75 % of meal served daily. The Care plan interventions included to monitor and evaluate any weight loss, assist with feeding as needed, if weight decline persists contact physician and dietician immediately. During a review of Resident 25's Care Plan titled, Unplanned/ Unexpected Weight loss related to poor food intake, the Care Plan indicated the resident had a weight lost as follows: 1. On 2/5/2024 3 % weight loss for one week, 2. On 2/13/2024 3.8 % weight loss for one week, 3.6 % weight loss for one month, 3. On 7/7/2024 3.8 % weight loss for one month (5/7/2024-7/8/2024 eight pounds) initiated on 2/6/2024 and revised on 8/8/2024. The Care plan goal was for Resident 25 to consume at least 50 % of meal served daily and not to have a further weight loss through review date. The Care Plan interventions included to monitor oral intake every meal, to document in the Medication Administration Record (MAR) a one (1) if less than 50 % of food consumed and document zero (0) if greater than 50 % was consumed, to administer Remeron 15 mg at bedtime for depression as manifested by poor oral intake, and monitor weight loss and if the weight decline persists to contact the physician and ensure dietitian was aware. During a review of Resident 25's RD's Nutritional Update notes dated 5/1/2024, the Nutritional Update notes indicated there was no significant Resident 25's weight changes and Resident 25's food intake was 50 to 75 %. The RD Nutritional Update note indicated there was no new diet order and to continue mechanical soft diet with thin liquid consistency, super cereal with breakfast, 8.0 oz of fortified milk. During a review of Resident 25's RD's Nutritional Update notes dated 8/13/2024, the Nutritional Update notes indicated resident's average meal percentage intake was 15 % in one week and the resident weight was 122 lbs. The Nutritional Update note indicated the resident's weight loss was related to poor food intake; IDT was following and would continue to monitor weights weekly until stable. During a review of Resident 25's RD Nutritional Update note dated 11/5/2024, the Nutritional Update note indicated Resident 25 had a body mass index (BMI- a measure that relates body weight to height) of 20 (under range for age), with a most recent weight of 120 lbs. and had 9.7 % weight loss in 6 months (5/7/2024- 11/8/2024). The RD's Nutritional Update note indicated the Resident 25's average meal percentage intake was 10 to 20 %. The Nutritional Update note indicated to continue plan of care. During a review of Resident 25's Weight Variance Team Update notes dated 11/12/2024, the Weight Variance Team Update notes indicated Resident 25 had 10.5 % weight loss in 6 months (dates not indicated). The Weight Variance Team Update note indicated IDT's recommendation were to request Pre-Albumin level (blood test that can indicate malnutrition), Zinc Sulfate (supplement used to help with wound healing) daily for three weeks and current nutritional supplements remained appropriate. During a review of Resident 25's Weights and Vitals Summary from 5/7/2024 to 11/8/2024, the Weights and Vitals Summary indicated Resident 25's weight was as follows: 1. 5/7/2024- 133 lbs. 2. 6/10/2024- 130 lbs. 3. 7/8/2024- 125 lbs. 4. 7/15/2024- 125 lbs. 5. 7/22/2024-123 lbs. 6. 7/29/2024-124 lbs. 7. 8/6/2024 -124 lbs. (nine lbs. weight loss within 3 months [6.77 %] weight loss from 5/7/24 to 8/6/24) 8. 8/7/2024 -124 lbs. 9. 8/12/2024 -122 lbs. 10. 8/20/2024 -122 lbs. 11. 9/7/2024- 118 lbs. 12. 10/8/2024-120 lbs. 13. 11/8/2024 -119 lbs. (14 lbs. weight lost in 6 months [ 10.53 %] weight loss from 5/7/24 to 11/8/24). During a review of Resident 25's Documentation Survey Report for Nutrition (Meal Percentage) from 9/1/2024 to 11/20/2024 the Documentation Survey Report indicated Resident 25's consumed meal percentage varied from 0% to 14 %, and from 40 to 50 %. During a concurrent observation and review on 11/20/2024, at 12:57 p.m., in Resident 25's room, Resident 25's lunch meal was observed. Resident 25 drank all the liquids provided for lunch but only ate small number of pureed potatoes. A Review of Resident 25's meal ticket indicated Resident 25 was on Control Carbohydrates Diet (CCD), puree texture, thin liquid consistency with no added salt. Resident 25's food likes were peanut butter and jelly (PBJ) sandwich and dislikes spinach, and pureed meal consistency Resident 25 lunch tray was observed to have pureed greens, pureed meat, and pureed potatoes. During an interview on 11/20/2024, at 1:15 p.m., and subsequent interview on 11/20/2024, at 3:12 p.m. Certified Nursing Assistant (CNA 3) stated he fed Resident 25 who consumed the milk, juice, few bites of pureed potatoes and peanut butter and jelly sandwich. CNA 3 stated Resident 25 was on pureed diet with a peanut butter and jelly sandwich, and her meal intake varied. CNA 3 stated today (11/20/2024) Resident 25 ate 20 % for breakfast and 50 % for lunch which included the peanut butter and jelly sandwich. CNA 3 stated charge nurse should be notified if a resident food intake was only 20 %. CNA 3 stated yesterday (11/19/2024) Resident 25's food intake was 15 % and he did not notify the charge nurse. During an interview on 11/20/2024, at 3:29 p.m. Licensed Vocational Nurse (LVN2) stated she was aware that Resident 25 was eating poorly and was on regular diet with puree texture and thin liquid consistencies. LVN 2 stated Resident 25 used to be on mechanical soft diet. LVN 2 stated Resident 25 was on Remeron since May 2024 for appetite stimulant (medication that increases feelings of hunger) but continued to eat poorly. During an interview on 11/20/2024, at 3:56 p.m. with Registered Nurse Supervisor (RN 3) stated Resident 25 had a weight loss greater than three lbs. from 5/7/2024 to 8/7/2024 (6.7 % weight loss) and had lost 14 lbs. within 6 months (5/7/2024 to 11/8/2024, which was a significant weight loss). RN 3 stated Resident 25's physician was not notified of the significant weight loss until 11/13/2024 and recommended hospice care (compassionate care for people who are near the end of life). RN 3 stated the facility failed to monitored food intake and notify MD1 of Resident 25 progressive significant weight loss. During a review of Resident 25's Nurses Progress Notes dated 11/13/2024, timed at 11:03 a.m. the Nurses Progress Notes indicated the Director of Nursing (DON) sent a message to Resident 25's physician through text to inform of Resident 25's significant weight loss. During a concurrent interview and record review on 11/21/2024, at 12:52 p.m. with Dietary Supervisor (DS Resident 25's electronic health record (EHR) was reviewed. The DS stated Resident 25 was part of Weight Variance Committee meeting and the Committee met weekly. The DS stated Resident 25 was receiving eight ounces of super milk, super cereal for breakfast and ice cream for dinner which was ordered on 8/9/2024 for weight loss. The DS stated Resident 25 was also receiving Glucerna 80 ml three times a day since February 2024. The DS stated Resident 25 continued to lose weight despite interventions. The DS stated if the calories were not enough to cover the nutritional needs of Resident 25, current interventions for weight loss should be evaluated because weight loss could get worse. During a concurrent telephone interview and record review on 11/22/2024, at 3:44 p.m. with RD Resident 25's HER was reviewed. The RD stated Resident 25 started to lose weight on 9/7/2024 and lost 12 lbs. in three months. RD stated she did not know why Resident 25 continue to lose weight with interventions in place. The RD stated the Interdisciplinary Team (IDT- group of professional and direct care staff that have primary responsibility for the development of a plan for the care of a resident) reached out to the resident and family. The RD stated she never saw Resident 25 to assess the resident and observe the resident's food intake. The RD stated Resident 25 was confused, does not communicate well so RD rely mostly on staff to talk to Resident 25. The RD stated her recommendations for weight loss would be to fortify (adding nutrients to a food that are not naturally present in it) foods and update resident's preferences. The RD stated if the resident continues to lose weight interventions should be reassessed and modify. During a concurrent interview and record review on 11/23/2024, at 12:43 p.m. RN 4 stated Resident 25 weight loss was observed on 9/7/2024 when Resident 25 weight dropped to 118 lbs. RN 4 stated on 11/12/2024 the RD recommended to check Pre-Albumin level and Zinc Sulfate 220 mg one tablet a day for three weeks. Reviewed Resident 25' Pre-Albumin laboratory result, RN 4 stated Resident 25's Pre-Albumin level was 13 (Normal Pre-Albumin level 16-30 milligrams (mg- unit of measurement) per deciliter (dL-) or 160-300 milligrams per liter (mg/L) Pre-Albumin 13 mg/dl is considered low and could indicate potential malnutrition). RN 4 stated Resident 25's meal intakes had been poor because resident only liked milk and PBJ sandwich. After reviewing Resident 25's EHR, RN 4 stated no COC or notification of physician was documented for the resident's significant weight loss identified on 9/7/2024. RN 4 reviewed Resident 25's Nurses Progress Notes from 11/13/2024 to 11/19/2024 and stated the Nurses Progress Notes indicated there was no follow up call to Resident 25's physician about his significant weight loss. RN 4 stated Resident 25's weight loss could be preventable if interventions to prevent further weight loss were reviewed, modify and physician notified in a timely manner. During a concurrent interview and record review on 11/23/2024, at 2:51 p.m. with the DON Resident 25's EHR was reviewed. The DON stated there was no documentation indicating that COC was completed, a change in a diet or dietary interventions to prevent a weight loss were attempted and that the physician was notified of the of Resident 25's significant weight loss. The DON stated weight loss was a change in condition and physician should have been notified. The DON stated all licensed nurses were responsible in monitoring Resident 25's food intake. During a review of facility's policy and procedure (P&P) titled Assisted Nutrition and Hydration, revised March 2023, the P&P indicated the facility assist the resident to maintain, to the extent possible, acceptable parameters of nutritional and hydration status. The P&P indicated the facility will recognize, evaluate, and address the need of every resident, including but not limited to, the resident at risk or already experiencing impaired nutrition and hydration. During a review of facility's P&P titled Notification of Change, revised 3/2023, the P&P indicated the facility informs the resident, resident's physician and the resident's representative when there is a significant change in resident's physical, mental or psychosocial status, deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications or a need to change treatment significantly or to start a new form of treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents, who were on pureed (food that had been mashed, ground, crushed until it is smooth and has the consistency of a creamy paste) diet received food consistent with diet order and according to the pureed menu recipe for one of 12 sampled residents (Resident 25. This failure had the potential to put Resident 25 at high risk for aspiration (condition when food, liquid, or other material enters a person's airway [passageway for air] and eventually the lungs), choking (life threatening condition where an object such as food lodges in the throat blocking the flow of air), and possible death. Findings: During a review of Resident 25's admission Record, the admission Record indicated Resident 25 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), paroxysmal atrial fibrillation (fast, irregular heartbeat that occurs suddenly and typically last for a short time), chronic kidney disease stage 3 (kidneys are moderately damaged and are not filtering waste and fluid from the blood as it should be), pulmonary hypertension( condition that affects the blood vessels in the lungs that makes the heart work harder than normal to pump). On 7/14/2020 Resident 25 had a diagnosis of moderate protein -calorie malnutrition (state of inadequate intake of food- during resident stay in the facility). During a review of Resident 25's Minimum Dat Set (MDS- resident assessment tool) dated 11/2/2024, the MDS indicated Resident 25 had severe cognitive (ability to think, understand, learn, and remember) impairment. The MDS indicated Resident 25 was dependent (helper does all of the effort) on staff with bed mobility, bathing, toileting hygiene, personal hygiene, dressing, and transfer to and from the bed to chair. The MDS indicated Resident 25 weigh was 120 lbs. and height were 65 inches. The MDS indicated Resident 25 was not on a physician's prescribed weight loss regimen. The MDS indicated Resident 25 had five percent (%) weight loss or more in the last month or loss of 10 % or more in the last 6 months. During a review of Resident 25's Physician Order Summary Report dated 8/9/2024, the Physician Order Summary Report indicated Resident 25 on Regular Pureed texture diet, thin liquid consistency, eight ounces super milk ( type of milk that is higher in protein and fat than regular milk) three times a day with meals; four ounces (oz-unit of measurement) of prune juice at breakfast, super cereal (fortified wheat, soy, milk that is processed and packed) at breakfast, ice cream lunch and dinner. During a review of Resident 25's Care plan, titled At Risk for Altered Nutrition/Hydration Status initiated 5/18/2021and revised on 8/2/2022, the Care Plan's goals included Resident 25 will adhere to therapeutic diet through review date of 8/8/2024. The Care Plan interventions included to monitor, document, and report signs and symptoms of dysphagia (difficulty of swallowing) like pocketing 9holds on food in the mouth without swallowing), choking, coughing, drooling, holding food in mouth, several attempts in swallowing, refusing to eat and appearing concerned at meals. During a concurrent observation and interview) on 11/20/2024, at 1:15 p.m. with Certified Nursing Assistant (CNA 3) observed of Resident 25's ate some of the pureed potatoes, while pureed green and pureed meat were untouched CNA 3stated he fed Resident 25 who consumed the milk, juice, few bites of pureed potatoes and peanut butter and jelly (PBJ) sandwich. During a review of Resident 25' meal tray ticket dated 11/21/2024, the meal tray ticket indicated Resident 25 on controlled carbohydrate diet (CCO- meal plan that involves eating the same amount of carbohydrates at each meal and snack to help manage blood sugar), pureed texture, thin liquid consistency and no added salt (NAS- a diet where no additional salt is added to food during preparation). The meal ticket tray indicated Resident 25 had no food dislikes and likes peanut butter and jelly sandwich. During a review of Speech Therapy Evaluation and Plan of Treatment dated 8/9/2024, the Speech Therapy Evaluation and Plan of Treatment indicated Resident 25 had dysphagia and diabetes mellitus and for the treatment of swallowing dysfunction and oral function for feeding. During a review of Resident 25's Speech Therapy Discharge summary dated [DATE], the Speech Therapy Discharge Summary indicated the diet recommendations was pureed consistencies and thin liquid and required close supervision for oral intake. During an interview on 1/21/2024, at 2:49 p.m. with CNA 3, CNA 3 stated Resident 25 had PBJ sandwich for lunch and had eaten all the sandwich. CNA 3 stated the resident is on puree diet with a sandwich. During a concurrent interview and record review on 11/21/1014, at 12:52 p.m. with Dietary Manager (DM), reviewed Resident 25's electronic health record (EHR). DM stated Resident 25 was not receiving the right diet because the resident supposed to receive pureed texture diet. DM stated peanut butter and jelly was not part of a pureed diet and the facility should have requested another speech therapy evaluation (speech therapist evaluate resident swallowing and recommend feeding strategies and appropriate food consistencies). DM stated the PBJ sandwich was already in the meal tray ticket, and he did not have enough time to check and verify Resident 25's diet. DM stated Resident could be at risk for choking and aspiration if physician's order and speech therapist's recommendation was not followed. During a telephone interview on 11/21/2024, at 2:39 p.m., and subsequent interview on 11/21/1014 at 4:13 p.m. with Speech Language Pathologist (SLP), SLP stated she received a referral for Resident 25 who was having difficulty in swallowing last August 2024. SLP stated her recommendation was pureed diet for easier chewing and Resident 25 used to be on mechanical soft diet (soft and moist food that are easy to chew and swallow) but was having difficulty of chewing and had trouble manipulating the food in her mouth. SLP stated large portion of food would be difficult for Resident 25 to chew and swallow. SLP stated pureed texture did not include PBJ sandwich and the facility should have asked another evaluation of Resident 25's swallowing or a referral to speech therapist before giving PB and J sandwich to ensure appropriateness of diet and for residents' safety. SLP stated PBJ sandwich was part of a mechanical soft diet and providing her a PBJ sandwich without proper evaluation and assessment of swallowing could lead to aspiration and weaker muscles could make her aspirate the food. During a review of facility's policy and procedure (P&P) titled Therapeutic Diet revised 3/2023, the P&P indicated The facility will ensure residents will receive and consume foods in the appropriate form and the appropriate nutritive content as prescribed by the physician to support the resident's treatment, plan of care ,and in accordance with his goals and preferences. The P&P indicated a mechanically altered diet means one in which the texture of a diet is modified, the type of texture modification should be specific and part of the physician's order or licensed dietician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure clinical records were accurately documented for one of five samples residents (Resident 2). The facility failed to: a Ensure Resident 2's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) discharge recommendations for a resting hand splint (splint [rigid material or apparatus used to support and immobilize a broken bone or impaired joint] secured from the hand to the forearm to position the hand in a functional position) to Resident 2's left arm and a hand roll splint (splint placed in the palm of the hand used to position the hand in a functional position) to Resident 2's right hand to be worn for four (4) hours on and 4 hours off (removed) on 6/28/2024 were accurately documented. b.Ensure the range of motion (ROM, movement ability of a joint) status of Resident 2's both hands were accurately documented in the OT Evaluation, dated 6/26/2024. These failures had the potential to negatively impact the provision of necessary care and services for Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right sided hemiplegia (weakness to the right side of the body) and hemiparesis (inability to move one side of the body) following a non-traumatic intracerebral hemorrhage (bleeding in the brain) and contractures (loss of motion of a joint associated with stiffness and joint deformity) of both hands and the lower leg. During a review of Resident 2's Physician Order Summary Report, the Physician Order Summary Report indicated a physician's order, dated 6/26/2024, for OT to evaluate Resident 2 to prevent further contractures (loss of motion of a joint associated with stiffness and joint deformity) of both hands. During a review of Resident 2's OT Evaluation and Plan of Treatment (OT Eval), initiated 6/26/2024, the OT eval indicated the reason for referral was due to a decline in ROM of Resident 2's both hands. The OT Eval indicated Resident 2 had impaired ROM in both shoulders and both hands and had rigid muscle tone (the amount of tension or resistance to movement in muscles) in both arms. The OT Eval indicated Resident 2 had contractures of both hands. The OT Eval indicated the OT recommended Resident 2 to wear a resting hand splint on the left hand and a hand roll on the right hand for 4 hours on and 4 hours off to maintain joint integrity and manage muscle tone. The OT Eval indicated short-term goals for Resident 2 to safely wear a resting hand splint on the left hand and a hand roll splint on the right hand for up to two hours with minimal redness, swelling, discomfort or pain. The OT Eval indicated long-term goals for Resident 2 to safely wear a resting hand splint on the left hand and a hand roll splint on the right hand for up to 4 hours with minimal redness, swelling, discomfort or pain. During a review of Resident 2's OT Discharge summary, dated [DATE], the OT Discharge Summary indicated Resident 2 was discharged from OT services due to transfer to Hospice care (care focused on comfort and quality of life of a person with a serious illness who is approaching the end of life). The OT Discharge Summary indicated Resident 2 tolerated 30 minutes of safely wearing both the resting hand splint on the left hand and a hand roll splint on the right hand at the time of discharge. The OT Discharge Summary indicated the OT recommended Resident 2 to wear a resting hand splint on the left hand and a hand roll on the right hand for 4 hours on and 4 hours off to maintain joint integrity and manage muscle tone. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 2 had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 2 was dependent in eating, hygiene, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 2 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation on 11/19/2024 at 2:31 p.m., in Resident 2's room, Resident 2 was lying in bed with both elbows slightly bent with rolled up towels positioned in both hands. During a concurrent interview and record review on 11/21/2024 at 1:10 pm, the Director of Rehabilitation (DOR) who was the OT who evaluated Resident 2 reviewed Resident 2's OT therapy notes. The DOR stated the physician referred OT to evaluate Resident 2 on 6/26/2024 for contracture management of both hands. The DOR reviewed Resident 2's OT Eval, dated 6/26/2024, and confirmed he documented Resident 2 had contractures of both hands. The DOR stated the documentation of the presence of contractures to Resident 2's both hands were inaccurate because Resident 2 did not have contractures. The DOR stated he did not know why he documented Resident 2 had contractures when she did not. The DOR confirmed OT recommended Resident 2 wear a left resting hand splint and a right-hand roll splint for 4 hours on and 4 hours off upon discharge from OT services on 6/28/2024. The DOR stated the OT discharge recommendations for splinting were inaccurate because Resident 2 was never issued hand splints upon discharge as recommended and was unable to safely tolerate wearing both hand splints for 4 hours. The DOR confirmed Resident 2 tolerated 30 minutes of wearing both hand splints at the time of discharge and should not have recommended on the OT Discharge Summary for Resident 2 to wear both hand splints for 4 hours on and 4 hours off because she would not be able to safely tolerate that amount of time. The DOR stated he accidentally documented the recommendation for both hand splints with a 4-hour wear time because he was not paying attention when he was writing the OT Discharge Summary. The DOR stated it was important documentation in a resident's clinical was accurate because it could potentially cause confusion, harm, and create an inaccurate picture of a resident's current level of function and needs. During an interview on 11/22/2024 at 10:14 am, the Director of Nursing (DON), the DON stated it was important for all documentation in a resident's clinical record to be accurate because it reflected the resident's status and ensured the facility provided the resident with all necessary care and services. The DON stated if documentation was inaccurate, it could potentially lead to confusion, an inaccurate picture of a resident's current level of function and could ultimately result in a functional decline because the residents may not receive the services they need. During a review of the facility's undated OT Job Description, titled Registered OT Job responsibilities, the Job Description indicated OT documented patient care services by charting in the patient and department record and evaluated results of OT by observing, noting, and evaluating patient's progress, recommending, and implementing adjustments and modifications. During a review of the facility's policy and procedure (P&P), titled Documentation Policy, revised 3/2023, the P&P indicated it was the facility's policy to document relevant findings in the clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure: a. Ensure Restorative Nursing Aides (RNA- trained nursing staff who help residents gain an improved quality of life by increasing their level of strength and mobility) 1 was competent to perform passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises to Resident 2's both arms. b. Ensure RNA 1 was competent to perform PROM exercises to Resident 18's right arm. These failures had the potential to cause resident pain, harm, injury, and inefficient delivery of ROM exercises resulting in decreased the range of motion and function for residents receiving RNA services. c. Performance Evaluation was completed on Registered Nurse (RN)4 and Licensed Vocational Nurse according to facility's policy and procedure. This failure had the potential for the facility not be able to assess the skills necessary to provide nursing services to assure resident safety. Findings: a. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right sided hemiplegia (weakness to the right side of the body) and hemiparesis (inability to move one side of the body) following a non-traumatic intracerebral hemorrhage (bleeding in the brain) and contractures (loss of motion of a joint associated with stiffness and joint deformity) of both hands and the lower leg. During a review of Resident 2's Occupational Therapy (OT, profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Evaluation and Plan of Treatment (OT Eval), dated 6/26/2024, the OT Eval indicated Resident 2 had impaired ROM on both arms and had rigid muscle tone (the amount of tension [resistance to movement] in muscles) with a muscle tone severity of two (slight increase in muscle tone with minimal resistance). During a review of Resident 2's Physician Order Summary Report, the Physician Order Summary Report indicated a physician's order, dated 9/11/2024, for RNA to perform PROM exercises to Resident 2's both arms, five times a week. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 10/2/2024, the MDS indicated Resident 2 had severely impaired cognitive (ability to think, understand, learn, and remember) skills for daily decision making. The MDS indicated Resident 2 was dependent in eating, hygiene, bathing, dressing, rolling to both sides, and transfers. The MDS indicated Resident 2 had functional limitations in ROM (limited ability to move a joint that interferes with daily functioning, including activities of daily living, or places the resident at risk of injury) in both arms and both legs. During an observation of an RNA session on 11/21/2024 at 9:51 a.m., in Resident 2's room, Resident 2 was lying in bed with both elbows bent and both hands held in fists. RNA 1 provided PROM exercises to Resident 2's both shoulders, elbows, wrists, and hands for ten repetitions each at every joint (where two bones meet) at a very fast speed. Resident 2 bent both elbows and tightened both fists when RNA 1 tried to quickly straighten both elbows and all the fingers on both hands. Resident 2 moaned, grimaced, and appeared to be in pain during PROM exercises of both elbows and both hands. RNA 1 continuously told Resident 2 to relax and stop closing her hands so tightly during PROM exercises because it was hurting RNA 1's hands. During an interview on 11/21/2024 at 1:06 p.m., RNA 1 stated she provided PROM exercises to Resident 2's arms and hands at a very fast rate of speed. RNA 1 stated she noticed Resident 2's arms and hands became tighter and harder for her to move and straighten when she was doing PROM exercises quickly. RNA 1 stated Resident 2 had pain during PROM exercises because she noticed Resident 2 became more resistive to the exercises as the session progressed, moaned, grimaced, and needed a lot of rest breaks in between exercises. During a concurrent interview and record review on 11/21/2024 at 1:10 p.m., the Director of Rehabilitation (DOR) who was also an OT stated Resident 2 had hypertonicity (condition where the muscles are in a constant state of contraction or increased tension usually due to neurological issues, injury, or certain medical conditions) in both arms and always held both hands in a fist. The DOR reviewed Resident 2's OT Eval, dated 6/26/2024, and confirmed Resident 2 had hypertonicity in both arms. The DOR stated ROM exercises must be done slowly for any resident with hypertonicity because providing ROM at a fast pace could cause the muscles of the arm to bend more instead of straightening which could cause pain. b. a. During a review of Resident 18's admission Record, the admission Record Resident 18 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including right sided hemiplegia hemiparesis following a cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death), muscle weakness, and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of Resident 18's OT Eval, dated 1/18/2024, the OT Eval indicated Resident 18 had impaired ROM of the right arm and had rigid muscle tone in the right arm. During a review of Resident 18's Order Summary Report, the Order Summary Report indicated a physician orders, dated 3/12/2024, for RNA to perform PROM exercises to Resident 18's right arm, five times a week. During a review of Resident 18's MDS, dated [DATE], the MDS indicated Resident 18 was cognitively intact. The MDS indicated Resident 18 required set-up assistance for eating, required partial/moderate assistance for upper body dressing and personal hygiene, and required substantial/maximal assistance for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 18 had functional limitations in ROM in one arm and one leg. During an observation of an RNA session on 11/21/2024 at 9:23 am, in Resident 18's room, Resident 18 was sitting in a wheelchair watching television. RNA 1 assisted Resident 18 with sit to stand exercises in the hallway, RNA 1 assisted Resident 18 with PROM of the right arm. RNA 1 provided Resident 18 with right arm shoulder, elbow, wrist, and hand PROM exercises for ten repetitions each at every joint at a very fast speed. Resident 18's right elbow, wrist, and fingers were observed to bend more while RNA was trying to quickly straighten each joint. Resident 18 grimaced, stated he had pain during PROM exercises, and asked RNA to stop. During an interview on 11/21/2024 at 1:06 pm, RNA 1 stated she provided PROM exercises to Resident 18's right arm and hand at a very fast rate of speed. RNA 1 stated she noticed Resident 18's right arm and hand became tighter and harder to move and straighten when she was doing PROM exercises quickly. RNA 1 stated Resident 18 had pain during PROM exercises because she noticed Resident 18 became more resistive to the exercises as the session progressed, moaned, grimaced, and had difficulty tolerating a lot of ROM exercises. During a concurrent interview and record review on 11/21/2024 at 1:10 p.m., the DOR who was also an OT reviewed Resident 18's OT Eval, dated 1/18/2024, and confirmed Resident 18 had hypertonicity in the right arm. The DOR stated ROM exercises must be done slowly for any resident with hypertonicity because providing ROM at a fast pace could cause the muscles of the arm to bend more instead of straightening which could cause pain. During a concurrent interview and record review on 11/22/2024 at 9:54 a.m., the DSD stated the RNAs in the facility were CNAs specialized training in RNA services. The DSD stated she was responsible for completing CNA competencies yearly but never completed any competencies for the RNAs. The DSD stated she did not know who was responsible for completing RNA competencies in the facility and did not know if they were being done. The DSD stated the CNA competency checklist did not assess staff's competency of RNA tasks such as ROM exercises, splinting, and ambulation exercises. The DSD stated it was important for the facility to have recurring competency assessments for staff to ensure the care and services provided were appropriate and safe. The DSD stated it placed the residents in the facility at risk for harm if staff were not competent in the services they were providing. During an interview on 11/22/2024 at 10:14 am, the DON and ADM stated conducting staff competencies were important to ensure staff were up to date and competent in performing their job duties. The DON stated there were three RNAs in the facility. The DON stated the RNAs assisted residents with activities such as ROM exercises, ambulation exercises, splinting, and feeding to ensure the residents in the facility maintained their current level of function and did not experience a functional decline. The DON and ADM stated the facility did not have a way to ensure the RNA staff were competent in their job duties since they did not conduct RNA competencies. The DON stated a licensed therapist from the contracted rehabilitation department provided the initial RNA certification but did not return to provide any additional training or competencies after the initial RNA certification was issued. The DON and ADM stated competencies for all staff should be done annually to ensure staff were competent in the services provided but were not being done for the RNAs. The DON and ADM stated if RNA competencies were not completed at least annually, the facility would not know the staff were up to date and competent in their job duties which could potentially lead to injury of staff and/or residents. During a review of the facility's policy and procedures (P&P), titled, Nursing Services, revised 3/2023, the P&P indicated the facility had sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. c.During a concurrent interview and record review on 11/23/2024, at 9:19 a.m., with Director of Staff Development (DSD), reviewed Certified Nursing Assistant (CNA 5) employment file. DSD stated CNA 5 Performance Review was not on file and was missing. DSD stated Performance Evaluation of any staff should be conducted annually and after 90 days from hire if a staff is a newly hired. During a concurrent interview and record review on 11/23/2024, at 9:19 a.m., with DSD, reviewed Licensed Vocational Nurse (LVN 2) employment file, DSD stated LVN 2 had no annual performance evaluation on file. DSD stated the Director of Nursing (DON) oversees performance evaluations of licensed nurses. During an interview on 11/23/2024, at 12:38 p.m. with Registered Nurse (RN 4), RN 2 stated he just had his performance review a few days ago. RN 4 stated all staff should be evaluated for their performance annually. RN 4 stated it was important to have your performance evaluated to know your weaknesses and strength which was important in providing quality of care to the residents. During an interview on 11/23/2024, at 2:51 p.m. with Director of Nursing (DON), the DON stated LVN 2 did not have her Performance Evaluation on file. The DON stated the facility conducts an annual Performance Evaluation to ensure staff competency because they are dealing with residents and to ensure safe delivery of care. During a review of facility's policy and procedure (P&P) titled 'Performance Evaluation dated 3/2024, the P&P indicated Job performance of each employee must be reviewed and evaluated per company guidelines and in accordance with State and Federal regulatory requirements. The P&P indicated performance evaluations are conducted to evaluate the employee's work performance and to be used as a tool for determination of employee eligibility for promotion, disciplinary actions and education, terminations, shift changes, transfers, improvement of quality and overall review of the employees 'work performance. The P&P indicated the employee's immediate supervisor or designee will be responsible for completing performance evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to accurately account for the use of controlled substances (medications with a high potential for abuse) for three out of four sampled residents (Resident 31, Resident 46, and Resident 12) reviewed. 1. Resident 31, the facility failed to accurately account for the administration of a lorazepam 0.5 milligrams ([mg-unit of measurement] a controlled substances used to relieve anxiety, a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities) on 10/5/2024 and 10/6/2024. 2. Resident 46, the facility failed to accurately account for the administration of tramadol (a controlled substances used to treat moderate to severe pain) 50 mg on 10/5/2024. 3. Resident 12, the facility failed to accurately account for the administration of tramadol 50 mg on 10/2/2024. These failures increased the risk that controlled medications to treat pain and anxiety may not be administered as ordered for Resident 31, Resident 46, and Resident 12 with the potential for the residents to experience uncontrolled pain, discomfort, or anxiety. And the facility's risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use), medication errors, or accidental exposure to controlled substances. Findings: 1. During a review of Resident 31 ' s admission Record, the admission Record indicated Resident 31 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis including anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress) disorder. During a review of Resident 31's History and Physical (H&P), dated 11/8/2024, the H&P indicated Resident 31 does not have the capacity to make decisions and dependent on facility staff for all Activities of Daily Living (ADL, include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). During a review of Resident 31's Physician Order Summary Report, included an order for lorazepam 0.5 mg, instructions to give one tablet by mouth every four hours as needed for anxiety as manifested by fidgeting (small movements), order date 10/3/2024. During a concurrent interview and record review on 11/21/2024 at 11:27 a.m., with Licensed Vocational Nurse (LVN) 3 and Director of Nursing (DON) on Station 2, at Medication Cart (Med Cart) 2, reviewed Resident 31's Medication Administration Record (MAR) and Controlled Drug Record (CDR, a complete and accurate record to help maintain inventories to avoid diversions and losses) and the following discrepancy was found between the CDR and the MAR for Resident 31: Resident 31's CDR indicated licensed nurse initialed the removal of two tablets of lorazepam 0.5 mg on 10/5/2024 at 9 p.m., and again on 10/6/2024 at 9 p.m. Resident 31 ' s MAR for the month of 10/2024 was missing licensed nurse's initials to indicate Resident 31 was administered two doses of lorazepam 0.5 mg on 10/5/2024 and 10/6/2024 at 9 p.m. on each of the two days. During a concurrent interview on 11/21/2024 at 11:27 a.m. with LVN 3 and the DON, LVN 3 stated, the licensed nurses signed for the lorazepam removal in the CDR but did not click on the MAR to document the administration of lorazepam 0.5 mg to Resident 31 on 10/5/2024 at 9 p.m. and 10/6/2024 at 9 p.m. The DON stated, the lorazepam used as needed for Resident 31 was not documented on as administered, on the MAR. 2. During a review of Resident 46's admission record, the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and osteomyelitis (inflammation of bone, usually due to infection). During a review of Resident 46's Minimum Data Set (MDS - a resident assessment tool), dated 9/19/2024, the MDS indicated Resident 46 was able to understand and be understood by others. The MDS indicated Resident 46 required setup or clean up assistance for eating and oral hygiene and partial assistance (helper performs less than half of the effort) for toileting and dressing. During a review of Resident 46's Physician Order Summary Report, included an order for tramadol 50 mg, instructions indicated to give one tablet by mouth every 24 hours as needed for moderate to severe pain (pain rating 4 to 10), order date 9/12/2024. During a review of Resident 46 ' s Care Plan titled Resident 46 at risk for pain and discomfort dated 9/13/2024, indicated, interventions to administer analgesic as ordered. Encourage rest period to facilitate relief. Re-check for efficacy at least 30 minutes after administration. If symptoms persist, notify physician (MD). During a concurrent interview and record review on 11/21/2024 at 11:30 a.m., with LVN 3, Resident 46's MAR and CDR for the month of 10/2024 was reviewed. The following discrepancy was found between the CDR and the MAR for Resident 46, Resident 46's CDR indicated licensed nurse initialed the removal of tramadol 50 mg on 10/5/2024 at 10:10 p.m., but Resident 46's MAR was missing a licensed nurse's initials to indicate the administration of the medication on 10/5/2024. LVN 3 stated, if the administration of the medication was not documented on the resident's MAR, the licensed nurses would not know if the resident was administered the medication. LVN 3 stated the licensed nurse must document on the MAR and on the CDR, both records must match and that did not happen for Resident 46. 3. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was admitted to the facility on [DATE], with diagnosis of wedge compression fracture of second lumbar vertebra (a type of spinal fracture that occurs when the front of the vertebra collapses, giving the bone a wedge shape). During a review of Resident 12's MDS dated [DATE], indicated the resident had severe cognitive (ability to think, understand, learn, and remember) impairment. During a review of Resident 12's Physician Order Summary Report, included an order for tramadol 50 mg, instructions indicated to give one tablet by mouth every eight hours as needed for moderate pain (pain rating 4 to 6), order date 9/21/2024. During a review of Resident 12 ' s Care Plan titled Resident 12 at risk for pain and discomfort dated 9/23/2024, indicated, interventions to administer analgesic as ordered. Encourage rest period to facilitate relief. Re-check for efficacy at least 30 minutes after administration. If symptoms persist, notify physician (MD). During a concurrent interview and record review on 11/21/2024 at 11:30 a.m., Med Cart 3, with LVN 2, Resident 12's MAR and CDR for the month of 10/2024 was reviewed. The following discrepancy was found between the CDR and the MAR for Resident 12, Resident 12's CDR indicated licensed nurse initialed the removal of tramadol 50 mg on 10/2/2024 at 11 a.m., but Resident 12's MAR was missing a licensed nurse's initials to indicate the administration of tramadol 50 mg on 10/2/2024. LVN 2 stated Resident 12's tramadol should have been documented on both the MAR and CDR to indicate the medication was administered. LVN 2 stated the discrepancy could lead to another nurse administering the tramadol again to Resident 12, or if the resident was not administered the medication could cause the resident to experience more pain. LVN 2 stated diversion of the medication could occur if the tramadol was popped out and not administered to the resident. During an interview on 10/21/2024 at 12:35 p.m., with a Registered Nurse Supervisor (RN) 4, RN 4 stated the CDR and MAR documentation for medication administration should match, if not it may indicate the medication was not given to the resident. RN 4 stated if the controlled medications, lorazepam, and tramadol was not documented as administered to the residents (Resident 31, Resident 46, and Resident 12) it could lead to drug (medication) diversion; residents experiencing pain or anxiety if the medications were not administered, or the residents could receive duplicate therapy if the medication is mistakenly administered again. During an interview on 10/21/2024 at 1:21 p.m., with the Registered Nurse Consultant (RNC), RNC stated the licensed nurse must during medication pass follow the steps of pour, pass, and chart any medication given to the resident on the MAR and for controlled medication, must document on the CDR. RNC stated if not documented it was not considered done. During a review of the facility's policy and procedures (P&P) titled, General Dose Preparation and Medication Administration, revised, 1/2013, indicated, Prior to administration of medication .Confirm that the MAR reflects the most recent medication order .During the medication administration .Document the administration of controlled substances in accordance with applicable law .After medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given .) on appropriate forms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent (%) or greater as evidenced by four medication errors out of 27 opportunities for error to yield a medication error rate of 14.81 %, for three of five residents (Residents 29, Resident 48, and Resident 42) observed during medication administration (med pass). The facility failed to ensure: 1. Resident 29's blood pressure ([BP] the force of blood against artery [blood vessel that carries blood away from the heart] walls as the heart pumps) and/or heart rate/pulse ([HR] the number of times the heart beats per minute [bpm]) was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's BP medication, amlodipine 2.5 milligrams (mg, unit of mass) 2a. Resident 48's BP and/or HR was accurately assessed as a parameter ordered by the physician to determine whether to hold or administer resident's BP medication, amlodipine 10 mg. 2b. Resident 48's ClearLax (also known as MiraLAX [polyethylene glycol 3350 powder, for solution] used to treat occasional constipation) was prepared in accordance with the physician's order and manufacturer's specification. 3. Resident 42 was administered metformin (a medication that treats type 2 diabetes [a long-term condition in which the body has trouble controlling blood sugar and using it for energy] 1000 mg, with food or a meal as order by the physician. These failures of medication administration error rate of 14.81 % exceed the five (5) percent threshold. Findings: 1. During a review of Resident 29's admission Record, the admission record indicated Resident 29 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and fall on same level from slipping, tripping, and stumbling. During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool) dated 10/12/2024, the MDS indicated Resident 29's cognitive (ability to think, understand, learn, and remember) skills for daily decisions making was severely impaired. During a review of Resident 29's Care Plan titled, At risk for altered level of comfort/pain; At risk for weakness or activity intolerance due to alteration in cardiovascular (relating to the heart and blood vessels) function r/t (related to) HTN (hypertension - high blood pressure). The care plan interventions included, amlodipine besylate (treat high blood pressure) oral tablet, give one tablet by mouth one time a day for hypertension. Hold for systolic blood pressure ([SBP] pressure in the arteries when the heart beats) less than 110 millimeters of mercury (mmHg) or heart rate less than 55 bpm, date initiated 3/22/2023 . Administer medication as ordered; monitor side effects and effectiveness and notify MD if ineffective or for any indication of side effects .monitor BP as needed, monitor pulse (heart rate) as needed . During a review of Resident 29's Physician Order Summary Report, included an order for amlodipine 2.5 mg, instructions to give one tablet by mouth one time a day for hypertension. Hold for SBP less than 110 mmHg or HR less than 55 bpm, order date 7/6/2023. During a Medication Pass observation on 11/20/2024 at 10:14 a.m., at Station 2 Medication Cart (MedCart) 2 with Licensed Vocational Nurse (LVN) 1, LVN 1 prepared and administered to Resident 29 four medications which included a BP medication, amlodipine without checking the resident's BP as a parameter ordered by the physician to determine when to administer or not administer the resident's BP medication. LVN 1 prepared and administered the following medications to Resident 29: 1. Amlodipine 2.5 mg, one tablet 2. Aspirin (prevention of cerebrovascular accident [CVA] a stroke, caused by interrupted blood flow to the brain) 81 mg, one tablet 3. Docusate Sodium (stool softener) 100 mg, one capsule 4. Multivitamin with Minerals (supplement), one tablet During an interview on 11/20/2024 at 11:06 a.m., with LVN 1, LVN 1 stated he was supposed to check resident's BP right before administering the BP medication when there is a parameter to indicated when to administer or hold the BP medication. LVN 1 stated resident's (Resident 29) BP could change or drop, which could lead to the resident experiencing a fall or injury. 2. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension, orthostatic hypotension (a drop in blood pressure when standing up from sitting or lying down, causing dizziness), difficulty walking, ulcerative colitis (a chronic, inflammatory bowel disease that causes inflammation in the digestive tract), and diverticulitis (inflammation that causing pain and disturbance of bowel function). During a review of Resident 48's MDS, dated [DATE], the MDS indicated Resident 48's cognitive skills for daily decisions making was severely impaired. During a review of Resident 48's care plan title At risk for altered level of comfort/pain; At risk for weakness or activity intolerance due to alteration in cardiovascular function related to HTN, orthostatic hypotension, and hypokalemia (low potassium level) initiated on 7/27/2023. Resident 48's care plan interventions included, amlodipine besylate 10 mg, give one tablet by mouth one time a day for HTN. Hold for SBP less than 110 mmHg or HR less than 55 bpm .monitor BP as needed, monitor pulse (HR - heart rate) as needed. During a review of Resident 48's care plan titled Has altered gastrointestinal (GI - stomach) status, at risk for: GI discomfort, decreased food intake, irregular bowel elimination, and signs and symptoms of constipations initiated on 7/27/2023. Resident 48's care plan interventions included, administer medications as ordered to facilitate relief of GI symptoms. Notify MD if ineffective .MiraLAX (used to treat occasional constipation) Powder (polyethylene glycol 3350), give 17 grams (gm, unit of mass), one time a day for constipation. Mix with 4 (four) to 8 (eight) ounces ([oz] - a unit of measure for volume) of water. Monitor for GI symptoms (i.e., abdominal pain, nausea, vomiting, diarrhea, constipation, blood in stool) and notify MD if present. During a review of Resident 48's Order Summary Report, included orders for: Amlodipine 10 mg, instructions indicated to give one tablet by mouth one time a day for HTN. Hold for SBP less than 110 mmHg or HR less than 55 bpm, order date 6/23/2023. MiraLAX Powder, instructions indicated to give 17 gm by mouth one time a day for constipation, mix with 4-8 oz of water, order date 6/23/2023 During a Medication Pass observation on 11/20/2024 at 10:30 a.m., on Station 2 at MedCart 2 with LVN 1, LVN 1 prepared and administered to Resident 48 six medications which included a BP medication, amlodipine without checking the resident's BP as a parameter ordered by the physician to determine when to administer or not administer the resident's BP medication. LVN 1 prepared the following medications for Resident 48: 1. Amlodipine 10 mg, one tablet 2. Vitamin C (supplement) 500 mg, one tablet 3. Docusate Sodium (treat constipation) 100 mg one capsule 4. Ferrous sulfate (used to treat and prevent iron deficiency anemia [lack of red blood cells]) 325 mg, one tablet 5. Fludrocortisone (a corticosteroid, used to help control the amount of sodium and fluids in the body) 0.1 mg, two tablets 6. MiraLAX 17 gm During a concurrent Medication Pass observation and interview on 11/20/2024 at 10:44 a.m. with LVN 1, LVN 1 after preparing Resident 48's medications entered the resident's room. LVN 1 stated he added five oz of water to the MiraLAX Powder, and the powder was observed undissolved at the bottom of the medication cup. Resident 48 began sipping the undissolved MiraLAX while taking the oral pills. LVN 1 stated he would let Resident 48 drink some of the MiraLAX and then add more water. LVN 1 was stopped and asked to fully mix and dissolve the MiraLAX before continuing to administer to Resident 48. During an interview on 11/20/2024 at 11:06 a.m., with LVN 1, LVN 1 stated he was supposed to check resident's (Resident 48) BP right before administering the BP medication when there was an ordered parameter to indicated when to administer or hold the BP medication. LVN 1 stated Resident 48's BP could change or drop, which could lead to the resident experiencing a fall or injury. During an interview on 11/20/2024 at 11:10 a.m., with LVN 1, LVN 1 stated he should have fully dissolved the MiraLAX Powder before allowing Resident 48 to drink it. During a concurrent interview and record review on 11/21/2024 at 9:46 a.m., with the Director of Nursing (DON), Resident 29 and Resident 48's physician orders were reviewed. The DON stated the licensed nurse must take the resident's (that include Resident 29 and Resident 48) BP first and then administer the medication if within the parameters per physician's order to administer. The DON stated residents BP could change and be low or high, if the resident's BP was low giving the BP medication could cause the resident to experience dizziness, increase risk for falls, change of condition, and possible to lead to hospitalization. DON stated licensed nurse needs to mix MiraLAX thoroughly prior to administering to the resident (Resident 48). During a concurrent interview on 11/21/2024 at 9:54 a.m., with the DON, the DON provided and read the manufacturer's specification for MiraLAX preparation that indicated: Mix with 4 to 8 oz of any beverage, hot or cold temperature Stir and dissolve one packet of powder in 4 to 8 ounces of any beverage, hot or cold Ensure that the powder is fully dissolved before drinking Do not drink if there are any clumps. 3. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE]. With diagnosis of type 2 diabetes mellitus (DM - a group of disease that result in too much sugar in the blood). During a review of Resident 42's Physician Order Summary Report, included an order for metformin oral tablet, instructions indicated to give 1000 mg by mouth two times a day for DM. Take with food/meals, order date 10/24/24 During a Medication Pass observation on 11/20/2024 at 11:14 a.m., on Station 1 at MedCart 1 with a Registered Nurse (RN) 1, RN 1 prepared and administered to Resident 42 ten medications which included a medication to treat DM, metformin without food or a meal as ordered by the physician. RN 1 prepared the following medications for Resident 42: 1. Aspirin 81 mg, 1 tablet 2. Bethanechol (treat urinary and bladder problems) 25 mg, 1 tablet 3. Biotin (supplement) 1000 mcg, 1 tablet 4. Clopidogrel (an antiplatelet, used to prevent blood clots from forming) 75 mg, 1 tablet 5. Lisinopril (lower blood pressure) 40 mg, 1 tablet 6. Metformin (lower blood glucose (a type of sugar) 1000 mg, 1 tablet 7. Metoprolol Tartrate (lower blood pressure) 50 mg, 1 tablet 8. Multivitamin (supplement), 1 tablet 9. Vitamin D3 (supplement) 25 mcg (1000 IU) 1 tablet 10. Heparin (a substance medication that slows the formation of blood clots) 5000 international units (IU, standardized unit of measure)/ milliliter ([ml] - a unit of measure for volume), one ml. During an interview on 11/20/2024 at 2:57 p.m., with RN 1, RN 1 stated he did not give Resident 42's metformin with food or a meal. RN 1 stated must give Resident 42's metformin with food according to the physician's order and to prevent the resident from experiencing an upset stomach. During a concurrent interview and record review on 11/21/2024 at 10:32 a.m., with the DON, Resident 42's physician order for metformin was reviewed. The DON stated Resident 42's order indicated to administer metformin with food or a meal. The DON stated by administering metformin without food or a meal could cause Resident 42 to experience side effects that include diarrhea, nausea, and upset stomach. The DON stated by taking metformin with a meal can help reduce the side effects for the resident. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 3/2022, indicated, Medications must be administered in accordance with the orders .The following information must be checked/verified for each resident prior to administering medications .Vital signs, if necessary. During a review of the facility's P&P titled, General Dose Preparation and Medication Administration, revised 1/2013, indicated, Follow manufacturer medication administration guidelines (e.g.providing medication with fluids or food .)

Based on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed on 11/19/202024 when: 1.Facility failed to ensure five residents on mechanical soft chopped diet (for residents who have limited chewing ability and intact swallowing ability) received Chicken alfredo texture in the form that meet their needs when the broccoli was not chopped and there were large pieces of chicken and pasta in the Chicken alfredo. (chicken measured at 1.5 inches using a ruler). 17 residents who were on mechanical soft ground diet received chopped chicken alfredo instead of the ground chicken alfredo per the food production guides (food portion and serving guide). These failures had the potential to result in meal dissatisfaction, decreased nutritional intake, weight loss and increased risk of choking for the residents who were on mechanical soft chopped and or ground diet. Findings: 1.During an observation in the kitchen on 11/19/202024 at 11:50 a.m., [NAME] 1 was mixing the sauce for the Chicken alfredo and preparing the chopped diet. [NAME] 1 stated the chopped Chicken alfredo was served with pasta and it was for residents on mechanical soft chopped or ground diet. Cook1 stated the pieces of the chicken, and the pasta should be about one inch long for the chopped diet. Cook1 stated the residents on ground diet receives the same chopped chicken. During an observation of the tray line service for lunch on 11/19/2024 at 12:00 p.m., the chopped Chicken alfredo had large chunks of chicken. The broccoli florets were big and not chopped. During the same observation for lunch service on 11/19/202024 at 12:00 p.m., residents on ground diet received the chopped Chicken alfredo with pasta there was no ground Chicken alfredo prepared. During an observation in the kitchen for lunch service on 11/19/202024 at 12:40 p.m., one plate was returned to kitchen requesting chopping the broccoli and chicken into smaller pieces. During an interview with Cook1 on 11/19/202024 at 12:45 p.m., Cook1 stated based on her understanding of the menu, all resident on the mechanical soft diet which includes chopped and ground diet, will receive the same food which was chopped Chicken alfredo with pasta today. Cook1 stated she chopped the chicken and pasta into one inch size using a knife. During an interview with [NAME] 1 and review of the production guides for noon meal dated 11/19/202024, Cook1 looked at the production guide and stated according to the guide [NAME] 1 should prepare five servings of chopped chicken alfredo and 17 servings of ground chicken alfredo. [NAME] 1 stated he thought all residents will receive the same chopped chicken alfredo with pasta. [NAME] 1 stated he should have prepared ground chicken alfredo and ground pasta. During a concurrent interview and taste test on 11/19/202024 at 1:00 p.m., for the mechanical soft chopped chicken alfredo and pasta with dietary supervisor (DS), the chopped chicken and pasta contained inconsistent sizes of chicken and pasta. There were some large pieces of chicken and pasta on the plate. The broccoli florets were not chopped. The size of the pieces of food was measured using a measuring tape and the chicken was at 1.5 inches long and the broccoli was at 2 inches long. During an interview on 11/19/202024 at 1:00 p.m., with DS, DS stated for the chopped diet, the chicken should be chopped into less than one inch long and the ground should be ground like ground beef. DS stated [NAME] 1 should have used the food blender to chop the chicken into smaller pieces. DS stated the residents on chopped and ground diet received large pieces of chicken. when the resident eats large pieces of chicken they can choke. DS stated he will in-service staff to make sure to follow the food production guide when serving meals. During an interview on 11/19/202024 at 2:00PM, with Registered Dietitian (RD), RD stated for chopped diet, the food should be chopped into half inch pieces. RD stated it was for our residents who require less chewing. RD stated resident on the ground diet, the food is served ground same consistency as ground beef. RD stated when the pieces are large the food can hardly get down and it will be hard for residents to swallow. During an interview on 11/20/202024 at 10:30 a.m., with Speech Therapist (SLP), SLP stated she orders the appropriate diet for the residents per their chewing and swallowing evaluation. SLP stated ground diet is when the meats are ground consistency and sometimes the vegetables can also be ground. SLP stated the Mechanical soft chopped diet, the meat is chopped. SLP cannot remember exactly how small the meat is chopped in the chopped diet. During a review of facility policy and procedure (P&P) titled Mechanical Soft/Ground (dated 4/2024) indicated, This order is for residents who have limited chewing ability and intact swallowing ability .All meat (such as beef, fish, poultry and pork) should be ground or chopped .some cooked vegetables may need to be chopped .Chopped is half inch - half inch pieces, Ground is 1/8 inch or less - consistency of ground meat During a review of the facility's P&P titled Menu (dated 11/2017) indicated, Residents receive food in the amount, type, consistency, and frequency to maintain normal body weight and acceptable nutritional values. During a review of the recipe for chicken alfredo indicated for mechanical soft chop or grind meat to desired texture. During a review of the recipe for broccoli florets indicated for mechanical soft chop portions prior to service. During a review of the production guide for the noon meal dated 11/19/202024 indicated to prepare five serving of chopped chicken alfredo and 17 servings of ground chicken alfredo.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1.Nutritional supplement labeled store frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. One box 30 single serve cartons of vanilla flavored high protein nutrition supplement and another box with 30 single serve cartons of sugar free chocolate high calorie nutrition supplements were stored in the walk-in refrigerator with no thaw date. This failure had the potential to result in food borne illnesses (any illness resulting from eating contaminated/spoiled foods) in 16 residents who were receiving nutrition supplements at the facility. 2.One large tray of boneless chicken thighs thawing on the bottom rack with no thaw date. 3.One bottle of thickened water stored in the reach in refrigerator with open date of 4/4/2024 exceeding storage period for the thickened water. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illnesses in 68 out of 70 residents who receive food from facility. Findings: 1.During an observation in the kitchen on 11/19/2024 at 9:00 a.m., there was one box with 30 single serve cartons of vanilla flavor nutrition supplement and another box with 30 single serve sugar free chocolate flavored nutrition supplement stored in the walk-in refrigerator with no date. During a concurrent interview with Dietary Supervisor (DS) stated the supplements are delivered frozen and was stored in the freezer, every two days facility goes through the whole box and there was a fast turn over. DS stated once they were thawed the product was safe for 14 days. DS agreed there should be a date on the supplements to monitor date of thaw and when to discard. 2.During an observation in the kitchen on 11/19/2024 at 9:00a.m., there was one large tray with raw boneless chicken thighs thawing on the bottom shelf in the walk-in refrigerator. There was no date on the chicken, and it was soft to touch. During a concurrent observation and interview with DS, DS stated the chicken was pulled out of the freezer and was thawing in the walk-in refrigerator. DS does not know when the chicken was removed from the freezer. DS stated there should be a thaw date to make sure food was stored safely and then cooked. During an interview with cook (Cook 1) on 11/19/2024 at 9:30 a.m., [NAME] 1 stated she removed the chicken from the freezer this morning and place them in the walk-in refrigerator to thaw. [NAME] 1 stated she was rushing and forgot to mark the thaw date on the chicken. [NAME] 1 stated when there was no thaw date on the food then food was not stored safely, and it can exceed storage period for chicken in the refrigerator. During an observation in the kitchen on 11/19/2024 at 9:35a.m., there was one bottle of honey thickened water (honey-thick liquids pour slowly like honey or molasses for people who have difficulty swallowing) stored with open date of 4/4/2024 and manufacturers use by date of 10/23/2024. During a concurrent interview with DS and Dietary aide (DA1), DS stated the honey thickened water was expired and should have been discarded. DS reviewed the manufacturer recommendation use by date on the bottle and verified that it was exceeding the storage period for the honey thickened water and discarded the bottle of the thickened water. DS stated when food or beverage exceeds use by date it decreases the quality and can be food safety issue. During the same observation and interview on 11/19/2024 at 9:35 a.m., DA 1 pointed to single serve containers of thickened water and stated, residents receive single serve containers of honey thickened water, DA 1 stated we don't use the bottle and we forgot to discard it. During a review of facility policy and procedure (P&P) titled Food Receiving and Storage (revised 3/2023) indicated, Practices to maintain safe refrigerated storage include: labeling, dating and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use by date, or frozen or discarded. During a review of the 2022 U.S. Food and Drug Administration Food Code titled Ready to Eat, Time/Temperature control for safety food, Date Marking Code#3-501.17, indicated, Ready to eat, time temperature control for safety food prepared and packaged by food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 2024 hours, to indicate the date or day by which the food shall be consumed, sold, or discarded.

Based on interview and record review the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintain and improve safety and quality in nursing homes) committee failed to implement corrective action to the potential systemic problems identified: 1. Maintain a system to monitor weight loss. 2. Maintain a system to ensure the reporting of falls with major injury. 3. Maintain a system to ensure pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) preventive measures were implemented. Findings: During an interview on 11/23/2024 at 4:40 p.m., with the Director of Nursing (DON), the DON stated the QAA discuss monthly falls, pressure injuries and weight loss. The DON stated there was a need for improvement and will be working on the issues identified as deficient practices. During a review of the facility's policy and procedures (P&P) titled, Quality Assurance Performance Improvement, revised dated 3/2023, the P&P indicated the facility's Purpose Statement was, To provide facility staff with a plan that describes the process for conducting QAPI/QAA activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain respect and dignity on one of three sampled residents (Resident 9) by standing over the resident while assisting her during a meal. This failure had the potential to result in decreased self-esteem and self-worth on Resident 9. Findings: During a review of Resident 9's admission Record indicated the Resident 9 was admitted on [DATE] with diagnoses including dementia (loss of cognitive functioning such as thinking, remembering and reasoning which can affect and interfere with daily life and activities), hypertension(high blood pressure) and osteoporosis( condition where bones become brittle and weak). During a review of Resident 9's Minimum Data Set( [MDS] a standardized assessment and care screening tool ) dated 7/20/2023, the MDS indicated the Resident 9 had severe cognitive impairment (person had trouble remembering things, making decisions, concentrating, or learning) and required one person assist with eating, toilet use and personal hygiene. During an observation on 10/31/2023, at 1:30 p.m. in Resident 9's room, observed Certified Nursing Assistant (CNA)1, positioned Resident 9 in an upright position in the bed and stood over the resident while feeding her during mealtime. During an interview on 11/1/2023, at 1:55 p.m. with CNA 1, CNA 1 stated she should be sitting in a chair when she was assisting and feeding Resident 9 with her meal. CNA 1 stated she had to be within eye level when feeding her to assist with bonding and maintaining Resident 9's dignity. During an interview on 11/3/2023, at 12:24 p.m. with Director of Staff Development (DSD), stated the CNA 1 should be facing the resident within eye level and seated when feeding a resident to protect resident's dignity. During a review of facility's policy and procedure (P/P) titled Dignity and Respect revised 3/2023, the P/P indicated residents shall be treated with respect and dignity at all times and residents and will be assisted in maintaining and enhancing their self-esteem and self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to identify, appropriately assess, and monitor two of two sampled residents (Resident 18 and Resident 270) during the use of wedges (foam devices used to position residents, that have one thick end and taper to a thin edge) to prevent residents from sliding and falling from the bed. This failure had the potential to result in entrapment (being caught in) and injury. Findings: During a review of Resident 18's admission Record, indicated Resident 18 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), gastrostomy (a surgical operation for making an opening in the stomach), functional quadriplegia (a partial to complete loss of strength and sensation in both the upper and lower limbs and torso), and pressure ulcer (an injury that breaks down the skin and underlying tissue due to continuous unrelieved pressure) on left upper back. During a review of Resident 18's History and Physical (H&P), dated 5/21/2023, the H&P indicated, Resident 18 did not have the capacity to understand and make decisions. During a review of Resident 18's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 8/31/2023, the MDS indicated Resident 18 was totally dependent (full staff performance without resident participation every time) from two or more staff for bed mobility, transfers, and total dependence from one staff for dressing, eating, toilet use, personal hygiene. During an observation on 10/31/2023, at 11:03 a.m., in Resident 18's room, Resident 18 was laying on his back with his eyes closed. There was a total of four wedges placed under the fitted sheet, two of them were under the shoulder to arm, and thickest parts of the wedge were on outer side of shoulders and arms, and thinnest parts of the wedge were closed to sides of his torso. Other two wedges were placed from hips to ankles. Thickest parts were close to both hips and thinnest parts were under both legs. During a review of Resident 18's Order Summary Report, dated 10/1/2023,indicated there was no order to use wedges to prevent falls or sliding from the bed. During a review of Resident 18's Care Plan (CP), initiated on 5/23/2023 indicated, use of wedges for preventing falls or pressure injury. During a review of Resident 18's Nursing Progress Notes, dated from 10/6/2023 to 10/31/2023, the Nursing Progress Notes did not indicate documentation regarding use of wedges for Resident 18. During a review of Resident 270's admission Record, indicated Resident 270 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including gastrostomy, progressive supranuclear ophthalmoplegia (a disorder that affects body movements, walking and balance, and eye movements), functional quadriplegia, generalized muscle weakness, and pressure injury on sacral region (a large, flat, triangular-shaped bone nested upper side of tail bone). During a review of Resident 270's H&P dated 10/24/2023, the H&P indicated, Resident 270 had fluctuating capacity to understand and make decisions. During a review of Resident 270's MDS, dated [DATE], the MDS indicated Resident 270 was totally dependent on two or more staff for eating, toileting, hygiene, shower/bath, lower body dressing, putting on/taking off footwear, personal hygiene, and maximal assistance (staff did more than half the effort. Staff lifts, holds, or supports trunk or limbs.) from one staff for oral care, moderate assistance (staff did less than half the effort) from one staff for upper body dressing. The MDS indicated, there were no physical restraints placed. During an observation on 10/31/2023, at 11:32 a.m., in Resident 270's room, Resident 270 was lying on her back and was sleeping. There were a total of four wedges placed under the bottom fitted sheet. Two of the wedges were under the shoulders to the arms and the thickest parts of the wedges were on the outer side of the shoulders and arms and the thinnest parts of wedges were close to the sides of her torso. The other two wedges were placed from the hips to the ankles. The thickest parts were close to both sides of the hips and the thinnest parts were under both legs. During an observation on 11/1/2023, at 4:04 p.m., in Resident 270's room, four wedges were placed in the same locations as the previous day. There were a total of four wedges placed under the fitted sheet. Two of them were under the shoulders to arms and the thickest parts of the wedge were on the outer side of the shoulders and arms and the thinnest parts of the wedges were close to the sides of her torso. The other two wedges were placed from the hips to the ankles. The thickest parts were close to both sides of the hips and the thinnest parts were under both legs. Resident 270's eyes were closed, and she was on her back. During an interview on 11/1/2023, at 4:08 p.m., with Certified Nurse Assistant (CNA) 3, CNA 3 stated, the wedges are placed on Resident 18 and 270 all day long. CNA 3 stated, she was not sure if anyone informed the family regarding the use of wedges. CNA 3 stated, these wedges were placed to prevent falls and injury, but not for repositioning to relieve pressure. CNA 3 stated, the residents could not move much after the wedges are tightly placed around their bodies. CNA 3 stated she did not assess or monitor the residents for the wedges. CNA 3 stated, Resident 18 and Resident 270 did not need the wedges because they slept through daytime and woke up at night only. During an interview on 11/1/2023, 4:15 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, staff placed the wedges to protect residents from fall and injury. LVN 2 stated, the wedges restricted the residents' movement. LVN 2 stated, she did not get an order from the physician, update the care plan, and get consent from the families of Residents' 18 and 270 to place the wedges. LVN 2 stated the wedges were placed based on nursing judgement. LVN 2 stated, she did not realize they were considered restraints (any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body), and she did not assess or monitor Residents 18 and 270 for the use of wedges. LVN 2 stated, the wedges were used to prevent falls or injury by restricting the residents' movements and they were not used to relieve pressure. During an interview on 11/2/2023, at 11:21 a.m. with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, restraints could be anything that restricted the residents' movements such as side rails and wedges. RNS 1 stated, it was not acceptable to use wedges for preventing falls because there were other interventions to prevent falls. RNS 1 stated, if they were used as restraints, nursing staff should get an order from the physician, obtain the consent from the family, update the care plan, monitor and assess the resident every two hours. RNS 1 stated, staff could not just do restrictive interventional measures without proper assessment and a valid reason because it could lead to further injury such as worsening of pressure injuries due to staying in the same position for prolonged time. During an interview on 11/2/2023, at 2:19 p.m., with the Director of Staff Development (DSD), DSD stated, anything could be considered as restraints if it restricted resident's movement. The DSD stated, the residents had a right to be free from restraints. DSD stated, if there was a concern regarding safety of the resident, staff should have tried less restrictive measures first. The DSD stated, if the resident was not properly monitored and assessed for restraint use, the resident could be contracted (shortening and hardening of muscles) and developed pressure injuries (or worsening of injuries). During an interview on 11/3/2023, at 3:00 p.m., with the Director of Nursing (DON), the DON stated, nursing staff should be able to identify possible restraints. DON stated, if use of restraints is identified, nursing staff should assess, monitor, and re-evaluate frequently. DON stated, all residents had rights to be free from restraints. During a review of Resident 270's Order Summary Report, dated 11/1/2023, the Order Summary Report indicated, there was no order to use the wedges to prevent falling or sliding. During a review of Resident 270's Care Plan (CP), revised 10/21/2023, the CP Problem indicated, Resident 270 was at risk for development of pressure injury due to immobility (unable to move) and incontinence (unable to control bowel and bladder). The CP Intervention indicated, wedges in bed for assistance with positioning. During a review of Resident 270's Nursing Progress Note dated from 10/21/2023 to 10/31/2023, the Nursing Progress Note indicated, no documentation regarding use of the wedges. During a review of the facility's policy and procedure (P/P) titled, Respect and Dignity-Physical Restraints, revised 3/2023, the P&P indicated, Policy Statement: The facility does not use physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Intent: To provide guidelines for staff when the use of a restraint when indicated, and to ensure the least restrictive alternative for the least amount of time, with documented ongoing re-evaluation of the need for restraints, is present in the medical record. Guidelines:1. The resident's physical condition and his/her cognitive status may be contributing factors in determining whether the resident has the ability to remove it . Physical Risks and Psychosocial Impacts Related to Use of Restraints 1.a. Decline in physical functioning including an increased dependence in activities of daily living (e.g., ability to walk}, impaired muscle strength and balance, decline in range of motion, and risk for development of contractures . c. Accidents such as falls, strangulation, or entrapment. 2 . Loss of dignity, self-respect, and identity .f. Feelings of imprisonment or restriction of freedom of movement. Assessment, Care Planning. and Documentation for the Use of a Physical Restraint: 1. The facility limits the use of any physical restraint to circumstances in which the resident has medical symptoms that warrant the use of restraints. 2. Staff shall document the medical symptoms being treated and the reason(s) a restraint is warranted. 3. The licensed nurse shall obtain a physician's order for the use and specific type of restraint. 4. The interdisciplinary team shall complete a physical restraint assessment to identify potential risks associated with the restraint use, specific to the resident. 5. The interdisciplinary team will complete a resident centered care plan, based on the restraint assessment with individualized interventions for care. 6. The interdisciplinary team will provide on-going documentation for the use of the physical restraint; and use the restraint for the least amount of time possible, with ongoing re-evaluation . Falls generally do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint . Documentation: Documentation shall reflect what the resident was doing and what happened that presented the imminent danger, alternate interventions attempted, response to those interventions, whether the resident was transferred to another setting for evaluation, whether the use of a physical restraint was ordered by the practitioner, and the medical symptom(s) and cause(s) that were identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of six sampled residents (Resident 4) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)]. This failure had the potential to prevent Resident 4 from receiving intervention and equipment to prevent a decline in ROM in both arms and both legs. Findings: During a review of Resident 4's admission Record, indicated Resident 4 was admitted on [DATE] with diagnoses including heart failure (heart unable to pump enough blood), right and left foot drop (difficulty lifting the front part of the foot), dysphagia (difficulty swallowing), and hemiplegia (paralysis) and hemiparesis (weakness of one side of the body) following a nontraumatic intracerebral hemorrhage (bleeding in brain tissue) affecting right dominant side. During a review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 8/10/2023, indicated Resident 4 had clear speech, was rarely understood, rarely understood verbal content, and severely impaired for cognition (ability to think, understand, learn, and remember). The MDS indicated Resident 4 was dependent for bed mobility, transfers (movement between surfaces), dressing, eating, toilet use, and bathing. The MDS indicated Resident 4 had impairments in ROM of both legs. During a review of Resident 4's physician's orders, dated 12/7/2022, the physician's orders included the following for Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) services: a. RNA program once daily, five times per week, for gentle passive range of motion (PROM, movement of joint through the ROM with no effort from the person) on both legs as tolerated. b. RNA program once daily, five times per week, for application of pressure relief ankle foot orthoses (PRAFO, worn on the lower leg and foot to relieve pressure on the heel and provide optimal ankle position) to both feet for four to six hours. c. RNA to perform PROM exercises on both arms daily, five times per week as tolerated. During a review of Resident 4's care plans, the care plans did not include any RNA services consistent with Resident 4's physician orders. During an observation and interview on 11/2/2023 at 8:46 am in Resident 4's bedroom, Resident 4 was lying in bed with the head-of-bed elevated and wearing a hospital gown and PRAFOs to both feet. Restorative Nursing Aide (RNA) 2 stated RNA 2 provided PROM to both of Resident 4's legs prior to applying both PRAFOs this morning. RNA 2 demonstrated PROM to both of Resident 4's arms. During a concurrent interview and record review on 11/2/2023 at 11:31 am with the MDS Coordinator (MDSC), the MDSC reviewed Resident 4's physician's orders for RNA services which included PROM to both arms, PROM to both legs, and application of the PRAFOs to both legs. MDSC reviewed Resident 4's care plans and stated the facility did not develop a comprehensive care plan for Resident 4's RNA services. MDSC stated care plans were important to the services the facility provided to residents. During a review of the facility's Policy and Procedure (P/P) titled, Develop-Implement Comprehensive Care Plans, revised on 3/2023, the P/P indicated the facility developed and implemented care plans to address the resident's medical, physical, mental and psychosocial needs. The P/P indicated the comprehensive care plan indicated Services that are to be furnished to attain to maintain the resident's highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P/P titled, Restorative Nurse Services, dated 3/2023, the P/P indicated Restorative goals and objectives are individualized and resident-centered and are outlined in each participating resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality of care for one of four residents (Resident 270) by failure to follow the facility's policy and procedures (P&Ps) titled, Feeding Tube - Administration of Medication, and Medication Administered through an Enteral Tube, to ensure medications was administered appropriately and safely to residents receiving medication through a gastrotomy/feeding tube (G-Tube, a tube inserted through the belly that brings nutrition and medication directly to the stomach). This failure had the potential to result in clogging and of medications in the G-tube and increased the risk for medication related complications for Resident 270. Findings: During a review of Resident 270's admission Record, dated 10/24/2023, the admission Record indicated, Resident 270 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included open-angle glaucoma and progressive supranuclear ophthalmoplegia (unable to move eyes at will in all directions, especially looking upward), dysphagia (difficulty swallowing), and hypertension (high blood pressure). During a review of Resident 270's History and Physical (H&P), dated 10/24/23, the H&P indicated, Resident 270 had fluctuating capacity to understand and make decisions. During an observation on 11/1/2023 from 9:29 AM until 9:47 AM with Licensed Vocational Nurse (LVN )1 on Station 2, Medication Cart 2, LVN 1 was observed preparing the following medications for Resident 270: 1. Bethanechol (helps to cause urination and emptying of the bladder) 10 milligrams (mg a unit of measure of weight), one tablet. 2. Docusate Sodium (stool softener) 100 mg, one tablet. 3. Dorzolamide HCL (used to treat glaucoma, a condition in which the pressure in the eye is too high) ophthalmic (eye) drop, instruction to instill one drop in to left eye 4. Klor-Con /EF (Potassium Bicarbonate Effervescent [a type of tablet that breaks up when dropped into liquid like water or juice], supplement) Tablet for Oral Solution 25 milliequivalents (mEq a unit of measure of volume), one tablet via G-tube 5. Lactulose (treat constipation) Solution 10 g/15 milliliters (ml, a unit of measure of volume), 30 ml. 6. Losartan Potassium (treat high blood pressure) 25 mg, 1/2 (12.5 mg) tablet. 7. One Daily, Multivitamin with Minerals (supplement), one tablet. 8. Timolol Maleate (used to treat glaucoma) 0.5 %, instruction to instill one drop into left eye During a concurrent observation and interview on 11/1/2023 at 9:48 AM with LVN 1, LVN 1 stated she prepared a total of eight medications for Resident 270. LVN 1 crushed each tablet and placed them into individual medications cups, entered Resident 270's room, checked the resident's G-tube placement and performed an initial flush with 30 ml of water. At 9:58 AM, LVN 1 began to administer Resident 270's medications by placing 15 ml of water into the G-tube syringe, poured the medication cup that contained undissolved crushed medication (Bethanechol) directly into the syringe, followed by flushing with 10 ml of water. At 9:59 AM, LVN 1 repeated the same process with the second medication, by pouring 15 ml of water into the syringe, followed by pouring the medication cup that contained undissolved crushed medication (multivitamins with minerals) directly into the syringe, followed by flushing with 10 ml of water. LVN 1 stated that she usually put the water into the syringe first and then add the crushed tablets to the water already in the syringe when she administers medication through a G-tube. During an interview on 11/1/2023 at 11:30 AM with LVN 1, LVN 1 stated, I found when I mix the water with the crushed pill it leaves some medication in the cup. I find that when I put the water into the syringe and then add the crushed medication and swirl it around, I feel like they get more of the medication. LVN 1 stated, she was observed once by facility staff for medication pass and she added water to each medication cup to dissolve the medication before administering the medication through the G-tube. LVN 1 stated, I forgot to bring a spoon to stir the medication. I messed up. During an interview on 11/1/2023 at 11:51 AM, with a Registered Nurse Supervisor (RNS) 3, RNS 3 stated for G-tube medication administration the licensed nurse will crushing the medication separately, place the powder of each medication into individual medication cups and mix each medication separately with 10 to 15 ml of water, then pour the dissolved medication into the G-tube syringe for administration to the resident. RNS 3 stated if there is medication residual remaining in the medication cup to add a little more water to ensure the resident receives the full dose of medication followed by flushing with water between each medication. RNS 3 stated crushed medications must be mixed with water to dissolve before administration through the G-tube to prevent medications from collecting on the sides of the syringe, which may result in the resident being under dosed. RNS 3 stated licensed nurse are supposed to be trained on G-tube medication administration during their orientation. During an interview on 11/1/2023 at 3:53 PM, with the Director of Nursing (DON), the DON stated, licensed nurses not dissolving crushed medication before administration through a G-tube was not the right thing to do, was not the standard for G-tube administration, and was not in accordance with the facility's policy for G-tube medication administration. DON stated the standard of practice is to mix the crushed medication with water or fluid before administering the medication through the G-tube. During a review of the facility's (P/P) titled, Feeding Tube - Administration of Medication, dated 7/20, the P&P indicated, Medications are administered appropriately and safely when the resident has a feeding tube in place and medications are delivered through the feeding tube. The procedures indicated: * Tablets are to be crushed/ground and diluted in water or other fluid as indicated. If the medication is in tablet form, make certain the particles are small enough to pass through the distal end of the gastrotomy . tube. * If the medication is in capsule form, (not a time released or sustained release medication), empty the content of the capsule into a separate medication cup and mix it with water . * Dilute medication according to resident's administration orders making sure that medications are dissolved completely prior to administration . * Verify that medication cups are clear of any remnants of crushed pills or liquid medication. During a review of the facility's P&P titled, Medication Administered through an Enteral Tube, dated 1/22, the P&P indicated, Medications are administered as prescribed in accordance with standard nursing principles and practices only by staff qualified and authorized to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 3) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] received passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to the right leg from 8/29/2023 to 10/31/2023. This failure had the potential for Resident 3 to experience a decline in ROM and development of contractures (chronic joint stiffness associated with joint deformities and pain). Findings: During a review of Resident 3's admission Record, indicated Resident 3 was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses including unspecified dementia (decline in mental ability severe enough to interfere with daily life), hemiplegia (paralysis) and hemiparesis (weakness to one side of the body) following cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side, and spinal stenosis (narrowing of the space surrounding the spinal cord causing pressure on the nerves). During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 9/6/2023, indicated Resident 3 had clear speech, sometimes expressed ideas and wants, sometimes understood verbal content, and had severely impaired cognition (ability to think, understand, learn, and remember). The MDS also indicated Resident 3 was dependent (full staff performance) for bed mobility (movement in bed), transfers between surfaces, dressing, eating, toilet use, personal hygiene, and bathing. The MDS indicated Resident 3 did not have any range of motion ([ROM], full movement potential of a joint {where two bones meet}) limitations in both arms and both legs. During a review of Resident 3's Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Discharge summary, dated [DATE], indicated a recommendation for a Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) program to PROM exercises on the right arm, five times per week as tolerated. During a review of Resident 3's Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], the PT Discharge Summary indicated a recommendation for an RNA program for ROM. During a review of Resident 3's physician's orders, dated 8/24/2023, indicated RNA to perform PROM exercises on the right arm every day, five times per week as tolerated. Another physician's order, dated 8/24/2023, for Resident 3 indicated RNA to perform PROM exercises on the right leg every day, five times per week as tolerated. During a review of Resident 3's care plan titled, Resident at risk for contracture on right leg, initiated 8/24/2023, the care plan indicated for RNA to perform PROM exercises on right lower extremity (RLE) every day, five times per week as tolerated. During a review of Resident 3's physician's orders, dated 8/29/2023, the physician's orders indicated Resident 3 was admitted to hospice care (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible). Another physician's order, dated 8/29/2023, indicated to discontinue RNA to perform PROM to both arms and both legs due to Resident 3's admission to hospice care. During a review of Resident 3's Documentation Survey Report (record of interventions provided) for RNA, dated the months of 8/2023, 9/2023, and 10/2023, Resident 3 received RNA for PROM exercises to the right arm five times per week from 8/24/2023 to 10/31/2023. Resident 3's Documentation Survey Reports did not indicate Resident 3 received RNA for PROM exercises to RLE. During an observation on 10/31/2023 at 10:26 am in Resident 3's bedroom, Resident 3 was awake watching television while lying in bed with the head-of-bed elevated. Resident 3 used the left hand to point to her mouth and stated, coffee. Resident 3 had active movement throughout the left arm but had difficulty understanding requests to move the right arm. Observed a blanket covered Resident 3's right arm and both legs. During concurrent observation and interview on 10/31/2023 at 10:32 am with Licensed Vocational Nurse (LVN) 2 in Resident 3's bedroom, LVN 2 stated Resident 3 had a stroke and was unable to move the right arm. LVN 2 lifted Resident 3's blanket to view both legs. Resident 3's legs were outstretched onto the mattress without any ROM limitation. Resident 3 did not actively move either leg. During a concurrent interview and record review on 11/01/2023 at 3:51 pm with the Director of Rehabilitation (DOR), the DOR stated Resident 3 was discharged from OT on 8/24/2023 with recommendations for RNA services to perform PROM to the right arm. The DOR stated Resident 3 was discharged from PT on 8/24/2023 with recommendations for RNA services to perform PROM to the right leg. The DOR stated Resident 3 was admitted to hospice services on 8/29/2023 and physician's orders for RNA services were discontinued. The DOR stated Resident 3 continued to receive PROM for the right arm since the RNA task (assigned work) was not discontinued. During a review of Resident 3's physician's orders, dated 11/1/2023, the physician's orders indicated for RNA to perform PROM exercises on Resident 3's right arm and the right leg, five times per week as tolerated. During a concurrent observation and interview on 11/02/23 at 8:35 am with Restorative Nursing Aide (RNA) 2 in Resident 3's bedroom, RNA 2 stated Resident 3 had a new physician's order to perform PROM on the right leg starting 11/1/2023. RNA 2 attempted to perform right arm PROM but Resident 3 complained of pain. RNA 2 then attempted to perform right leg PROM but Resident 3 also complained of pain. RNA 2 stopped all attempts to perform PROM with Resident 3 and informed LVN 1 of Resident 3's pain. During a concurrent interview and record review on 11/03/23 at 9:04 am with the Director of Nursing (DON), the DON stated RNA services were important to maintain a resident's ability and prevent contractures. The DON reviewed Resident 3's physician's orders, including Resident 3's admission to hospice on 8/29/2023 and discontinuation of RNA services for PROM in both arms and both legs on 8/29/2023. The DON did not know the reason Resident 3's RNA services were discontinued and stated RNA services should have been continued after Resident 3's admission to hospice. The DON reviewed Resident 3's Documentation Survey Report for 8/2023, 9/2023, and 10/2023 and stated Resident 3 received PROM to the right arm but did not receive PROM to the right leg since 8/2023. The DON stated Resident 3 had the potential to develop discomfort and limitations in ROM, including the development of contractures to the right leg without PROM exercises. During a review of the facility's Policy and Procedure (P/P) titled, Increase/Prevent Decline in ROM Mobility, revised 3/2023, the P/P indicated the facility provided Treatment and services to maintain or improve each resident's range of motion and to reduce further decline in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 174) was free from unnecessary medications by failing to clarify with Resident 174's physician the need of continuance of antibiotic (medication to treat infection) medication after a negative chest x-ray result. This failure had the potential for Resident 174 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 174's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including fracture of upper end of left humerus (broken left upper arm), chronic kidney disease (kidneys are damaged and unable to filter waste products and excess fluids from the blood) and chronic obstructive pulmonary disease ([COPD] group of diseases that cause airflow blockage in the lungs which can cause breathing related problems). During a review of Resident 174's Minimum Data Set ([MDS]- a standardized assessment and care screening tool ) dated 11/1/2023, the MDS indicated the resident had moderate cognitive impairment (person had trouble remembering, learning new things, concentrating, and making decisions that affect their daily life) and required substantial (helper does more than half the effort) assistance with bed mobility, toilet hygiene and shower. ` During a review of Resident 174's Progress Notes dated 10/29/2023 timed at 3:36 p.m., indicated Resident 174 had non- productive cough (cough without phlegm) with no difficulty of breathing and congestion (excessive accumulation of body fluid like mucus or secretions). The Progress Notes indicated Resident 174 was notified of the non-productive cough and ordered chest x-ray (imaging test). During a review of Resident 174's Physician Orders dated 10/30/2023, timed at 10:15 a.m., indicated an order for Zithromax (antibiotic) 250 milligrams ([mgs] unit of measurement) two tablets by mouth one time only until 10/30/2023 and Zithromax 250 mgs. 1 tablet by mouth one time a day for cough for 4 days. During a review of Resident 174's chest x-ray result performed on 10/30/2023 at 1:21 p.m., the chest x-ray result indicated Resident 174's lungs were clear, and no acute pulmonary finding was present (no significant abnormalities or issues found in the lungs). During a concurrent interview and record review of Resident 174's Progress Notes on 11/3/2023, at 11:16 a.m. with RN Supervisor (RNS1), RNS 1 stated he informed Resident 174's physician the result of chest x-ray on 10/30/2023 at 2:00 p.m. RNS 1 stated he failed to mention to the physician Resident 174 was on Zithromax and asked if it will be continued after a negative chest x-ray (no significant abnormalities or issues found in the lungs). RNS 1 stated Resident 174 was still receiving Zithromax 250 mg one tablet for the cough once a day and the last dose was administered today (11/3/2023). During a review of Resident 174's Medication Administration Record (MAR) for month of October and November 2023, the MAR indicated Resident 174 received Zithromax 250 mg two tablets by mouth one time only for cough on 10/30/2023, and Zithromax 250 mg 1 tablet by mouth once a day for four days which was started on 10/31/2023. The MAR indicated the last dose of Zithromax was administered to the resident on 11/3/2023, at 9:00 a.m. During an interview on 11/3/2023, at 9:20 a.m. with Infection Preventionist Nurse (IPN), stated RNS 1 should have asked Resident 174's physician if continuance of Zithromax was necessary as the chest x-ray results showed lungs were clear and Resident 174 only symptoms was dry cough without any other respiratory symptoms (shortness of breath, productive cough). IPN stated unnecessary use of antibiotics can lead to antibiotic resistance. During a review of facility's policy and procedure (P/P) titled Unnecessary Drugs revised on 11/2017, the P/P indicated each resident's drug regimen shall be free from unnecessary drugs. The P/P indicated unnecessary drugs include medications used on residents without adequate indications for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent or greater as evidence by two out of 32 opportunities for error to yield medication error of 6.25 percent (%) for one out of four residents (Resident 270) observed during medication pass (MedPass). This failure resulted in Licensed Vocational Nurse (LVN 1) administering prescribed eye drops for Resident 270 into the wrong eye creating the potential for the resident's glaucoma (a condition in which the pressure in the eye is too high) to worsen (symptoms include, eye pain and pressure, headaches, and vision loss). Findings: During a review of Resident 270's admission Record, dated 10/24/23, the admission Record indicated, Resident 270 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses that included open-angle glaucoma and progressive supranuclear ophthalmoplegia (unable to move eyes at will in all directions, especially looking upward). During a review of Resident 270's History and Physical (H&P), dated 10/24/23, the H&P indicated, Resident 270 had fluctuating capacity to understand and make decisions. During a review of Resident 270's Order Summary Report, signed by the resident's primary care physician dated 10/24/23, included the following orders: 1. Dorzolamide Hydrochloride (HCL) (used to treat high pressure inside the eye due to glaucoma) Ophthalmic Solution, order dated 10/21/23, instructions indicated, instill one drop in left eye two times a day for Glaucoma. 2. Timolol Maleate Ophthalmic Solution 0.5 %, order dated 10/21/23, instructions indicated, instill one drop in left eye two times a day for Glaucoma at 9:05 AM and 5:05 PM. During a concurrent MedPass observation and interview on 11/1/23 with LVN 1 on Nursing Station 2, Cart 2 the following was observed on: 11/1/23 at 9:48 AM LVN 1 stated that she prepared a total of eight medications for Resident 270 that was scheduled for 9:00 AM administration that included two eye drops, Timolol 0.5 % and Dorzolamide 11/1/23 at 9:50 AM, LVN 1 entered Resident 270's room to administer the prepared medications to the resident. 11/1/23 at 9:53 AM, LVN 1 stated she will administer Resident 270's Timolol 0.5% eye drop into the resident's left eye. LVN 1 was standing on Resident 270's left side of the bed and reach across and instill one drop into the resident's right eye. 11/1/23 at 10:17 AM, LVN 1 stated she was going to administer Resident 270's second eye drop (Dorzolamide) into the resident's left eye. LVN 1 reach across the resident and held the bottle of Dorzolamide eye drop above the resident's right eye and was stopped and asked if that was the eye, she intended to administer the medication. LVN 1 stated, Yes, the left eye, and pointed to Resident 270's right eye. LVN 1 looked again and then realized the left eye was the eye closest to where she was standing. During an interview on 11/1/23 at 11:25 AM, with LVN 1, LVN 1 stated, I instilled the eye drop into the wrong eye. I did my left and not the patient's left. The left eye did not get the medication of Timolol. I was going to give the second eye drop into the right eye until you (surveyor) said something. The resident did not get the medication for the glaucoma which could make the glaucoma worse. During a review of the facility's policy and procedure (P/P) titled, Administering Medications, dated 3/22, the P/P indicated, Medications must be administered in accordance with the orders .The licensed nurse must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow up necessary dental service for one of three sampled residents (Resident 7). This failure had resulted in delay of dental services and the potential to cause Resident 7 at risk for difficulty chewing and weight loss. Findings: During a review of Resident 7's admission Record, indicated the Resident 7 was admitted on [DATE] to the facility with diagnoses that included diabetes(high blood sugar level),heart failure( lifelong condition in which the heart muscle cannot pump enough blood to meet body's needs for blood and oxygen) and hemiplegia affecting the right dominant side( partial weakness or paralysis of the right side of the body) following cerebral infarction(stroke). During a review of Resident 7's Minimum Data Set ([MDS] standardized screening and care tool) dated 10/27/2023, the MDS indicated Resident 7 had moderately impaired cognition(when a person had trouble remembering, learning new things, concentrating, or making decisions that affect everyday life) and required partial /moderate assistance with rolling to left and right, sitting to lying, lying to sitting on the side of the bed. The MDS indicated resident can eat independently but maximum assistance with toilet use. During a concurrent observation and interview on 10/31/2023 at 9:21 a.m. with Resident 7, observed missing teeth on the upper mouth. Resident 7 stated she was able to eat but would like to have an upper denture. During a review of Resident 7's Dental Notes dated 2/3/2023, Dental Notes indicated a periodic evaluation was performed and Resident 7 wanted to have new front upper denture. The Dental Note indicated a recommendation for new front upper denture. During a review of Resident 7's Social Services Evaluation dated 4/25/2023, 7/26/2023 and 10/27/2023, the Social Services Evaluation indicated no dental, hearing or vision issues addressed or evaluated. During an interview on 11/1/2023, at 3:55 p.m. with Director of Social Service (DSS), DSS stated she was responsible for Resident 7's dental care and needs. She stated it slipped from her mind to follow-up for Resident 7's front upper denture. DSS stated she took over the role of a Social Service in July 2023 and the issue about the Resident 7's front upper denture was not endorsed to her by the outgoing Social Service. During an interview on 11/2/2023, at 9:47 a.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated it could lead to weight loss and inability to eat well if Resident 7 had no upper teeth. During a review of facility's policy and procedure titled Dental Services dated 10/2017, the P/P indicated the facility will assist in obtaining needed dental services to meet the needs of each resident. The P/P indicated if resident requested dental services facility will assist residents in making appointments and shall attempt to find alternative funding sources for residents unable to pay for needed dental services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure therapeutic diets of mechanical soft (a diet that was designed for people who have trouble chewing and swallowing, chopped, ground and pureed foods [cooked and blended into a smooth, creamy consistency] as well as foods that break apart without a knife) were served as prescribed by the physician for two of 22 sampled residents (Resident 48 and Resident 9) This failure had the potential for Resident 48 and Resident 9 to choke and aspirate (food, liquid, or other material enters a person's airway and eventually the lungs by accident). Findings: During a review of Resident 48's admission Record, indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life) , physical debility (loss of strength or increased frailty and weakness), pathological fracture (broken bones in an area already weakened by another disease, not by an injury), and congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 48's History and Physical (H&P), dated 9/12/2023, the H&P indicated, Resident 48 had fluctuating capacity to understand and make decisions. During a review of Resident 48's Minimum Data Set ([MDS]-a standardized assessment and care screening tool), dated 10/31/2023, the MDS indicated Resident 48 required total dependence (full staff performance every time) from two or more staff for toileting hygiene, shower/bath, lower body dressing, putting on/taking off footwear, moderate assistance (staff does less than half the effort) from one staff for personal hygiene, upper body dressing, and set up or clean- up assistance from one staff for eating. During a review of Resident 48's Care Plan (CP), revised on 10/12/2021, the CP Problem indicated, Resident 48 was at risk for altered nutrition related to poorly fitting dentures and reported weight loss trend. The CP Intervention indicated, provide mechanical soft diet as ordered and monitor for signs and symptoms of dysphagia. During an observation on 10/31/2023, at 1:00 p.m., in the kitchen during the tray line (a food preparation method in which food trays travel around the production line), Dietary Aid (DA) 1 placed a big chuck of sliced steaks with gravy on Resident 48 and Resident 9's lunch tray. Resident 48's meal ticket indicated, mechanical soft/ground meat with thin liquid consistency and four ounces of health shake. Resident 9's meal ticket indicated, mechanical soft/ground meat with thin liquid consistency, no ham, no cheese, four ounces of health shake with meal. Dietary Service Supervisor (DSS) pointed out that both residents had order for mechanical soft/ground meat. DA 1 chopped more and placed them on each resident's plate. The meat on the plate was not ground. It was chopped. During an interview on 11/3/2023, at 1:35 p.m., with Registered Dietitian (RD) via phone, RD stated, the resident should be evaluated by Speech-Language Pathologist ([SLP]-individual who provides professional services in the areas of communication and swallowing) to determine the level and type of texture when there was order for mechanical soft diet. RD stated, Resident 48 and 9's meal order listing indicated ground meat. During an interview on 11/3/2023, at 3:00 p.m. with Director of Nursing (DON), DON stated, kitchen staff including the cook should be able to identify different types of diets including therapeutic diet and should have followed the written menu and recipe to provide meals as physician ordered. DON stated, it was important to make sure that residents received appropriate diet as physician order to prevent chocking or aspiration. During a review of Resident 9's admission Record, indicated the Resident 9 was admitted on [DATE] with diagnoses including dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities), hypertension (high blood pressure) and osteoporosis (condition where bones become brittle and weak). During a review of Resident 9's Minimum Data Set([MDS] standardized screening tool) dated 7/20/2023, the MDS indicated the resident had severe cognitive impairment (person had trouble remembering things, making decisions, concentrating, or learning) and required one person assist with eating, toilet use and personal hygiene. During a concurrent observation and interview on 10/31/2023, at 1:30 p.m. observed Resident 9's spit food from her mouth after being fed by Certified Nursing Assistant (CNA 1) with chopped meat during lunch time. Observed big chunks and cuts of meat, cut green beans, seaweed, rice and 2 sticks of garlic bread were in Resident 9's tray. CNA 1 stated Resident 9 had missing teeth and the meat on the tray was not ground but chopped. During a review of Resident 9's meal ticket for lunch dated 10/31/2023, the meal ticket indicated Resident 9 's diet consistency was mechanical soft/ ground (diet that is texture- modified, foods can be pureed, finely chopped, blended, or ground to make them smaller) with thin consistency for beverage. During a review of Resident 9's Physician Order, the Physician Order indicated the resident was on mechanical soft texture, thin liquid consistency, no ham, no cheese, fortified cereal at breakfast, fruit for lunch, dinner, and ice-cream at dinner. During a concurrent interview and record review on 10/31/2023 with [NAME] 2 (CK 2), showed CK 2 Resident 9's photograph of lunch plate served on 10/31/2023. CK 2 stated for mechanical soft texture, the meat should be chopped more. During a review of the facility's policy and procedure (P/P) titled, Mechanically Altered/Texture Modified Diets, revised 1/2022, the P/P indicated, Intended Use: Mechanical altered foods are available for residents with chewing and/or swallowing problems. Chopped, or ground food is commonly called mechanical soft and is for the resident with chewing problems. The dysphagia textures are specifically for the resident with swallowing problems. It is recommended that the SLP perform a screening procedure to determine which consistency should be ordered .five levels of mechanically altered foods: mechanical soft/ground (chewing issues), dysphagia diets (difficulty in swallowing), pureed, minced & moist, soft and bite sized. During a review of the facility's P/P titled, Mechanical Soft, revised 1/2022, the P&P indicated, Intended Use: To provide a nutritionally adequate diet that requires a reduced amount of mastication (chewing). Normally this order is for residents who have limited chewing ability and intact swallowing ability . Recommendations: All meat should be ground or chopped. Gravy or sauces should be added to moisten ground and chopped meats, poultry, and fish for lubrication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross referenced F757 Based on interview and record review, the facility failed to implement their protocol for antibiotic stewardship for one of six sampled residents (Resident 174) by prescribing antibiotic (drug that treats infection) without meeting the criteria (checklist used for Infection surveillance) for respiratory tract infection (infection affecting the lungs) used in the facility. This failure had the potential for Resident 174 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 174's admission Record indicated Resident 1 was admitted on [DATE] with diagnoses including fracture of upper end of left humerus (broken left upper arm), chronic kidney disease (kidneys are damaged and unable to filter waste products and excess fluids from the blood) and chronic obstructive pulmonary disease ([COPD] group of diseases that cause airflow blockage in the lungs which can cause breathing related problems). During a review of Resident 174's Minimum Data Set ([MDS]- standardized screening tool) dated 11/1/2023, the MDS indicated the resident had moderate cognitive impairment (person had trouble remembering, learning new things, concentrating, and making decisions that affect their daily life) and required substantial (helper does more than half the effort) assistance with bed mobility, toilet hygiene and shower. ` During a review of Resident 174's McGeer Criteria for Infection Surveillance Checklist (guidelines used for initiation of antibiotic) indicated Resident 174 had a dry cough that started on 10/29/2023 but no other symptoms presented. The McGeer Criteria Checklist indicated there must be two criteria to fulfill for common cold or pharyngitis (inflammation of the back of the throat [pharynx]) for antibiotic use. During a review of Resident 174's Progress Notes dated 10/29/2023 timed at 3:36 p.m., indicated Resident 174 had non- productive cough (cough without phlegm) with no difficulty of breathing and congestion (excessive accumulation of body fluid like mucus or secretions). The Progress Notes indicated Resident 174 was notified of the non-productive cough and ordered chest x-ray (imaging test). During a review of Resident 174's Physician Orders dated 10/30/2023, timed at 10:15 a.m., indicated an order for Zithromax (antibiotic) 250 milligrams ([mgs] unit of measurement) two tablets by mouth one time only until 10/30/2023 and Zithromax 250 mgs. 1 tablet by mouth one time a day for cough for 4 days. During a review of Resident 174's chest x-ray result performed on 10/30/2023 at 1:21 p.m., the chest x-ray result indicated Resident 174's lungs were clear, and no acute pulmonary finding was present (no significant abnormalities or issues found in the lungs). During a concurrent interview and record review of Resident 174's Progress Notes on 11/3/2023, at 11:16 a.m. with RN Supervisor (RNS1), RNS 1 stated he informed Resident 174's physician the result of chest x-ray on 10/30/2023 at 2:00 p.m. RNS 1 stated he failed to mention to the physician Resident 174 was on Zithromax and asked if it will be continued after a negative chest x-ray (no significant abnormalities or issues found in the lungs). RNS 1 stated Resident 174 was still receiving Zithromax 250 mg one tablet for the cough once a day and the last dose was administered today (11/3/2023). During a review of Resident 174's Medication Administration Record (MAR) for month of October and November 2023, the MAR indicated Resident 174 received Zithromax 250 mg two tablets by mouth one time only for cough on 10/30/2023, and Zithromax 250 mg 1 tablet by mouth once a day for four days which was started on 10/31/2023. The MAR indicated the last dose of Zithromax was administered to the resident on 11/3/2023, at 9:00 a.m. During an interview and record review of Resident 174's McGeer Criteria Checklist on 11/3/2023, at 9:20 a.m. with Infection Preventionist Nurse (IPN), IPN stated she should have reviewed and monitored the use of antibiotic (Zithromax) on Resident 174. IPN stated she should have asked the physician if he wants to continue the Zithromax on Resident 174's cough because the chest x-ray result was normal and was not an appropriate use of antibiotic. IPN stated Resident 174 had the potential to develop antibiotic resistance. During a review of facility's Job Description of Infection Preventionist, the Job Description of an Infection Preventionist indicated the IPN will oversee the facility's antibiotic stewardship program and provide education related to infection prevention and control principles, policies, and procedures to staff, residents, and families. During a review of facility's policy and procedures (P/P) titled Antimicrobial Stewardship revised 3/2023, the P&P indicated the Infection Preventionist will be responsible for infection surveillance, will collect and review data about the type of antimicrobial was ordered and route of administration, ordering physician, whether appropriate tests were obtained before antimicrobial was ordered. The P/P indicated facility may consider protocols that address improvement of evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection.

1.Ensure one of three sampled residents (Resident 37) wheelchair's brakes was in operating condition. This failure had the potential to cause injury and fall to Resident 37 who used the wheelchair for mobility. 2. Ensure therapy equipment in the rehabilitation room were properly functioning, including one of one mechanical treatment mat (cushioned mat used in therapy that allows the therapist to customize the surface to different heights), one of one combination ultrasound (use of sound waves to penetrate soft tissues which increases blood flow) and electrical stimulation (use of mild electrical pulses through the skin to help stimulate injured muscles or manipulate nerves to reduce pain) combination machine. These failures had the potential to place residents receiving therapy services from safe and optimal use of the therapy equipment. Findings: 1.During a review of Resident 37's admission Record, indicated the Resident 37 was admitted on 7/1/2017 with diagnoses including dementia (group of symptoms affecting memory, thinking and social abilities that can interfere with daily life), diabetes (high blood sugar level), history of falling and osteoporosis (disease that weakens the bones). During a review of Resident 37's History and Physical (H&P) dated 3/31/2023, the H&P indicated Resident 37 had the capacity to understand and make decisions. During a review of Resident 37's Minimum Data Set ([MDS] standardized assessment and care screening tool) dated 10/6/2023, the MDS indicated Resident 37 used a manual wheelchair for mobility (ability to moved or be moved) and required supervision or touching (helper provides verbal cues or contact guard ) assistance with transfer and personal hygiene. During a concurrent observation and interview on 11/1/2023, at 1:40 p.m. with Resident 37, Resident 37 was sitting on her wheelchair eating her lunch and stated her wheelchair's brakes were not working. During a concurrent observation and interview on 11/1/2023, at 1:47 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 checked Resident 37's wheelchair brakes and stated the wheelchair was not in safe operating condition. CNA 1 stated Resident 37 wheelchair still moves when the brakes were put in locked position. CNA1 stated Resident 37's wheelchair brakes were not working for one week. CNA1 stated she had notified the Licensed Vocational Nurse 2 and Maintenance Supervisor regarding Resident 37's wheelchair brakes not working. CNA1 stated she should have not used the wheelchair on Resident 37 because Resident 37 can fall and get injured due to wheelchair brakes that would not lock. During an interview on 11/1/2023, at 2:03 p.m. with Licensed Vocation Nurse (LVN) 2, stated she was aware Resident 37's wheelchair brakes would not lock and had reported the issue to the Maintenance Supervisor (MS). LVN 2 stated facility should not use Resident 37 wheelchair because the brakes were not locking, and it could lead to fall and injury. During an interview on 11/1/2023, at 2:15 p.m. with MS, MS stated LVN 2 reported to him about the Resident 37's wheelchair but was not able to fix it because the Resident 37 was using the wheelchair during lunch. MS stated Resident 37 should not be using the wheelchair because the brakes would not lock which can lead to potential fall from the wheelchair. 2. During a concurrent observation and interview on 10/31/2023 at 9:31 am in the rehabilitation gym with the Director of Rehabilitation (DOR), there was one mechanical treatment mat in the room. The DOR stated the mechanical treatment mat used to have a controller to increase and decrease the height of the mat. The DOR stated the treatment mat had been broken for an unknown period of time. A combination ultrasound and electrical stimulation machine was located directly in front of the treatment mat. An inspection sticker on the machine indicated the last inspection date was on 2/2016 and a reinspection was due on 2/2017. The DOR stated the therapy staff have not used the machine in a while (unknown period of time). During a concurrent observation and interview on 11/1/2023 at 8:13 am in the rehabilitation gym with the DOR, the combination ultrasound and electrical stimulation machine was removed from the rehabilitation gym. The DOR stated the machine removed from the gym and was never inspected since the therapists did not use it. The DOR stated the mechanical treatment mat used to adjust higher and lower but stopped functioning. The DOR stated a resident could stand up easier if the treatment mat's height was adjustable. During an interview on 11/1/2023 at 9:35 am with the Maintenance Supervisor (MS), the MS stated the equipment in the rehabilitation room was checked monthly but did not keep a log. The MS found out yesterday (10/31/2023) that the therapy mat was not functioning but did not know prior since no one reported it to MS. The MS stated the combination ultrasound and electrical stimulation machine was not something MS would inspect. During a review of facility's policy and procedure (P/P) titled Equipment in Safe Operating Condition revised 3/2023, the P/P indicated the facility maintains mechanical, electrical, and patient care equipment in safe operating condition. The P/P indicated the facility will refer to the manufacturer's recommendations to maintain equipment in safe operating condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure one of 19 sampled residents (Resident 6) was provided a safe environment by not repairing the transition strip (strips that cover the gap between two different floor types) on Resident 6's bedroom floor. This failure had the potential to result in serious injury related to slips, trips and falls for Resident 6, staff, and visitors. Findings: During a review of Resident 6's admission Record, the admission Record indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses of but not limited to spinal stenosis (narrowing of the spinal canal in the part of the back), scoliosis (an abnormal curvature of the spine (backbone), osteoarthritis ( a type of degenerative joint disease that results from breakdown of joint tissue and the underlying bone), and low back pain. During a review of Resident 6's Minimum Data Set (MDS-a comprehensive assessment and care-planning tool), dated 10/5/2023, the MDS indicated, Resident 6 had the ability to make self understood and the ability to understand others. The MDS indicated Resident 6 required moderate assistance with toileting, showering, lower body dressing, putting on and taking off footwear. The MDs indicated Resident 6 required supervision with upper body dressing and oral hygiene. The MDS indicated Resident 6 needed setup and clean-up assistance with eating. During an observation on 10/31/2023 at 10:27 am, Resident 6 was in the hallway in a wheelchair participating in activities. Upon entry into Resident 6's room the surveyor tripped over the transition strip that was not secured in place on the floor in Resident 6's room. During an observation and interview on 10/31/2023 at 11:36 a.m. with Resident 6, a yellow caution sign that was placed over the loose transition strip, Resident 6 stated the only concern she had was the strip on the floor. Resident 6 stated she did not like things like that. During an observation on 10/31/2023 at 12:31 p.m. in Resident 6's room the caution sign was removed. During an observation and interview on 10/31/2023 at 1:24 p.m. with Resident 6, the black transition strip was removed from the floor. Resident 6 stated, she told the nursing staff that the floor does not look right, and something needed to be done about it. During an interview on 11/2/2023 at 9:19 a.m. with Registered Nurse (RN) 3, RN 3 stated, the transition strip was removed yesterday by the Director of staff Development (DSD). During an interview on 11/2/2023 at 9:22 am with the Maintenance Supervisor, the MS stated the transition strip on the floor got loose and was pulled up all the way and needed to have it re-glued. During an interview on 11/2/2023 at 9:26 a.m. with the DSD, the DSD stated Resident 6 called her to her room on 10/31/2023 in the morning holding the transition strip in her hand, the DSD stated she called the MS and gave the transition strip to him to repair. The DSD stated the transition strip is missing and that causes the floor to be uneven and the resident might trip. During a concurrent observation and interview on 11/2/2023 at 9:27 am with the MS, the MS was holding a roll of transition strips and glue. The MS stated he should have repaired the transition strip right away when he was told by the DSD, the transition strip needed to be repaired. The MS stated, the transition strip should have been repaired earlier this week. During a review of Resident 6's Care Plan, dated 7/13/2020, the Care Plan indicated, Resident 6 is a risk for major injury related to the history of repeated falls, and poor safety awareness. The Care Plan indicated, Resident 6 should have adequate lighting and to keep the environment free of slip and trip or fall hazards. During a review of Resident 6's Rehab-Post Fall Assessment form, dated 2/28/2023, the Rehab-Post Fall Assessment form indicated, Resident 6 fell in the bathroom. During a review of the facility's policy and procedure (P/P) titled, Preventative Maintenance Program, dated 2/2023, the P&P indicated, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff and the public. During a review of the facility's policy and procedure (P/P) titled, Safe Environment, dated 3/2023, the P&P indicated, Resident care areas and equipment shall be kept clean and in good repair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure: A. Dietary Aid (DA) 1 who worked as a cook to fill in the absences of the morning (AM) shift cook had an appropriate competencies and skills set to carry out the duties of a cook for four out of 70 total sampled residents in the facility by not: 1. providing a fortified (added vitamins and minerals that are not naturally present in those foods) diet for Resident 59. 2. providing mechanical soft diet (a diet that was designed for people who have trouble chewing and swallowing) for Resident 48 and Resident 9. This failure resulted in DA 1 not preparing and serving meals as ordered by the physician, to prevent unintended weight loss and accidents such as chocking and aspiration (when food or liquid enters the person's airway and eventually the lungs causing severe illness). Findings: 1. During a review of Resident 59's admission Record, the admission Record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses including but not limited to dysphagia (difficulty in swallowing), severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and dementia (a decline in cognitive abilities that impacts the ability to perform everyday activities). During a review of Resident 59's Minimum Data Set (MDS-a comprehensive assessment used as a care-planning tool), dated 10/20/2023, the MDS indicated, Resident 59 rarely had the ability to make self-understood and rarely had the ability to understand others. The MDs indicated, Resident 59 was dependent on staff for eating, oral hygiene, toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 59 required a mechanically altered therapeutic diet. During an observation on 10/31/2023, at 12:38 p.m., in the kitchen during tray line (a meal preparation method in which food trays travel around the production line), DA 1, who filled in during the absence of the morning shift cook, poured the miso soup (soup made from a kind of broth or stock, called dashi into which miso paste is dissolved) in a bowl for Resident 59 when DA 3 asked if it should be Super Soup (soup that is enriched with vitamins or minerals so that nutritional value is improved) for Resident 59's lunch tray. Dietary Service Supervisor (DSS) asked DA 1 if he cooked super soup, DA 1 replied he cooked miso soup only and he did not know if he supposed to cook another soup. DSS replied and stated miso soup was not the super soup. During a review of the facility's Noon Meal (lunch menu for regular diet), dated 10/31/2023, the Noon Meal menu indicated, miso soup, smothered steak with gravy, noodle [NAME], seared green beans, and a bread stick. During a review of the facility's Super Soup Recipe, revised 2022, the Super Soup Recipe indicated, prepare cream soup according to directions on can except use evaporated milk in place of water or regular milk, add margarine and heat to 165-degree Fahrenheit(F), stir until well mixed, serve six ounce per portion. During a review of Resident 59's Care Plan, revised on 10/25/2023, the Care Plan indicated, to give Resident 59 Super Soup (a high protein and high calorie soup made with any cream soup, evaporated milk, and margarine). During an interview on 11/3/2023, at 1:35 p.m., with Registered Dietitian (RD) via phone, RD stated, the cook should have checked the menu and recipes before preparing meals and cooked as it was written. RD stated the facility was having difficulty hiring kitchen staff and currently there was no back up cooks especially for morning shift. RD stated, it was important to provide fortified meals as ordered to prevent unintended weight loss. During a review of Resident 59's Order Summary Report, dated 11/1/2023, the Order Summary Report indicated, Resident 59 had an order for a low sodium diet, pureed (food prepared to have the consistency of a creamy paste) texture, and Super Soups with lunch. 2. During a review of Resident 48's admission Record, the admission Record indicated Resident 48 was admitted to the facility on [DATE] with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily life) , physical debility (loss of strength or increased frailty and weakness), pathological fracture (broken bones in an area already weakened by another disease, not by an injury), and congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should). During a review of Resident 48's H&P, dated 9/12/2023, the H&P indicated, Resident 48 had fluctuating capacity to understand and make decisions. During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 was totally dependent (full staff performance of each task, with no resident participation, every time) from two or more staff for toileting hygiene, shower/bath, lower body dressing, putting on/taking off footwear, moderate assistance (staff does less than half the effort) from one staff for personal hygiene, upper body dressing, and set up or clean- up assistance from one staff for eating. During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted on [DATE] with diagnoses that included dementia (loss of cognitive functioning such as thinking, remembering, and reasoning which can affect and interfere with daily life and activities), hypertension (high blood pressure) and osteoporosis (condition where bones become brittle and weak). During a review of Resident 9's MDS dated [DATE], the MDS indicated the resident had severe cognitive impairment (person had trouble remembering things, making decisions, concentrating, or learning) and required one person assist with eating, toilet use and personal hygiene. During an observation on 10/31/2023, at 1:00 p.m., in the kitchen during the tray line, DA 1 who filled in for the absence of the morning shift cook placed a big chunk of sliced steaks with gravy on Resident 48 and Resident 9's lunch tray. Resident 48's meal ticket indicated, mechanical soft/ground meat with thin liquid consistency and four ounces of health shake. Resident 9's meal ticket indicated, mechanical soft/ground meat with thin liquid consistency, no ham, no cheese, four ounces of health shake with meal. Dietary Service Supervisor (DSS) pointed out that both residents had order for mechanical soft/ground meat. DA 1 chopped more and placed them on each resident's plate. The meat on the plate was not ground. It was chopped in smaller pieces. DA 3 placed lunch trays for Resident 48 and Resident 9 into meal cart. During an interview on 10/31/2023, at 4:28 p.m., with DA 1, DA 1 stated, he did not attend the in-service (staff education session) on 9/27/2023 for dysphagia (difficulty swallowing) ground. During a review of the facility's In-service attendance record titled, Dysphagia Ground, dated 9/27/2023, the in-service attendance record indicated, DA 1's name, job title, signature, and shift was not documented. During an interview on 11/3/2023, at 1:35 p.m., with Registered Dietitian (RD) via phone, RD stated, the resident should be evaluated by a Speech-Language Pathologist ([SLP]-individual who provides professional services in the areas of communication and swallowing) to determine the level and type of texture when there was an order for mechanical soft diet. RD stated, Resident 48 and 9's meal order listing indicated ground meat. During an interview on 11/3/2023, at 3:00 p.m. with the Director of Nursing (DON), the DON stated, kitchen staff including the cook should be able to identify different types of diets including therapeutic diets and should have followed the written menu and recipe to provide meals as ordered by the physician. The DON stated, it was important to make sure that residents received appropriate diet as physician order to prevent choking or aspiration. During a review of Resident 48's Care Plan (CP), revised on 10/12/2021, the CP Problem indicated, Resident 48 was at risk for altered nutrition related to poorly fitting dentures and reported weight loss trend. The CP Intervention indicated, to provide a mechanical soft diet as ordered and monitor for signs and symptoms of dysphagia. During a concurrent observation and interview on 10/31/2023, at 1:30 p.m. observed Resident 9 spit food from her mouth after being fed by Certified Nursing Assistant (CNA) 1 with chopped meat during lunch time. Observed big chunks and cuts of meat, cut green beans, seaweed, rice and 2 sticks of garlic bread were in Resident 9's lunch tray. CNA 1 stated Resident 9 had missing teeth and the meat on the tray was not ground but chopped. During a review of Resident 9's meal ticket for lunch dated 10/31/2023, the meal ticket indicated Resident 9 's diet consistency was mechanical soft/ ground (diet that is texture- modified, foods can be pureed, finely chopped, blended or ground to make them smaller) with thin consistency for beverage. During a review of Resident 9's Physician Order, the Physician Order indicated the resident was on mechanical soft texture, thin liquid consistency, no ham, no cheese, fortified cereal at breakfast, fruit for lunch, dinner, and ice-cream at dinner. During a concurrent interview and record review of Resident 9's photograph of lunch plate on 10/31/2023 with [NAME] 2 (CK2), CK 2 stated for mechanical soft texture, the meat should be chopped to smaller pieces. During a review of the facility's Policy and Procedure (P/P) titled, HPSI Fortified/High Calorie Diet, revised 1/2022, the P/P indicated, Intended Use: This diet is used when additional amounts of protein and/or calories are needed. This diet is also used to help prevent weight loss and tissue wasting .Recommendations .2. This diet includes fortification of two menu items per day with ingredients such as evaporated milk, butter, and sugar. These recipes provide 16 grams of additional protein and approximately 750 additional calories per day .5. Fortified/high Calorie Menu recipes are designated by Super in the recipe book .Recipe #6318 super soup provides 252 calories with 7.9 grams of protein, 18 grams of fat, and 16 grams of carbohydrates (food consisting of or containing sugars, starch, or similar substances that can be broken down to release energy in the human body and make up one of the main nutritional food groups.) During a review of the facility's P/P) titled, Mechanically Altered/Texture Modified Diets, revised 1/2022, the P&P indicated, Intended Use: Mechanical altered foods are available for residents with chewing and/or swallowing problems. Chopped, or ground food is commonly called mechanical soft and is for the resident with chewing problems. The dysphagia textures are specifically for resident with swallowing problems. It is recommended that the SLP perform a screening procedure to determine which consistency should be ordered .five levels of mechanically altered foods: mechanical soft/ground (chewing issues), dysphagia diets (difficulty in swallowing), pureed, minced & moist, soft and bite sized. During a review of the facility's P/P titled, Mechanical Soft, revised 1/2022, the P&P indicated, Intended Use: To provide a nutritionally adequate diet that requires a reduced amount of mastication (chewing). Normally this order is for residents who have limited chewing ability and intact swallowing ability . Recommendations: All meat should be ground or chopped. Gravy or sauces should be added to moisten ground and chopped meats, poultry and fish for lubrication. During a review of facility's P/P titled Mechanical Soft revised 8/2023, the P&P indicated mechanical soft diet is used to provide a nutritionally adequate diet that requires a reduced amount of mastication (chewing) and it's ordered for residents who have limited chewing ability. The P&P indicated all meat should be ground or chopped as follows: Chopped: ¼ -1/2 pieces Chopped fine: 1/8 -1/4 pieces. During a review of facility's policy and procedure (P/P) titled, Job Description Cook, dated 2022, the P&P indicated, Job Summary: Prepares and/or pre-portions food for regular and therapeutic diets according to the planned menu and production sheets and as directed . Job Specific Duties .Follows correct procedure for adherence to information on patient profile card and menus. During a review of facility's P/P titled, Job Description Dietary Aid, dated 2022, the P&P indicated, Prepares, seasons and cooks food for the patients of the facility. Responsible for various tasks within the dietary department (such as kitchen clean up and maintenance, etc.). Must poses the required health, knowledge, and skills to assist in the preparation and service of assigned patient food items . Job Specific Duties .Prepares all food according to the menu in a safe, sanitary manner .Serve meal components properly including, but not limited to portions, textures, and substitutions in accordance to regular and therapeutic diet planning menus and adhering to patient's needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review the facility failed to ensure the written diet menu instructions were followed for two of 45 sampled residents (Resident 59 and Resident 171) when making soup for Resident 59 and failed to honor Resident 171's food preferences. This failure had the potential to result in weight loss for Resident 59 and Resident 171 by not receiving the nutrition they needed for a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietician as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, (e.g., sodium) or to increase specific nutrients in the diet (e.g., potassium), or to provide food the resident is able to eat (e.g., a mechanically altered diet (a diet in which the texture of a diet is altered). During a review of Resident 59's admission Record, the admission Record indicated, Resident 59 was admitted to the facility on [DATE] with diagnoses of but not limited to dysphagia (difficulty in swallowing), severe protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and dementia (a decline in cognitive abilities that impacts the ability to perform everyday activities). During a review of Resident 59's Minimum Data Set (MDS-a comprehensive assessment and care-planning tool), dated 10/20/2023, the MDS indicated Resident 59 rarely had the ability to make self-understood and rarely had the ability to understand others. The MDs indicated, Resident 59 was dependent on staff for eating, oral hygiene, toileting, showering, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS indicated Resident 59 required a mechanically altered therapeutic diet. During an observation on 10/31/2023, at 12:38 p.m., in the kitchen during tray line (a food preparation method in which food trays travel around the production line), Dietary Aid (DA)1, who filled in for absence of morning shift cook, poured the miso soup (It is made from a kind of broth or stock, called dashi into which miso paste is dissolved) in a bowl for Resident 59 when DA 3 asked Super Soup (soup that is enriched with vitamins or minerals so that nutritional value is improves)? for Resident 59's lunch tray. The Dietary Service Supervisor (DSS) asked DA 1 if he cooked super soup, DA 1 replied he cooked miso soup only and he did not know he was supposed to cook other soup. The DSS replied and stated miso soup was not the super soup. During a review of the facility's Noon Meal (lunch menu for regular diet), dated 10/31/2023, the Noon Meal indicated, miso soup, smothered steak with gravy, noodle [NAME], seared green beans, and a bread stick. During a review of the facility's Super Soup Recipe, revised 2022, the Super Soup Recipe indicate, prepare cream soup according to directions on can except use evaporated milk in place of water or regular milk, add margarine and heat to 165-degree Fahrenheit (F a unit of measure of temperature), stir until well mixed, serve six ounce per portion. During a review of Resident 59's Care Plan, revised on 10/25/2023, the Care Plan indicated, to give Resident 59 Super Soup (a high protein and high calorie soup made with any cream soup, evaporated milk, and margarine). During a concurrent observation, interview, and record review on 10/31/2023 at 1:15 p.m. with Certified Nurse Assistant (CNA) 2 at Resident 59's bedside, Resident 59 was served a lunch tray with soup. CNA 2 read the meal ticket and said this looks like miso soup and Resident 59 should have a fortified (having one or more ingredients added, as vitamins, mineral, etc. to increase nutritional value) soup. CNA 2 stated the treatment nurse is supposed to check the tray to make sure the resident is receiving the correct food according to the physician prescribed diet. CNA 2 went to the kitchen and stated now the kitchen is making chicken noodle soup for Resident 59. During an interview on 11/3/2023, at 1:35 p.m., with the Registered Dietitian (RD) via phone, the RD stated, the cook should have checked the menu and recipe before preparing the meal and cooked it as it was written. The RD stated the facility was having difficulty hiring kitchen staff and currently there was no back up cooks especially for the morning shift. RD stated, it was important to provide fortified meals as ordered to prevent unintended weight loss. During a review of Resident 59's Order Summary Report, dated 11/1/2023, the Order Summary Report indicated, Resident 59 had an order for a low sodium diet, pureed (food processed to have the consistency of a creamy paste) texture, and Super Soups with lunch. During a review of Resident 59's Nutritional Update form dated 10/17/2023, the Nutritional Update form indicated, Resident 59 was receiving a diet to treat his malnutrition that consisted of Super Soup with lunch. During a review of the facility's Policy and Procedure (P&P) titled, HPSI Fortified/High Calorie Diet, revised 1/2022, the P&P indicated, Intended Use: This diet is used when additional amounts of protein and/or calories are needed. This diet is also used to help prevent weight loss and tissue wasting .Recommendations .2. This diet includes fortification of two menu items per day with ingredients such as evaporated milk, butter, and sugar. These recipes provide 16 grams of additional protein and approximately 750 additional calories per day .5. Fortified/high Calorie Menu recipes are designated by Super in the recipe book .Recipe #6318 super soup provides 252 calories with 7.9 grams of protein, 18 grams of fat, and 16 grams of carbohydrates (food consisting of or containing sugars, starch, or similar substances that can be broken down to release energy in the human body and make up one of the main nutritional food groups.) During a review or Resident 171's admission Record, the admission Record indicated, Resident 171 was admitted to the facility originally on 8/1/2023 with diagnoses of but not limited to diabetes (high blood sugar), kidney disease (gradual loss of kidney function), lipid storage disorder (harmful amounts of fat that accumulate in some body cells and tissues), and constipation (bowel movements that are infrequent or hard to pass). During a review of Resident 171's MDS, dated [DATE], the MDS indicated, Resident 171 had the ability to make self-understood and had the ability to understand others. The MDs indicated, Resident 171 needed staff to provide set up and clean up assistance for eating. The MDS indicated, Resident 171 needed supervision assistance with oral hygiene. The MDS indicated, Resident 171 needed partial to moderate assistance with upper body dressing. The MDS indicated, Resident 171 needed the maximal assistance with showering, lower body dressing, and putting on and taking off footwear. The MDS indicated, Resident 171 was dependent on staff for toileting. The MDS indicated Resident 171 was provided a therapeutic diet while a resident at the facility. During a concurrent observation and interview on 10/31/2023 at 1:12 p.m. with the Restorative Nurse Aide (RNA) 1 in Resident 171's room, Resident 171 was served a thin liquid regular diet with broth. RNA 1 stated, the treatment nurse checks the meal trays to ensure the residents are getting the physician prescribed diets and Resident 171 is supposed to have chicken soup or potato soup. RNA 1 read Resident 171's meal ticket and stated, Resident 171 got miso soup. RNA 1 Left Resident 171's room and returned to Resident 171's room stating I got chicken noodle soup for Resident 171. During an interview on 11/3/2023, at 3:00 p.m., with the Director of Nursing (DON), the DON stated, the cook should have followed the written menu and recipe to provide meals as ordered. The DON stated, it was important to provide fortified and preferred meals to residents to improve their health and well-being. The DON stated, DSS should have assessed competency of DA 1 before preparing meals. During a record review of Resident 171's Care Plan undated, the Care Plan indicated, to honor Resident 171's food preferences. During a review of the facility's policy and procedure (P/P) titled, Therapeutic Diet, dated 3/2023, the P&P indicated, The facility ensures residents receive and consume food in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his or her goals and preferences. During a review of the facility's P/P titled, Food and Nutritional Services, dated 3/2023, the P&P indicated, The facility staff supports the nutritional well-being of the residents while respecting an individual's right to make choices about his or her diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide lunch at the facility's established mealtime on 10/31/2023, which included five of five meal carts leaving the kitchen at least 42 minutes late. This deficient practice caused one of 10 sampled residents (Resident 169) for dining observation to feel hungry. Findings: During a review of the facility's undated mealtimes and locations schedule, the facility mealtimes indicated lunch begins at 12:15 pm. During an interview on 10/31/2023 at 11:27 am with the Dietary Supervisor (DS), the DS stated lunch was served at 12:15 pm. During an observation on 10/31/2023 at 12:42 pm, the lunch trays had not come out of the kitchen. During a review of Resident 169's admission Record, indicated Resident 169 was admitted on [DATE] with diagnoses including fracture (break in the bone) of the neck of the right femur (near the hip bone), presence of a right artificial hip bone, and muscle weakness. During a review of Resident 169's Clinical admission Evaluation, dated 10/30/2023, Resident 169 was assessed as alert and oriented (awareness of self, place, time, and/or situation) with clear speech and understanding. During a concurrent observation and interview on 10/31/2023 at 12:54 pm with Resident 169 in Resident 169's bedroom, Resident 169 was lying in bed and stated feeling hungry due to not having any lunch. During an observation on 10/31/2023 at 12:57 pm, the first cart of lunch trays came out of the kitchen. On 10/31/2023 at 1:03 pm, the second cart of lunch trays came out of the kitchen. On 10/31/2023 at 1:23 pm the third cart of lunch trays came out of the kitchen. During an observation on 10/31/2023 at 1:43 pm, a bulletin board in front hallway indicated the mealtimes for the facility. The mealtime for lunch indicated the first lunch tray would leave the kitchen at 12:15 pm. During an interview on 10/31/2023 at 4:28 pm with the DS, stated the lunch trays were prepared and served late due to a kitchen staffing shortage. The DS stated the regular morning cook and dietary aide did not come into work today. The DS stated the dishwater had to cook both breakfast and lunch. The DS stated it was important for meals to be on time for the residents' health and nutrition.

Based on observation, interview, and record review, the facility failed to secure a handrail to the wall on 11/2/2023 and 11/3/2023. This failure had the potential to cause injury for residents who require the use of the handrail for balance and safety. Findings: During a concurrent observation and interview on 11/2/2023 at 2:13 pm, Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) 1 leaned against a hallway handrail which caused the handrail to move. RNA 1 stated the handrail moved after leaning against it. During an observation on 11/3/2023 at 7:38 am, the hallway handrail, which measured approximately 10 feet (unit of measure) long, was loose. There were seven support brackets (structural part securing the handrail to the wall) underneath the handrail. The handrail was not secured to four of the seven support brackets causing the handrail to be loose. During an interview on 11/3/2023 at 8:28 am with RNA 1, RNA 1 observed the handrail and stated it was not safe for residents because it was loose. RNA 1 stated the handrail should be reported to the charge nurse or to the Maintenance Supervisor (MS) directly. During an interview on 11/3/2023 at 8:41 am with the MS, the MS stated the loose handrails were just reported today (11/3/2023). The MS stated there were two broken screws and two loose screws underneath the handrail which were fixable. During a review of the facility's Policy and Procedure (P/P) titled, Secured Handrails, revised in 3/2023, the P/P indicated the facility had corridors (hallways) with firmly secured handrails affixed to the wall. The P/P further indicated the Environmental services department routinely evaluates facility handrails to ensure they are firmly affixed to the corridor walls. During a follow-up interview and policy review on 11/3/2023 at 10:00 am with the MS, the MS stated the handrails were not evaluated regularly and relied on the staff to report any problems. The MS reviewed the facility's P/P for secured handrails and was unaware that the handrails should be routinely checked.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms (an organism that can be seen only through a microscope) that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, disease causing bacteria, viruses, or parasites that contaminate food, as well as toxins) for 70 out 73 total residents in the facility by not: 1. ensuring Foods were dated, labeled, properly sealed, and discarded before the used by date (expiration dates). 2. monitoring and documenting the temperature for the facility's freezers. 3. maintaining a clean environment around the dumpsters outside. 4. monitoring and documenting sanitization bucket log. 5. ensuring Kitchen staff did not touch face, scratch nose and head, and touch doorknob of walk-in refrigerator while wearing their gloves used to prepare food and did not wash hands between changing their gloves during food handling and preparation. These failures had the potential to affect residents and result in pathogen (germ) exposure and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During an observation on 10/31/2023, at 8:45 a.m., in walk-in refrigerator 1 next to the freezers, there were food items that were not properly dated or labeled as follows: a. Nilla wafers in a plastic bag with open date of 10/15/2023 and no received-on date or use by date. b. Sweet coconut flakes in a plastic container with an open date of 6/13/2023, no received date or use by date. c. Mashed potatoes powder in a plastic container with open date of 10/28/2023, with no received-on date or used by date. d. Non-dairy powder in a plastic container with an open date of 10/25/2023, and no received-on date or use by date. e. Marshmallows in a zip lock bag with an open date of 10/19/2023, and no received-on date or use by date. f. Worcestershire sauce in plastic bottle with open date of 1/7/2023, and no received-on date or use by date. g. California Calrose rice 50 pounds bag with no received-on, opened on, or use by date. h. Red potatoes in a plastic container with half of them being rotten, and sprouted, and no received-on, or use by date. During an interview on 10/31/2023, at 9:00 a.m., with the Dietary Service Supervisor (DSS), at the kitchen, the DSS stated, all food items should have been labeled with received-on date when the facility got delivery from vendors. The DSS stated, all food items should have an open date and use by date (expiration date). DSS stated, it was the cook's responsibility to check all food items for labels, dates, and its freshness. The DSS stated, all expired items should have been discarded. The DSS stated, these practices were important to make sure all food items were in good condition because the residents consumed these food items. During an observation on 10/31/2023, at 9:09 a.m., in freezer 1 near the door, there were food items that were not properly sealed, labeled, and dated as follows: a. Unlabeled frozen tamales (per DSS) in a zip lock bag with open date of 1/25/2023 with no received-on date or use by date. b. Pork eggrolls in an open box, not properly sealed with no received-on date or use by date. c. A box of opened sausage patties that were not sealed with an open date of 10/27/2023 no received-on date or use by date. During an observation on 10/31/2023, at 9:18 a.m., in freezer 2 near the wall, there were food items that were not labeled and dated as follows: a. Eight bags of frozen peas (per DSS) in original packages were unlabeled and not dated. b. Five bags of frozen vegetable blends in original packages were unlabeled and not dated. During an observation on 10/31/2023, at 9:35 a.m., in walk-in refrigerator 2 close to the sink, there were food items that were not properly sealed, dated, or labeled or discarded as follows: a. Grated cheese in a plastic container with an open date of 10/17/2023 and no received-on date or use by date. b. An unlabeled block of cheese in plastic wrap with no label and dates. c. Sour cream in an original container with use by date of 10/9/2023 which was expired 22 days ago. d. Cottage cheese with open date of 10/3/2023 and used by date of 10/31/2023 without a received-on date. e. Kimchi in the plastic bottles, that were leaking onto the floor. The floor was sticky and had an odor. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, revised 3/2023, the P&P indicated, PURPOSE STATEMENT: When food. food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. During a review of the facility's undated P&P titled Refrigerator and Freezers (RAF), the P&P indicated, Policy Interpretation and Implementation .6. All food shall be appropriately dated to ensure proper rotation by expiration dates. '·Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Expiration dates on unopened food will be observed and use by dates indicated once food is opened. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. 7.Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturer when expiration dates are in question or to decipher codes. 2. During a review of the facility's Temperature Monitor Log for freezer 1 near the door, dated 10/2023, the Temperature Monitor Log indicated, there were no temperatures, times, and initials documented on 10/27/2023 night (PM)shift, 10/28/2023 afternoon shift, 10/28/2023 PM shift, 10/29/2023 morning (AM) shift, 10/29/2023 afternoon shift, 10/29/2023 PM shift, 10/30/2023 afternoon shift, 10/20/2023 PM shift, and 10/31/2023 AM shift. During a review of the facility's Temperature Monitor Log for freezer 2 near the wall, dated 10/2023, the Temperature Monitor Log indicated, there were no temperatures, times, and initials documented on 10/27/2023 night (PM)shift, 10/28/2023 afternoon shift, 10/28/2023 PM shift, 10/29/2023 morning (AM) shift, 10/29/2023 afternoon shift, 10/29/2023 PM shift, 10/30/2023 afternoon shift, 10/20/2023 PM shift, and 10/31/2023 AM shift. During an observation on 10/31/2023, 9:18 a.m., in the kitchen, the thermometer (an instrument for determining temperature) 1 which was hanging on the left side of the metal shelf inside of freezer 2 indicated a temperature of 18° Fahrenheit ([F]- a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees) and thermometer 2 which was hanging on the right side of the same metal shelve indicated 10° F. During an interview on 10/31/2023, at 9:25 a.m., with the DSS, the DSS stated, the Temperature Monitor Log was not filled out because the cook who was in charge of that had called in sick this morning (10/31/2023). The DSS stated, she was not sure about the other days because the cook should have filled the temperature log out. The DSS stated, she did not have any back up cooks to fill-in in the absence of assigned cooks and she asked Dietary Aid (DA) 1 to cook for breakfast and lunch today. During an interview on 10/31/2023, at 10:23 a.m., with the DSS, the DSS stated, kitchen staff did not calibrate (make fine adjustments or divide into marked intervals for optimal measuring) the thermometers for freezers. The DSS stated, she would just replace the thermometer with new one. The DSS stated, the cook should have documented the temperature for the freezers every shift. The DSS stated, it was important to monitor temperatures to ensure food safety (the conditions and practices that preserve the quality of food to prevent contamination and food-borne illnesses). During a review of the facility's Refrigerator and Freezers (RAF), undated, the RAF indicated, Policy Interpretation and Implementation: 1. Acceptable temperatures should be 35° F to 40° F for refrigerators and less than 0° F for freezers. 2.Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. 3.Dietary Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. 4.The supervisor or designated employee will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. 3. During a concurrent observation and interview on 10/31/2023, at 9:54 a.m., with the Maintenance Supervisor (MS), of the outside dumpster area, there were open trash bags inside of dumpsters and trash including food items were on the ground around the dumpsters. The MS stated, he cleaned the dumpster area daily and all trash bins were picked up twice a week. The MS stated, there was a squirrel that was messing with trash bags, but he could not do anything about it. MS stated, it was important to maintain a clean dumpster area to prevent attracting vermin (any of various small animals or insects that are pests). During an interview on 10/31/2023, at 10:31 a.m., with the Registered Dietitian (RD), the RD stated, it was important to maintain a clean environment and all food items fresh because it would directly affect residents' health. During a review of the facility's Position Description: Maintenance Supervisor (PD:MS), undated, the PD:MS indicated, Statement of Purpose .assure that the facility is maintained in a clean, safe, and sanitary manner .Specific Requirements . oMust maintain care and use of supplies, equipment, etc. and maintain the appearance of maintenance areas. 4. During a concurrent observation and interview on 10/31/2023, at 10:10 a.m., with DA 1, in the kitchen, there was a sanitizing bucket on the shelf near the outside door. The sanitizing bucket contained a solution with lots of bubbles formed on the top of the solution. DA 1 stated, he was not sure what kind of solution was in it and he was not sure where the log was kept. DA 1 placed the PH (quantitative measure of the acidity or basicity of aqueous or other liquid solutions) testing strip in the bucket and there was no color change on the strip. DA 1 stated, it should have changed color if the correct solution, was in there and he did not know what solution was in the bucket. During the review of the facility's P/P titled, Safe Food Preparation, revised 3/2023, the P&P indicated, Safe Food Preparation .3. b. Between uses, store towels/cloths used for wiping surfaces during the kitchen's daily operation in containers filled with sanitizing solution at the appropriate concentration per manufacturer's specifications. c. Assure that these sanitizing solutions are safe and do not have a risk of chemical contamination when preparing foods. Periodically testing the sanitizing solution helps assure that it maintains the correct concentration. 5. During an observation on 10/31/2023, at 12:19 p.m., in the kitchen during tray line (a food preparation method in which food trays travel around the production line), DA 1 put on gloves without washing hands first. DA 1 was adjusting his mask, scratched his nose and then touched the countertop without changing gloves or washing hands. DA 1 took the trash out of the kitchen and came back. DA 1 took off his gloves and put on new gloves without washing hands first. During an observation on 10/31/2023, at 1:00 p.m., during tray line, DA 1 was asking for help from DA 2. DA 2 put gloves on without washing hands. DA 2 grabbed the rusty doorknob of the walk-in refrigerator near the sink and took a small cup of liquid out of the refrigerator. Then she grabbed the doorknob to close the door. DA 2 placed the small cup on the tray and placed the tray in the lunch cart without changing gloves or washing hands. During an interview on 11/3/2023, with Director of Nursing (DON), in DON's office, DON stated, it was important to keep the kitchen and storage areas clean because it would affect the well-being of all the residents. DON stated, performing hand hygiene was the most effective way to prevent spreading of infection and cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another). During a review of the facility's policy and procedure(P/P) titled, Hand Washing-Hand Hygiene, revised 3/2023, the P&P indicated, POLICY STATEMENT: This facility considers hand hygiene the primary means to prevent the spread of infections. Procedure . 2. Personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. When indicated, employees must wash their hands for at least fifteen (20) seconds using antimicrobial or non-antimicrobial soap and water. During a review of facility's P/P titled, Job Description Cook, dated 2022, the P/P indicated, Job Summary: Prepares and/or pre-portions food for regular and therapeutic diets according to the planned menu and production sheets and as directed . Job Specific Duties . Maintains the proper temperature of food during preparation and service. Records food temperatures according to established policy. Sanitize dishes and service ware appropriately. Complete scheduled cleaning accurately and thoroughly. During a review of facility's P/P titled, Job Description Dietary Aid, dated 2022, the P&P indicated, Prepares, seasons and cooks food for the patients of the facility. Responsible for various tasks within the dietary department (such as kitchen clean up and maintenance, etc.). Must poses the required health, knowledge, and skills to assist in the preparation and service of assigned patient food items . Job Specific Duties . Prepares all food according to the menu in a safe, sanitary manner. Follows proper procedure for receiving food and supplies. Stores food and supplies following established procedures; including frozen, thawed, and cooked animal products . Label and date all food items in accordance to facility policies and procedures. During a review of facility's P/P titled, Glove Use-Personal Protective Equipment, dated 3/2023, the P&P indicated, Glove use in Dining Rooms . 3. If gloves become contaminated, the cook needs shall remove gloves, wash their hands, and apply a new glove(s) . 5. If gloves are worn when opening cabinets, bread wrappers, etc., gloves must be removed, HANDS WASHED, and new gloves applied before continuing to dish.

1.During an interview on 11/3/2023, at 3:47 p.m. with Maintenance Supervisor (MS), MS stated he had no log for checking the water for Legionella. MS stated he did not actually test the water in the facility for Legionella for the whole year. (2022-2023) During a subsequent interview on 11/3/2023, at 4:40 p.m. and 5:43 p.m. with Administrator (ADM), ADM stated MS would test the water for chlorine (chemical used for water treatment) and potential hydrogen ( pH-a measurement of how acidic or basic of a solution) and if there was any variation on chlorine level of the water that's when facility will performed water test for Legionella. The ADM stated facility had no logbook to track activities related to water testing. ADM stated MS was testing the pH of the drinking water. 2.During a concurrent observation and interview on 11/3/2023, at 5:43 p.m. with MS, stated he checked the chlorine level and pH level of the water dispensers located in the Rehabilitation Department and staff break room. MS stated he learned how to test water for Legionnaire's disease (water borne illness caused by contaminated water) thru online and use of google (internet search engine) and the Administrator would be notified if the pH of the water was above 8.5 pH level range between 6.5 to 8.5) and chlorine level above 3 according to what he had learned from google. MS stated he did not test the water in the kitchen for pH and chlorine level. During an interview on 11/3/2023, at 5:45 pm with Registered Nurse Supervisor (RNS 1), RNS 1 stated the water dispenser in the staff break room was intended for staff members use. During an interview on 11/3/2023, at 6:00 p.m. with Director of Rehabilitation (DOR), DOR stated the water dispenser in the Rehabilitation Department were used by residents and staff members. During a review of facility's policy and procedure (P/P) titled Legionella/Legionnaires Disease revised 10/2021, the P/P indicated The facility will describe the building water systems using text and flow diagrams, identify areas where legionella could grow and spread, document and communicate by keeping a log book with all the information such as control points, control measurements, date, by whom, temperatures, chlorine levels, meeting minutes of Water Management Team and visual inspection if needed. The P/P indicated the facility will test both for chlorine level and temperatures at the same time, ensures the water management program is running as designed and is effective. B. During a review of Resident 6's physician's orders, dated 5/23/2022, indicated for the Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) to perform assisted ambulation (the act of walking) with Resident 6 using the front wheeled walker (FWW, an assistive device with two front wheels used for stability when walking), five times per week as tolerated. During a review of Resident 7's physician's orders, dated 11/17/2022, indicated for the RNA to assist Resident 7 with sit to stand transfers (moving from a seated to standing position) using the side rails, five times per week as tolerated. During a review of Resident 1's physician's orders, dated 3/6/2023, indicated for the RNA to provide ambulation with Resident 1 using a FWW, five times per week as tolerated. During an observation on 10/31/2023 at 1:15 pm in the hallway, a multicolored gait belt hung from a FWW in the hallway. The gait belt was made of cloth material. During an observation on 11/1/2023 at 9:32 am in the hallway, Restorative Nursing Aide (RNA) 1 used sanitizing wipes to clean the multicolored cloth gait belt. RNA 1 placed the multicolored gait belt around Resident 6's waist prior to having Resident 6 walk down the hallway using the FWW. During an observation on 11/1/2023 at 9:39 am, RNA 1 removed the multicolored cloth gait belt from around Resident 6's waist and used sanitizing wipes to clean the cloth gait belt and the FWW. RNA 1 walked into Resident 1's room. RNA 1 placed the cloth gait belt around Resident 1's waist prior to having Resident 1 walk down the hallway using the FWW. On 11/1/2023 at 9:46 am, Resident 1 returned to the room. RNA 1 removed the cloth gait belt from Resident 1's waist and cleaned the cloth gait belt and FWW using the sanitizing wipes. During an observation on 11/2/2023 at 9:49 am, RNA 2 held a cloth gait belt which had R.N.A. printed on the gait belt with black marker. RNA 2 cleaned the cloth gait belt using sanitizing wipes. Resident 7 was fully dressed and seated in a wheelchair. RNA 2 wheeled Resident 7 into the hallway to perform sit to stand exercises along the hallway handrails. RNA 2 placed the cloth gait belt around Resident 7's waist. RNA 2 used the gait belt to assist Resident 7 from sitting in the wheelchair to standing at the hallway handrail. RNA 2 removed the cloth gait belt after Resident 7 performed six repetitions of sit to stand transfers. RNA 2 used sanitizing wipes to clean the cloth gait belt and the hallway handrail. During an interview on 11/2/2023 at 9:57 am with RNA 2, RNA 2 stated the cloth gait belt and handrails were cleaned using the sanitizing wipes before and after use. During a concurrent observation and interview on 11/2/2023 at 2:13 pm with RNA 1, RNA 1 stated the multicolored gait belt and FWW were cleaned using the sanitizing wipes before and after use. During a review of the manufacturer's recommendations for the sanitizing wipes, the recommendations indicated the sanitizing wipes disinfected and deodorized hard, nonporous surfaces (material which do not allow water to flow through them, examples include stainless steel, metal, glass, and hard plastic). During a concurrent observation, interview, and review of manufacturer's recommendations on 11/3/2023 at 7:56 am with the Infection Preventionist Nurse (IPN) in the RNA room, the IPN observed both RNA gait belts and stated they were made of cloth material. The IPN stated the RNAs used the sanitizing wipes to clean the gait belts and provided a demonstration of cleaning. The IPN read the manufacturer's recommendations for the sanitizing wipes which included use on hard, nonporous surfaces. The IPN stated using the sanitizing wipes should not be used on the gait belts, which were made of cloth. The IPN stated the gait belts should be laundered after every use to prevent the spread of any infection. During a review of the facility's Policy and Procedure (P/P) titled, Cleaning and Disinfection of Resident Care Items and Equipment, revised on 3/2023, the P/P indicated Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Based on observation,interview, and record review the facility failed to: A. Follow their own policy and procedures (P/Ps) titled, Glove Use - Personal Protective Equipment, and Hand Washing - Hand Hygiene to ensure licensed nurses wash or sanitized their hands after removing gloves and before putting on a new pair of gloves. This deficient practice had the potential to expose one out of four residents (Resident 270) to contaminants and infection. B. Clean two of two cloth gait belts (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) in accordance with the manufacturer's recommendations for sanitizing wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces) in-between residents' use with three of 19 sampled residents (Resident 1, 6, and 7). This failure had the potential to result in the spread of disease throughout the facility. C. Follow their policy and procedure on preventing the growth of Legionella (bacteria that causes a type of serious lung infection and are naturally found in the water) and water borne infections in the facility by: 1. Failing to document and keep a log of information related to all activities that will reduce the risk of Legionella disease. 2. Failing to identify areas where legionella can grow and spread in the facility. This failure had the potential to place resident at risk for waterborne disease (illnesses caused by microorganisms in an untreated or contaminated water). Findings: A. During an observation on 11/1/23 at 10:13 am, with a Licensed Vocational Nurse (LVN 1) on Station 2, during medication pass (MedPass), LVN 1 administered the prepared medication to Resident 270 through the gastrostomy tube ([G-Tube], a tube inserted through the belly that brings nutrition and medication directly to the stomach). Afterwards LVN 1 removed her gloves and put on a new pair of gloves without washing or sanitizing her hands and administered a prescribed eye drop, (Dorzolamide Hydrochloride [HCL], a medication used to treat high pressure inside the eye due to glaucoma) into Resident 270's eye. During an interview on 11/1/23 at 11:17 am, with a Registered Nurse Supervisor (RNS 4) on Nursing Station 3, RNS 4 stated, licensed nurses must perform hand washing (using soap and water to remove germs from hands) or sanitize (a substance for making your hands clean and free from bacteria or viruses [e.g., an alcohol-based hand rub]) their hands before and after removing gloves as a form of infection control. RNS 4 stated without sanitizing the hands increases the potential for passing bacteria that may have come in contact with the nurse's hands on to residents which may lead to infections. During an interview on 11/1/23 at 11:34 am, with LVN 1, LVN 1 stated, that she did not sanitize her hands before putting on a new pair of gloves to administer the eye drops into Resident 270's eye, and she should have. During an interview on 11/2/23 at 10:06 am with the Director of Nursing (DON), DON stated, licensed nurses must sanitize their hands before putting on gloves and between glove changes to prevent the spread of infection. During a review of the facility's P/P titled, Glove Use - Personal Protective Equipment, dated 3/23, the P&P indicated, The facility uses gloves to reduce the spread of contaminants and for the protection of employees and residents . Employees shall perform hand hygiene after removal of gloves. During a review of the facility's P/P titled, Hand Washing - Hand Hygiene , dated 3/23, the P&P indicated, Personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure call light was within easy reach for one of three sampled residents (Resident 41). This deficient practice could potentially cause Resident 41 feeling frustrated, neglected, leading to falls and injury. Findings: A review of Resident 41's admission Record (face sheet ) indicated Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnoses include dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbance, diabetes mellitus (high blood sugar level), hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), urinary incontinence (means a person leaks urine by accident). A review of Resident 41's Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 9/20/22 indicated Resident 41 had moderate cognitive (ability to learn, understand, and make decisions) impairment and required limited assistance for transfer and extensive assistance for toilet use, dressing, and personal hygiene. A review of Resident 41's Care Plan (CP) dated 7/18/22, Resident 41 had ADL (activities of daily living) self-care performance deficit related to age debility, dementia, glaucoma (group of eye conditions that can cause blindness) history of falls and history of transient ischemic attack (stroke) and resident requires assistance for toilet use and transfer. During an observation on 11/1/2022 at 11:09 a.m., in Resident 41 room, observed Resident 41's call light was on the floor, was not accessible to the resident and not within reach. During an observation on 11/2/2022 at 9:26 a.m., in Resident 41 room, observed Resident 41's call light was on the floor, was not accessible to the resident and not within reach. During an observation on 11/2/2022 at 9:53 a.m., in Resident 41 room, observed Resident 41's call light was on the floor, was not accessible to the resident and not within reach. During an observation on 11/2/2022 at 10:28 a.m., in Resident 41 room, observed Resident 41's call light was on the floor, was not accessible to the resident and not within reach. During an observation on 11/2/2022 at 10:51 a.m., in Resident 41 room, observed Resident 41's call light was on the floor, was not accessible to the resident and not within reach. During an interview on 11/3/2022 at 9:24 a.m., with certified nursing assistant (CNA) 3, CNA 3 stated, when a resident cannot reach the call light button to call for help, resident can fall and potential for injury. CNA 3 stated if resident cannot reach the call light button, resident had the potential to feel less of a person because the resident does not have control to ask for help, this had a potential to lead to depression, anxiety and restlessness. During an interview on 11/04/2022 at 12:43 p.m., with licensed vocational nurse (LVN) 2, LVN 2 stated, if Resident 41 call light button was not easily accessible, resident cannot call staff for help when needed, and had the potential to affect resident psychosocial wellbeing, and resident might get up and fall. During an interview on 11/14/2022 at 12:51 p.m., with LVN 3, LVN 3 stated, if Resident 41 cannot reach the call light button, resident can get frustrated. Resident can get up and had the potential for fall and injury. During a review of facility's policy and procedure (P&P) titled, Resident Call System dated June 2016, the P&P indicated, The facility is adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from the resident's bedside, floor, or toileting facilities. To provide staff a method to respond to the resident's requests and needs. Resident all system shall be accessible to residents while in their bed of other sleeping accommodations within the residents' room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an individualized, comprehensive, resident-centered plan of care with measurable objectives, timeframes, and interventions to meet the residents needs for one of three sampled residents (Resident 7) who had an indwelling catheter (catheter drains urine from your bladder into a bag outside your body). This failure had the potential to result in the delay of nursing care and placed the resident at risk for urinary tract infections ([UTI] infection in any part of the urinary system) and urinary complications. Findings: During a review of Resident 7's admission Record (face sheet), the face sheet indicated Resident 7 was admitted to the facility on [DATE] with diagnoses of but not limited to spinal stenosis (a condition where the spinal column narrows and compresses the spinal cord), paraplegia (paralysis of the legs and lower body, caused by spinal injury or diseases), and retention of urine (a condition where the bladder does not empty all the way or at all when urinating). During a review of Resident 7's History and Physical (H&P), dated 10/3/22, the H&P indicated, Resident 7 does not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/11/2022, the MDS indicated Resident 7 had difficulty communicating some words or finishing thoughts but was able if prompted or given time. The MDS indicated, Resident 7 needed extensive assistance with bed mobility, transfer, and personal hygiene, was totally dependent on staff for toilet use and locomotion on and off the unit. The MDS indicated, Resident 7 required supervision from staff for eating. The MDS further indicated Resident 7 had an indwelling urinary catheter. During a concurrent interview and record review on 11/3/22 at 2:33 p.m., with the Registered Nurse Supervisor (RNS), RNS stated Resident 7 does not have care plan for foley catheter (rubber tube that is inserted into the bladder to drain the urine) care. RNS stated it was the responsibility of charge nurse, MDS nurse, licensed vocational nurse, registered nurse supervisors, and whoever admits the resident to the facility, to initiate, update and revise Resident 7's care plan. RNS stated Resident 7 care plan for indwelling foley catheter should be initiated upon Resident 7's admission to the facility on 9/29/2022, to monitor her urine output for excessive sediments (particles in the urine) and hematuria (blood in the urine). During an interview on 11/3/2022 at 4:15 p.m., with the MDS nurse, MDS nurse stated the admitting nurse was responsible for initiating the Resident 7's care plan. MDS nurse stated it was important to have a care plan for Resident 7, to ensure appropriate care will be given to resident. MDS nurse stated, is care plan was not initiated admission, resident care could be missed or not done. During a review of the facility's policy and procedure (P&P) titled, Develop Implement Comprehensive Care Plans, revised October 2022, the P&P indicated, The facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care plans shall describe the resident's needs and preferences and how the facility will assist in meeting these needs and preferences. Care plans shall include the discipline providing care or services, measurable objectives, and timeframes to evaluate the resident's progress toward his/her goal(s). During a review of the facility's policy and procedure (P&P) titled, Incontinence Care-Catheter Use, revised October 2021, the P&P indicated, The care plan will reflect the resident/resident representative education provided, including interventions to restore as much urinary function as possible without the use of catheter, recognizing and assessing for complications and their causes, maintaining a record of any catheter-related problems attempts to remove the catheter as soon as possible when no indications exist for its continuing use, and monitoring for excessive post void residual after removing a catheter that was inserted for obstruction or overflow incontinence, keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter and securing the catheter to facilitate flow of urine, preventing kinking of the tubing and position below the level of the bladder as applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure one of four sampled residents (Resident 3) who was assessed as high risk to develop pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) received an appropriate assessment and that changes in condition are recognized, evaluated, addressed, and reported to the practitioner, physician, and family. This deficient practice resulted in Resident 3 developing skin breakdown and delay in necessary treatment and services for Resident 3. Findings: A review of Resident 3's admission Record (face sheet) indicated Resident 3 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 3's diagnoses include heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), diabetes mellitus (high blood sugar level), dysphagia (difficulty of swallowing), hemiplegia and hemiparesis (loss of strength in the arm, leg, and sometimes face on one side of the body) and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Resident 3's Minimum Data Set (MDS- a comprehensive assessment and care planning tool) dated 8/11/22 indicated Resident 3 had severe cognitive (ability to learn, understand, and make decisions) impairment and required total dependence for transfer, toilet use, dressing, and personal hygiene. A review of Resident 3's Care Plan (CP) revised on 2/11/22, CP indicated, Resident 3 was high risk for development of pressure injury due to immobility, incontinence, DM II and history of pressure injuries and resident requires total assistance for toilet use and personal hygiene. CP interventions includes: to inspect for any skin breakdown and notify medical doctor (MD), moisturize dry skin areas with lotions and creams as needed, keep clean and dry, monitor skin areas for signs and symptoms of skin breakdown, reposition in bed/chair as needed, use pressure reducing device in chair, use pressure reducing device in bed. During a concurrent observation and interview on 11/1/2022 at 10:26 a.m., in Resident 3 room, Resident 3 was observed lying on her bed, confused. Resident 3 was not able to answer questions coherently. Resident 3 complained of pain in her lower back and verbalized Mama I need help. During an observation on 11/2/2022 at 10:10 a.m., in Resident 3 room, observed Resident 3 had open sore in the lower coccyx area (tailbone). During an interview on 11/2/2022 at 12:09 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, she was not aware of Resident 3's pressure ulcer. LVN 3 stated, assigned staff to Resident 3 on 11/1/2022 failed to report Resident 3's pressure ulcer. LVN 3 stated she called Resident 3 medical doctor and started a change of condition ([COC] a communication tool used among healthcare professionals) document on 11/2/2022. LVN 3 stated Resident 3 received treatment in the past that helps prevents skin breakdown. LVN 3 stated, Resident 3's pressure ulcer could have developed on 11/1/2022, because Resident 3 stays in bed most of the time and requires total assistance with ADL's. LVN 3 stated when Resident 3 was soaked with urine or feces, Resident 3 had the potential for her skin to break and can lead to re-opening of Resident 3's healed pressure sore. During a concurrent interview and record review on 11/3/2022 at 10:27 a.m., with LVN 3, LVN 3 stated, if Resident 3's skin breakdown was reported to her attention in a timely manner, the facility could have started the wound treatment to Resident 3 right away by calling the medical doctor promptly to obtained proper wound treatment. Resident 3's physician order indicated, the wound treatment for pressure sore in coccyx area was discontinued on 3/11/22. LVN 3 stated failure to report Resident 3's skin breakdown and obtain necessary treatment in a timely manner resulted in Resident 3 suffering for pain and affects her quality of care. During a review of facility's policy and procedure (P&P) titled, Skin Assessment revised December 2020, indicated, To provide guidelines for routine assessment of residents' skin to maintain skin integrity and promote healing in accordance with standard of care practice guidelines. The sacrum and heels should be inspected for pressure related concerns and are the area of greatest vulnerability. The licensed nurse completes routine monitoring of the resident's existing and potential risk factor for developing a pressure injury through completion of a weekly assessment. The skin assessment should include an evaluation of the skin integrity and tissue tolerance (ability of the skin and its supporting structures to endure the effects of pressure without adverse effects) after pressure to that area has been reduced or redistributed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 15) menus met nutritional needs and preferences reflecting ethnic and cultural needs of the resident population. This deficient practice had the potential to result in weight loss due to an inadequate caloric intake because of a lack of preferred cultural food choices. Findings: During a review of nursing diet order, dated 7/26/2022, nursing diet order indicated, 28 residents had diet order for Korean food and 21 residents had diet order for American food. During a review of Resident 15's admission Record (face sheet), the face sheet indicated Resident 15 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissue) and diabetes mellitus (a disease that body does not control the amount of sugar in the blood). During a review of Resident 15's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/21/2022, indicated Resident 15's cognitive (relating to the process of acquiring knowledge and understanding) status and decision-making skills were intact. The MDS indicated Resident 52 required no assistance and was independent for moving in bed, transfer, walking, and eating. During an interview on 11/1/2022, at 9:44 a.m., with Resident 15, Resident 15 stated, when Korean food were requested, the facility only serves rice, seaweed, and kimchi and wishes the facility had more of a variety of Korean food. Resident 15 got tired of eating same items all the time. During an observation on 11/2/2022, at 1:00 p.m., in Resident 15's room, Resident 15's meal ticket indicated, Asian Carb Controlled Regular Diet. A cheese sandwich, steamed cabbage, rice, and a small bowl of fruit were on the tray. Resident 15 was very upset and asked Certified Nurse Assistant (CNA) 3 to bring some Korean food items. CNA 3 brought two packs of seaweed. Resident 15 stated, I'd rather not eat food and just starve! During a phone interview on 11/ 3/2022, at 8:25 a.m., with Registered Dietitian (RD) 1, RD 1 stated, the facility's planned menus were made quarterly and revised as needed, at least monthly. RD 1 stated, the majority of the residents in the facility are Asian, especially Koreans. RD 1 stated, the Korean food items in the facility are rice, seaweed, and kimchi because RD 1 was not familiar with any other items. RD 1 stated, menus were pre-determined and fixed, and not picked by the residents. During a review of weight and vital signs, dated 7/ 11/2022 to 10/ 3/2022, the weight record indicated, Resident 15's weight was 168 pounds ([lb.] unit of weight) on 7/11/2022 and 162 pounds on 10/ 3/2022 with a weight loss of 3.57 percent (%) (5 pounds weight loss) in nearly three months. During a review of quarterly menu, dated 9/2022 to 12/ 2022, indicated mostly American food items with few Asian food items on the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided a therapeutic diet (consistent carb diet) as ordered by the physician for one of three sample residents (Resident 52). This deficient practice had the potential for Resident 52 not receiving benefit of the therapeutic diet (a meal plan that controls the intake of certain foods or nutrients) and controlling blood sugar. Findings: During a review of Resident 52's admission Record (face sheet), the face sheet indicated Resident 52 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (a disease that body does not control the amount of sugar in the blood) and chronic kidney disease (a disease that kidneys are damaged and can't filter blood the way they should slowly over a long period of time). During a review of Resident 52's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/15/2022, indicated Resident 52's cognitive (relating to the process of acquiring knowledge and understanding) status and decision-making skills were moderately impaired with short term memory loss. The MDS indicated Resident 52 required supervision from the staff for eating. During an observation on 11/1/2022, at 10:58 a.m., in Resident 52's room, Resident 52's meal ticket indicated Consistent Carb Diet (a diet that keeps carbohydrate consumption at a steady level, through every meal and snack to prevents blood sugar spikes or falls) with double portion. During an observation on 11/1/2022, at 1:15 p.m., in Resident 52's room, there were two hotdogs with buns and two scoops of rice with steamed carrots for Resident 52's lunch tray. The meal ticket indicated consistent carb diet with double portion. During an interview on 11/2/2022, at 10:00 a.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated, Resident 52 should not be on double portion because the doctor's order did not indicate double portion. Resident 52's blood sugar was over 200's milligram per deciliter ([mg/dl] unit of measure) in the daytime. During a review of the order summary report, dated 11/3/2022, the order summary report indicated, consistent carbohydrate diet, mechanical soft texture, thin liquid consistency ordered on 11/22/2021 by the physician. There was no double portion ordered by the physician. During a review of the blood sugar summary, dated from 11/2/2022 to 11/8/2022, the blood sugar summary indicated, Resident 52's blood sugar range from 72 mg/dl to 298 mg/dl, values over 120 indicate hyperglycemia (an excess of glucose in the bloodstream). During an interview on 11/4/ 2022, at 10:26 a.m., with Registered Dietitian (RD) 1, RD 1 stated, the portion sizes were depending on resident's preference not by physician's order. RD 1 stated double portion was not proper for the resident with diabetes. RD 1 stated, there was no physician order for double portion for Resident 52. During a phone interview on 11/4/2022, at 10:41 a.m., with RD 2, RD 2 stated, the double portion for a diabetic resident with uncontrolled blood sugar levels was not appropriate. RD 2 stated double portion was provided based on the resident's preference. RD 2 stated, there was no physician order for double portion for Resident 52. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diet, dated November 2020, indicated, The facility ensures residents receive and consume foods in the appropriate form and /or the appropriate nutritive content as prescribed by a physician, and /or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his/her goals and preferences. During a review of undated dietary manual for Carbohydrate-Modified Diet (Consistent Carbohydrate-CCHO) indicated, The diet provides a consistent-carbohydrate meal plan to provide appropriate energy to maintain desirable body weight and to improve overall glycemic control (typical levels of blood sugar) for residents with diabetes. Given the primary predictor of glycemic response was the total amount of carbohydrate consumed, the CCHO 1800 diet order will be provided to residents who require 1800 calories (+/-200 calories) to maintain nutritional status using 4-5 carbohydrate exchanges per meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure information on how to file a grievance or complaint was made available to three of three sampled residents (Resident 15, 40, and 42). This deficient practice resulted in Residents 15, 40 and 42 unable to exercise his or her right to file grievance. Findings: During an interview on 11/2/2022, at 10:43 a.m., with Resident 40 and 42 during the resident council meeting, Resident 40 and 42 stated, they did not know how to file grievance and did not get the information regarding how to file grievance from the staff. During an interview on 11/2/2022, at 12:00 p.m., with Resident 42 in a hallway, Resident 42 stated, he did not get any information regarding how to file grievance during resident council meeting and did not really understand what grievance was. During a review of Resident 40's admission Record (face sheet), the face sheet indicated Resident 40 was admitted to the facility on [DATE], with diagnoses that included dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and history of falling. During a review of Resident 40's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/7/2022, indicated, Resident 40's cognitive (relating to the process of acquiring knowledge and understanding) status and decision-making skills were intact. The MDS indicated Resident 40 required extensive assistance from one staff for bed mobility, transfer, walking, dressing, supervision from one staff for eating, total dependence from one staff for toilet use, and limited assistance from one staff for personal hygiene. During a review of Resident 42's admission Record (face sheet), the face sheet indicated Resident 42 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissue) and diabetes mellitus (a disease that body does not control the amount of sugar in the blood). During a review of Resident 42's MDS, dated [DATE], indicated Resident 42's cognitive status and decision-making skills were intact. The MDS indicated Resident 42 required extensive assistance from one staff for bed mobility, transfer, walking, dressing, toilet use, personal hygiene, and supervision from one staff for eating. During an interview on 11/ 2/2022, at 12:14 p.m., with Social Service Director (SSD) in conference room, SSD stated, there was no systemic process to inform or to educate the residents regarding how to file grievance and to validate if the residents understood the filing process. SSD stated the facility attempted to give information during the resident council meeting and daily rounding with residents, but SSD was not sure how to inform, or how to ensure majority of the residents got informed regarding how to file grievance. SSD stated, residents should know how to file grievance to exercise their rights. During an interview on 11/3/2022, at 9:07 a.m., with Administrator (Admin) in conference room, Admin stated, he was not aware of residents' lack of knowledge regarding how to file a grievance because he was told by facility staff in resident council meeting that they went over how to file a grievance many times. Admin stated, Admin was not sure how to validate the residents' understanding of the grievance filing process. During an interview on 11/ 3/ 2022, at 9:26 a.m., with Resident 40 in Resident 40's room, Resident 40 stated, she did not recall if the staff ever mentioned about how to file a grievance during the resident council meeting. Resident 40 stated, she does know how to file a grievance, and nobody told her the process. During an observation on 11/3/2022, at 11:40 a.m., at nursing station 2, there was no grievance form accessible to residents. During a review of Resident 15's admission Record (face sheet), the face sheet indicated Resident 15 was admitted to the facility on [DATE], with diagnoses that included cerebral infarction (a loss of blood flow to part of the brain, which damages brain tissue) and diabetes mellitus (a disease that body does not control the amount of sugar in the blood). During a review of Resident 15's MDS dated [DATE], indicated Resident 15's cognitive (relating to the process of acquiring knowledge and understanding) status and decision-making skills were intact. The MDS indicated Resident 15 required no assistance and independent for moving in bed, transfer, walking, eating, and required supervision from one staff for dressing, toilet use, and personal hygiene. During an interview on 11/4/2022, at 3:00 p.m., with Resident 15 in Resident 15's room, Resident 15 stated, the facility staff did not tell him about how to file a grievance neither in English nor in Korean. During a review of the facility's Policy and Procedure (P&P) titled, Grievance Policy, dated 2/2017, indicated, The facility will notify residents through postings in prominent locations throughout the facility of the right to, and how to file grievances or complaints orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the Grievance Official with whom a grievance can be filed; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, State survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system. During a review of the facility's Policy and Procedure (P&P) titled, Grievance Policy, dated 2/2017, there was no information regarding who the grievance official was and where to contact for the facility in P&P of Grievance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure it was free of medication error rate of five percent or greater as evidenced by four out of 26 opportunities for error to yield medication error of 15.38 percent (%) for three out of five sample residents (Resident 115, Resident 16, and Resident 11). a. Facility failed to flush the gastrostomy tube ([G-tube] tube inserted through the belly that brings nutrition directly to the stomach) after each medication administration (Resident 115). b. Facility failed to flush the G-tube after each medication administration and follow and administer Omeprazole capsule delayed release (medication that treat certain conditions where there is too much acid in the stomach) 20 milligrams ([mg] unit of weight) according to manufacture specification (Resident 16). c. Facility failed to administer Potassium Chloride Extended Release (medication to treat and prevent low blood potassium )20 milliequivalent (mEq) with adequate fluid (Resident 11). These deficient practices had the potential to place Resident 115 and Resident 16 at risk for potential complications of G-tube and adverse reactions with medications and placing Resident 11 at risk for gastrointestinal issues and dehydration. Findings: a. A review of the admission Record indicated that Resident 115 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including metabolic encephalopathy (chemical imbalance in brain), severe protein-calorie malnutrition (when a person doesn't eat enough protein and calories to meet nutritional needs), dysphagia (difficulty swallowing), vascular dementia (issue with reasoning and thought process), hypertension (high blood pressure), dementia (progress loss of memory), and adult failure to thrive (arrested physical growth ). A review of the Minimum Data Set (MDS) a standardized assessment tool, dated 8/8/2022 indicated Resident 115 does not have the mental capacity to make decisions for self. Resident 115 was totally dependent on staff for all activities of daily living (ADL) (activities related to personal care). Resident 115 has a feeding tube (gastrostomy tube[G-Tube]) to aid with nutritional support due to the inability to swallow. During an observation on 11/3/2022 at 8:23 a.m., with Licensed Vocational Nurse (LVN) 2 assigned to medication cart station 2, observed LVN 2 prepared the following four medications to administer to Resident 115 through a G-tube: 1.Colace Capsule 100 milligram (mg) (Docusate Sodium) (stool softener) 100 milligram (mg): one (1) tablet via G-tube two times a day for bowel management/stool softener. 2.Multi Vitamin with minerals: one (1) tablet via G-tube one time a day for supplement (supporting body with lacking vitamins). 3.Vitamin C 500 mg (Ascorbic Acid): one (1) tablet via G-tube one time a day for supplement. 4.Zinc Sulfate Tablet 220 (50 Zn (zinc)) mg one (1) tablet via G-tube one time a day for supplement LVN 2 was observed preparing the medications in separate medication cups as well as crushing the medications one by one. Water was added to each medication cup and was mixed. Observed LVN 2 administered the second medication without flushing Resident 115's G-tube with water after the first medication was administered. b. A review of the admission Record indicated that Resident 16 was admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including severe protein-calorie malnutrition, dysphagia (difficulty swallowing), gastrointestinal hemorrhage (type of bleeding in digestive tract), hypertension (high blood pressure), type II diabetes mellitus (group of disease that result in too much sugar in the blood), dementia, hemiplegia (one sided paralysis), and cerebrovascular disease (group of condition affection blood flow to brain). A review of the Minimum Data Set (MDS), a standardized assessment tool, dated 8/12/2022 indicated Resident 16 does not have the mental capacity to make decisions for self. Resident 16 was totally dependent on staff for all activities of daily living (ADL) (activities related to personal care). Resident 16 has G-tube to aid with nutritional support due to the inability to swallow. A review of the Physician's Order Summary Report for Resident 16 on 5/30/2022, indicated an order for Omeprazole (help decrease stomach acid) capsule delayed release 40 mg with instructions to open capsule then dissolve in water for at least 20 minutes then administer via G-tube. Physician order on 10/10/2022 indicated Omeprazole capsule delayed release 20 mg: give one (1) capsule via G-tube one time a day for gastrointestinal prophylaxis (preventive measurement). The physician order on 10/10/2022, had no clear instructions on how to administer the Omeprazole capsule through a G-tube. A review of Resident 16's care plan, dated 3/31/2022, the care plan indicated Resident 16 requires tube feeding, intervention/task includes: allowed medication to be crushed and administer via G-tube as ordered with water flush five (5) to10 cubic centimeter (cc) as recommended. During an observation on 11/3/2022 at 9:23 a.m., with LVN 2 assigned to medication cart station 2, LVN 2 was observed preparing the following seven medications to administer to Resident 16 through a G-tube. 1.Docusate Sodium tablet 100 mg: 1 tablet via G-tube two times a day for constipation (difficulty emptying bowel) 2.Memantine HCL (Hydrochloride) (help treat severe confusion) tablet 10 mg: 1 tablet via G-tube two times a day for dementia 3.Multi Vitamin with minerals: 1 tablet via G-tube one time a day for supplement (supporting body with lacking vitamins) 4.Omeprazole capsule delayed release 20mg: 1 capsule via G-tube one time a day for GI prophylaxis 5.Sucralfate tablet 1 gram: 1 tablet via G-tube three times a day for related to gastrointestinal hemorrhage, dissolve 1 tablet in 10 milliliter (ml) water. 6.Senna (help clean out intestine) tablet 8.6 mg: two tablet via G-tube two times a day for constipation. 7.Tapazole tablet (also known as Methimazole): 7.5 mg via G-tube one time a day for hyperthyroidism (overactive thyroid). LVN 2 was observed preparing each medication separately. LVN 2 placed applesauce in the medicine cup, opened the Omeprazole capsule delayed release 20 mg and emptied the pellets into the applesauce. LVN 2 stated, about 15 ml of water was added into each medicine cup before it was mixed and administered. LVN 2 was observed giving each Resident 16's medication without flushing in between prior to administering the next medication. During an interview on 11/3/2022 at 9:38 a.m., with LVN 2, LVN 2 stated, medication was prepared separately, and the initial flush of 30 milliliter (ml) water should be administered to clear the G-tube. LVN 2 stated after each medication administered, the G-tube should be flushed with 15 ml of water in between each medication administered followed by a final flush of 30 ml water, after the last medication was administered. LVN 2 stated the G-tube was not flushed with 15 ml of water after each medication administration. LVN 2 stated the importance of flushing the G-tube after each medication administration was to prevent and ensure the G-tube does not get clogged and prevent drug interactions that had the potential to cause adverse reactions. During an interview on 11/3/2022 at 10:00 a.m. with the Director of Nursing (DON), DON stated that for medication administration through the G-tube, the G-tube should be checked for patency, medications should be prepared one at a time, crushed, and flushed with 10 ml of water in between each medication administration. DON stated the tube should be flushed with 30 ml water prior to administering medications as well as after the final medication administered. The DON also stated if an order is unclear, the physician should be called for clarification or the pharmacy consultant for additional questions. During an interview on 11/3/2022 at 10:36 a.m. with the pharmacist, the pharmacist stated, according to Clinical Pharmacology Omeprazole delayed release should be mixed with 40 ml of apple juice, as the acidity of the apple juice aids to make the granules smaller. Pharmacist stated the mixture were put in a syringe with a stopper and shaken up for one minute to make the granules smaller to ensure it can pass through the G-tube faster. A review of the facility's policy and procedure (P&P) titled Medication Administration Via Tubes dated January 2020, the P&P indicated, Medications are to be crushed, opened, diluted, and administered separately through the tube, Proper technique for administration of medication through tubes is administer medication .Follow with sufficient fluid to flush medications through the tube. A review of an undated document titled Clinical Pharmacology Omeprazole provided by the facility's PharmD indicated for administration via nasogastric (NG) tube (tube that carried food and medicine to stomach through the nose), the Omeprazole capsules can be opened, and the enteric-coated granules will remain intact when exposed to selected juices such as apple or cranberry juice for ease of administration. A review of an undated document titled Administration of Proton Pump Inhibitors in Patients Requiring . provided by the facility's PharmD indicated, the following steps to give Omeprazole capsules through a G-tube: 1.Empty contents of 30-mg capsule into 60 ml catheter-tipped syringe. 2.Draw 40 ml of apple juice in syringe. 3.Gently mix. 4.Administer contents through tube by tilting and gently tapping syringe. 5.Flush tube with 40 mL of apple juice, repeat once. 6.Total volume of apple juice to be used=120ml. c. A review of the admission Record indicated, Resident 11 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses including dementia (progressive loss of memory), melena (dark tarry stools resulting from damage to the upper gastrointestinal (GI) lining), hypertensive heart disease with heart failure (long term condition of having high blood pressure), chronic atrial fibrillation (irregular heart rhythm). A review of the Minimum Data Set (MDS), a standardized assessment tool, dated 10/25/2022 indicated Resident 11 had the capacity to communicate with staff members. Resident 11 was totally dependent on staff for all activities of daily living (ADL) (activities related to personal care) Resident 11 required supervision with eating. A review of the Physician Order Summary Report indicated, Potassium Chloride (mineral supplement [KCL]) extended release (ER) (medication delivered slowly throughout body) 20 mEq: give one tablet by mouth one time a day for hypokalemia (low potassium level) was ordered on 10/13/2022 and Pantoprazole Sodium (helps decrease stomach acid) tablet delayed release (delay the release of drug in the body) 20 mg one tablet by mouth before meals for gastrointestinal prophylaxis was ordered on 10/21/2022. During a concurrent observation and interview on 11/2/2022 at 9:11a.m., with LVN 2, LVN 2 was observed preparing the following five medications: 1. Lasix/Furosemide (removing excess fluid in body) 40 mg tablet: 1 tablet by mouth two times twice a day for congestive heart failure (fluid buildup in heart). 2.Multi Vitamin with minerals: one tablet by mouth one time a day for supplement (supporting body with lacking vitamins). 3.Potassium Chloride ER 20 mEq tablet: one tablet by mouth one time a day for hypokalemia (low potassium level) 4.Prednisone (reduces inflammation) five (5) mg tablet: one tablet by mouth one time a day for bullous pemphigoid (rare skin condition). 5.Vitamin C 500 mg (Ascorbic Acid): one (1) tablet by mouth one time a day for supplement. Observed LVN 2 entered Resident 11's room with a cup of water that was not fully filled to the top. LVN 2 gave Resident 11's medications one medication at a time, taking a sip of water after each medication. After Resident 11's medication administration was completed, there was water remaining in Resident 11's cup before LVN 2 took the cup back. LVN 2 stated Resident 11 consumed approximately 90 ml of water during the administration of five medications. During an interview on 11/2/22 at 10:31 a.m., with LVN 2, LVN 2 stated, there was a certain amount of water that was given to resident taking Potassium Chloride medication. The bubble pack (designated sealed compartments, or spaces for medicines) indicated Medication should be taken with plenty of water The bubble pack does not have specific instructions on the amount of water to be administer with KCL. LVN 2 stated Resident 11 is on 1800mL fluid restriction and does not know how much water should be given with KCL. During an interview on 11/3/22 at 10:00 a.m., the Director of Nursing (DON) stated it was a standard practice to give Potassium Chloride medication with 120 mL of water. DON stated the sticker on the bubble pack for Potassium Chloride indicated, plenty of water. DON stated it was not clear on the amount of water needed and should have been clarified with the physician to specify how much water should have been given with the medication. DON read from the document titled Clinical Pharmacology Potassium Chloride Administration Information dated 9/21/2021 indicated administer full glass of water or immediately after food. During an interview on 11/3/22 at 10:36 a.m., with the pharmacist (PharmD), PharmD stated, Potassium should be administered with at least four (4) ounces (oz) of water or fluid, The PharmD recommended Potassium to be administered with four (4) to eight (8) oz (120ml to 240ml) of water or fluid. PharmD stated if Potassium was not given with enough fluid, it can cause stomach upset.

Based on observation, interview, and record review, the facility had: 1.Food items had no open dates and were not properly sealed. 2.One of three dietary staff, did not wear gloves during food handling and preparation. 3.One ice machine with black sediments around the machine upon inspection. These deficient practices had the potential for causing food-borne illnesses (caused by consuming contaminated food, beverages, or water) to residents. Findings: 1.During an observation on 11/1/2022, at 8:20 a.m., in the kitchen, 15 food items that were stored in Storage 1, next to the freezers, and seven (7) food items that were stored in Storage 2, dry storage, had no received date and open date. There was yellow cheese stored in the refrigerator without a covering (open to air). 2. During an observation on 11/1/2022, at 12:30 p.m., during the lunch tray line preparation in the kitchen, Dietary Staff (DS) 1 was observed touching the refrigerator door, to grab yogurt. DS 1 touched the refrigerator doorknob before and after entering the refrigerator with gloves. DS 1 walked to the ice cream freezer and opened the sliding door to grab ice creams with the same gloves. DS 1 grabbed four small cartons of milk from the refrigerator still using the same gloves. DS 1 was observed to not wash hands or change gloves and then touched residents' utensils while putting them on the meal trays. During an interview on 11/1/2022, at 3:38 p.m., with DS 1, DS 1 stated, all kitchen staff was required to wash hands and to change gloves after touching dirty surfaces, poultry meats, and trash cans. DS 1 stated, it was a mistake of not washing hands or changing gloves after touching the door of the refrigerator. 3. During an observation and interview on 11/1/2022, at 4:00 p.m., in the presence of Dietary Staff (DS) 2, black sediments were noted after wiping the ice machine on a white paper towel around the inner part of the machine, above the ice. DS2 stated, residents consume ice in their drinks and having an unclean ice machine can contaminate the ice and lead to an infection control issue. During an interview on 11/2/2022, at 3:06 p.m., with the Maintenance Personnel (MP), the MP stated, no formal training was received regarding how to clean the ice machine. MP stated the ice machine was cleaned once a month as instructed by facility Administrator (Admin) and there was no manufacturer instruction, and facility policy and procedure available. During an interview and concurrent record review on 11/2/ 2022, at 12:40 p.m., with Dietary Service Supervisor (DSS) 1, DSS 1 stated, there was a daily food safety checklist which included hand hygiene and food items needed to be labeled, where staff should check to ensure the food safety policy and procedures were followed. The Daily Food Safety Checklist were not available from 10/24/2022 to 11/2/2022. During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated November 2022, P&P indicated, When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all foods stored in the refrigerator or freezer as indicated. During a review of the facility's P&P titled, Hand Washing- Hand Hygiene, dated August 2020, indicated, Personnel shall follow the hand washing /hand hygiene procedure to help prevent the spread of infections to other personnel, residents, and visitors. When indicated, employees must wash their hands for at least fifteen seconds using antimicrobial or non-antimicrobial soap and water.

Based on interview and record review, the facility failed to establish a water management program to ensure the prevention of water borne pathogens (illnesses caused by microorganisms in untreated or contaminated water). There were 66 residents in the facility at the time of recertification survey. This deficient practice had the potential to expose residents and staff to Legionella (bacteria that can cause serious lung infections) and water borne infections. Findings: During an interview on 11/4/2022 at 8:23 a.m., with Maintenance Personnel (MP), the MP stated there were six water heaters in the facility. The MP stated the facility does not have a water program or Legionella program in place at the facility. MP stated a follow up needs to be conducted on how to test waters for signs of Legionella. During an interview and record review on 11/4/2022 at 11:01 a.m., with the Administrator (Adm), the Adm stated that the facility does not have a system in place regarding legionnaires disease or any form of detecting the disease in the facility's water system. There were no policies available for review for water management.