Based on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for two of seven abuse allegations. Specifically, the facility failed to: -Thoroughly investigate an allegation of sexual abuse on 4/12/25 for Resident #9 in order to prevent a second incident from occurring on 4/23/25; and, -Thoroughly investigate an allegation of physical abuse between Resident #7 and Resident #8. I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised 4/11/25, was provided by the director of nursing (DON) on 5/6/26 at 12:22 p.m. It read in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include investigating different types of alleged violations; identifying and interviewing all involved persons, including the alleged victim, the alleged perpetrator, witnesses, and others who might know about the allegations; focusing the investigation on determining if abuse has occurred, the extent, and the cause; and providing complete and thorough documentation of the investigation. II. Incident of alleged sexual abuse between Resident #9 and her boyfriend on 4/12/25 A. Facility investigation The investigation of the alleged sexual abuse incident between Resident #9 and her boyfriend was provided by the NHA on 5/6/25 at approximately 3:30 p.m. The witness statement, dated 4/12/25 and written by an unidentified CNA (according to the NHA), documented that Resident #9's boyfriend touched Resident #9 in what appeared to be an inappropriate manner. The resident, who had severely impaired cognition and who was non-verbal, was heard screaming. The CNA entered Resident #9's room and advised the boyfriend that he and Resident #9 needed to go to the television room so staff could monitor the visit. The CNA immediately reported the incident to the nurse on duty, and the nurse took over from there. The 4/12/25 nurse incident note revealed that nursing staff reported the incident to the NHA and called the police regarding Resident #9's boyfriend, reporting an allegation of sexual abuse, because they did not believe Resident #9 was able to consent to sexual contact of that nature. The resident's boyfriend left the facility soon after the incident of inappropriate touching. The resident was deemed safe by the facility, as the boyfriend was no longer in the facility. CNA #7, CNA #8, CNA #9 were interviewed on 4/14/25. The interview questions were: Do you feel safe here? Do you have specific concerns? Have you ever been hurt, frightened, or made uncomfortable here? Who made you uncomfortable here? If made uncomfortable here, did you report it? -However, the questions for the staff interviews failed to ask staff if they had any knowledge of the incident on 4/12/25 or prior incidents. -The investigation failed to reveal that an interview was completed with the CNA who witnessed the 4/12/25 incident to determine what the CNA specifically saw related to inappropriate touching of Resident #9 by her boyfriend. -The investigation failed to reveal documentation to indicate that an interview was completed with the alleged assailant, Resident #9's boyfriend. -The investigation failed to reveal documentation that the alleged assailant was unable to enter the facility during the investigation process, or what intervention was put in place to keep the resident safe. -The investigation failed to reveal documentation on what education was provided to the staff to keep the alleged victim safe while the investigation was in progress. B. Staff interview The DON was interviewed on 5/8/25 at 11:32 a.m. The DON said she was familiar with Resident #9 and the alleged sexual abuse on 4/12/25. She said Resident #9 was unable to make her own decisions since before she was admitted to the facility. She said the sexual activity capacity for consent was completed by the DON, the SSD, the unit manager, the assistant director of nursing (ADON) and the NHA. She said the medical director and ombudsman were not part of the decision. She said Resident #9's sexual activity capacity for consent was not completed until 4/14/25, after the alleged sexual abuse incident. -Review of the 4/14/25 sexual activity capacity for consent provided by the facility revealed Resident #9 had an inability to communicate effectively and describe her thoughts and feelings. The interdisciplinary team (IDT) determined the resident could not make or express her desire to engage in sexual intimacy with others. -However, despite the determination that Resident #9 did not have the capacity to consent to sexual intimacy, the facility failed to put effective interventions in place to protect the resident from another alleged sexual incident with the boyfriend on 4/23/25. Cross-reference F600 for failure to keep residents free from abuse. The DON said the resident's boyfriend visited on Saturdays when Resident #9's parents brought him to the facility. The DON said prior to the allegation, there were no restrictions on where he could visit with the resident in the facility. The DON said some staff reported to her that Resident #9's boyfriend tickled her, held her hand, and kissed her on her cheek. She said she was not aware of prior allegations. The NHA was interviewed on 5/7/25 at 2:05 p.m. He said the incident between Resident #9 and her boyfriend occurred on Saturday, 4/12/25. He said prior to the allegation, the facility did not have the boyfriend's contact information to inform him that he could not visit until after the incident was fully investigated. He said he contacted the parents on Monday, 4/14/25, two days after the incident occurred to obtain the boyfriend's contact information. The NHA said the boyfriend visited the resident on the weekends and the resident's parents provided transportation. The NHA said if the boyfriend visited on a Saturday, he would not visit on a Sunday. The NHA said he thought the resident was safe and he did not need to contact the parents for the boyfriend's contact information until Monday. The NHA said he was responsible for the questions management used for the resident and staff interviews. The NHA said the interview questions asked of the staff during the investigation for Resident #9 did not make sense for the investigation process. He said the questions were more relevant to ask residents instead of staff members. The NHA was interviewed a second time on 5/8/25 at 1:27 p.m. The NHA said he did not obtain an interview from the CNA who witnessed the incident with Resident #9 and her boyfriend on 4/12/25 to clarify exactly what she saw. The NHA said the witness statement lacked specific information in regards to what the CNA saw related to inappropriate touching of the resident on 4/12/25. The NHA said the investigation did not include an interview from the alleged assailant and an interview or observation from the alleged victim. The NHA said the interview questions for staff were incomplete and did not ask if they witnessed any other potential concerns or incidents with Resident #9 and her boyfriend prior to the 4/12/25 incident. The NHA said since there was a lack of interviews and statements and it was difficult to determine if the allegation was unsubstantiated. The NHA said, looking at the timeline of when the care plan was updated on 4/18/25 to ensure the boyfriend was only in the highly observable areas, to when the NHA contacted the boyfriend on 4/23/25, the investigation process was not completed in a timely manner in order to protect Resident #9 from another allegation of sexual abuse on 4/23/25. III. Incident of physical abuse between Resident #7 and Resident #8 on 4/8/25 A. Facility investigation The investigation of the resident-to-resident altercation between Resident #7 and Resident #8 was provided by the nursing home administrator (NHA) on 5/6/25 at approximately 3:30 p.m. The 4/8/25 incident note revealed that Resident #7 was observed entering Resident #8's room without permission. This caused Resident #8 to become upset and yell at Resident #7. The yelling caused Resident #7 to become upset and both residents began hitting each other. Both residents were separated and assessed for injuries. The facility investigation revealed that the investigator, who was the assistant director of nursing (ADON) interviewed certified nurse aide (CNA) #1, registered nurse (RN) #1, dietary aide (DA) #1, licensed practical nurse (LPN) #1, and the social services director (SSD). -However, the staff interviews were not specific to the incident between Resident #7 and Resident #8 and did not indicate if any of the staff members interviewed witnessed or overheard the resident-to-resident altercation. -The investigation failed to reveal that either Resident #7 or Resident #8 were interviewed following the incident to gain understanding of what potentially led to the incident in order to prevent any further incidents from occurring. B. Staff interviews The DON was interviewed on 5/8/25 at 11:32 a.m. The DON said if a facility staff member became aware of resident abuse, they should notify the abuse coordinator, who was the nursing home administrator (NHA), after ensuring the safety of the resident. She said the CNA should document the behavior in the residents' electronic medical records (EMR), on the residents' daily tasks records. She said the nurse was also responsible for initiating an incident report that included completing a skin assessment and pain assessment, notifying the family and notifying the physician. She said the nurse was responsible for developing an immediate intervention to keep the resident safe during the investigation process. The DON said the nurses documented everything they saw and what they did following the incident in the incident report. The DON said the alleged abuse and interventions were communicated to the next shift during the investigation process by a written report called a shift-to-shift report and a verbal report. She said a statement was obtained by the abuse coordinator (the NHA). The DON said she was familiar with the altercation between Resident #7 and Resident #8 on 4/8/25. She said she completed the physical aggression incident report because she heard the yelling between the two residents. She said she was not sure if CNA #1, RN #1, DA #1, LPN #1, or the SSD saw or heard the altercation but she said she was sure other staff members must have heard the yelling based on where Resident #8's room was located in proximity to the nurses' station. The DON said she was not certain which staff witnessed the resident-to-resident abuse because the investigator (the ADON) did not interview all staff on duty. The DON said there was no specific behavior linked to the resident-to-resident abuse that occurred between Resident #7 and #8, per the investigation statements obtained by the NHA. The NHA was interviewed on 5/7/25 at 2:05 p.m. The NHA said when he investigated an abuse allegation, he asked the staff member who saw the resident altercation/abuse to write a statement. He said if he did not directly interview staff, he designated someone in management to conduct the interviews. The NHA said he tried to obtain a statement and interview from the alleged assailant and victim. He said residents and staff interviews were completed by someone in management. He said there should be an intervention put in place to keep the residents safe while the investigation was in process. The NHA said he attempted multiple times to obtain Resident #7's statement, but he did not document the attempts. He said he obtained a statement from Resident #8 but he did not document his statement. The NHA said when he obtained Resident #8's statement, Resident #8 said he put his hands on Resident #7. The NHA said the immediate actions to keep the resident safe was the stop signs in front of Resident #8's room. The NHA said the sign was placed on 5/5/25. The NHA said he should have substantiated the alleged physical abuse. The NHA was interviewed again on 5/8/25 at 1:27 p.m. He said if staff saw or heard alleged abuse, they should notify him after ensuring the safety of the resident. He said any staff member who saw an alleged abuse incident should write a statement and then they should be interviewed by management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Failed to prevent two incidents of physical abuse of Resident #4 by Resident #22 A. First incident of physical abuse of Resident #4 by Resident #22 on 5/1/25 at 1:10 a.m. An incident report, dated 5/1/25 at 1:10 a.m. and written by LPN #6, related to an unwitnessed physical aggression, revealed LPN #6 and a CNA were on duty and heard yelling from down the hall and went to investigate. Resident #22 was observed walking out of Resident #4's room and began walking down Hall 200. The CNA went to check on Resident #22, while LPN #6 spoke with Resident #4 to ensure his safety. Resident #4 said Resident #22 hit him on his cheek. Resident #4 said that Resident #22 told him that the belongings in Resident #4's room were his (Resident #22's) and they were not. Resident #4 said he told Resident #22 the room was his room and then Resident #22 hit him on the cheek. When LPN #6 asked Resident #4 if he felt safe, he said that the police should be called because Resident #22 hit him on the cheek. Resident #4 said he was okay and asked if Resident #22 could be kept out of his room. Resident #4 was assessed with no noted injuries. LPN #6 administered Tylenol as needed and offered ice for his cheek, which he resident declined. Resident #4 was escorted back to his room and staff would ensure Resident #22 remained out of Resident #4's room. Resident #4 was oriented to person, place, time and situation. The local police department, the DON, the physician and the family were notified. The facility's summary of the physical abuse allegation on 5/1/25 at 1:10 a.m. revealed Resident #4 reported that Resident #22 wandered into his room. According to Resident #4, he asked Resident #22 to leave his room. Resident #22 became agitated and allegedly struck Resident #4 in the face. Resident #4 reported the incident to staff, who immediately intervened and placed Resident #22 on one-on-one staff supervision. Interventions prior to the incident for Resident #22 included for staff to assess Resident #22 for physical distress, or needs, assess for emotional needs such as being anxious or feeling lost and when wandering, staff were to redirect the resident. Interventions put into place after the incident for Resident #22 were to allow Resident #22 sufficient time to calm down and reapproach at a later time. Staff were to evaluate the resident's need for psychological services, interact with the resident in an empathetic manner and offer one-to-one staff supervision as needed. B. Second incident of physical abuse of Resident #4 by Resident #22 on 5/1/25 at 11:15 p.m. An incident report, dated 5/1/25 at 11:15 p.m. and written by LPN #3 related to an unwitnessed physical aggression, revealed LPN #3 was sitting at the East nurse's station and heard somebody say Hey! LPN #3 ran down Hall 300 and observed Resident #4 walking midway down the hall. Resident #4 said that Resident #22 was in his room. Resident #4 said he wanted the police called on Resident #22. Resident #4 said Resident #22 was in his room and when he yelled at Resident #22 to leave, Resident #22 hit him in the face. Both residents were separated, a full skin assessment was completed on Resident #4 and the police were called. The aggressor, Resident #22 was placed on one-to-one staff supervision. Resident #22 had no complaints of pain and was oriented to person, place and situation. The NHA, the DON, the family and the physician were notified. An investigation summary was provided by the NHA on 5/8/25 at 8:47 p.m. The summary revealed that at approximately 11:15 p.m. on 5/1/25, LPN #3 was at the East nurse's station when she heard someone call out Hey! LPN #3 immediately responded and proceeded to Hall 300 where she observed Resident #4 walking midway down the hallway. Resident #4 reported that Resident #22 had entered his room without permission. Resident #4 said after he told Resident #22 to leave, Resident #22 allegedly struck him in the face. Resident #4 expressed that he wanted the police called to report the incident. LPN #6 was also on duty that evening, and attempted to contact the NHA to report the altercation. When she was unable to reach the NHA by phone, she sent a text message to him at approximately 11:27 p.m., describing Resident #4's report that Resident #22 had entered his room and punched him after being told to leave the room. LPN #6 was training another nurse during this time and was able to provide the one-to-one staff supervision for Resident #22 immediately after the incident until the DON relieved her around 5:00 a.m. (on 5/2/25). The NHA responded to the message around 4:30 a.m., referencing a prior physical abuse incident (on 5/1/25 at 1:10 a.m.) in which Resident #4 had made a similar allegation. Unaware that LPN #6's message was regarding a new physical abuse incident, the NHA assumed the report was a follow-up to the earlier situation. As a result, there was no immediate clarification or action taken through text, although Resident #22 was on one-to-one supervision. When the NHA arrived at the facility at approximately 9:00 a.m. (on 5/2/25), it was confirmed that LPN #6's message was regarding a new and separate incident between Resident #4 and Resident #22. At that point, a new investigation was initiated. It was later identified, through the facility's investigation, that no one-to-one staff supervision for Resident #22 had been scheduled for the 6:00 p.m. to 6:00 a.m. overnight shift on 5/1/25 into 5/2/25. The gap in staff coverage was not recognized during the shift change at 6:00 p.m. on 5/1/25. and was not identified until after the second physical abuse incident had occurred on 5/1/25 at 11:15 p.m. The facility's summary at the conclusion of the investigation revealed the incident on 5/1/25 at 11:15 p.m. highlighted a breakdown in communication and shift handoff procedures, resulting in a critical gap in one-to-one staff supervision coverage for Resident #22. The facility's staffing scheduler failed to ensure there was appropriate staff coverage and received disciplinary action. Although staff responded promptly once the situation was identified, the lack of scheduled one-to-one staff supervision and staff being unaware of the one-to-one staff supervision requirement for Resident #22 resulted in the second physical abuse incident between Resident #4 and Resident #22. Resident #4 repeated an identical story that matched the first incident that had occurred earlier in the day. Resident #4 had a BIMS score of 15 out of 15 with a diagnosis of schizophrenia. It was revealed that Resident #4 had redness on his cheek following the skin assessment after the second physical abuse incident. Due to the redness on Resident #4's cheek, interview and the failure of staff to maintain the one-to-one staff supervision of Resident #22, the facility substantiated abuse. The root cause analysis of the incident revealed Resident #22 required one-to-one staff supervision following a previous incident involving Resident #4. The one-to-one staff supervision from 6:00 p.m. to 6:00 a.m. on 5/1/25 into 5/2/25 was unassigned. The oversight was not included in the shift report so the oncoming charge nurse did not know Resident #22 required one-to-one staff supervision. Therefore, Resident #22 did not have one-to-one staff supervision from 6:00 p.m. on 5/1/25 until the second incident of physical abuse occurred on 5/1/25 at 11:15 p.m. C. Resident #4 - (victim) 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included schizophrenia, risk of homelessness and drug induced subacute dyskinesia (various movement disorders characterized by involuntary, repetitive, and/or abnormal movements). The 4/17/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident had no impairments in his upper or lower extremities. The resident was ambulatory without the need for a mobility device. The MDS assessment indicated the resident had disorganized thinking that was present and fluctuated (came, went and changed in severity). 2. Resident interview Resident #4 was interviewed on 5/6/25 at 1:48 p.m. Resident #4 said Resident #22 hit him on the right side of his face twice. He said it hurt and they were solid punches. He said he did not hit Resident #22 back. He said he had the facility call the police and that Resident #22 no longer resided in the facility. He said he was not afraid of Resident #22 or any other residents in the facility. 3. Record review Resident #4's care plan for mood and behavior, initiated 10/10/24 and revised 5/6/25 (during the survey), revealed the resident had a behavior success plan designed to encourage positive actions through reinforcement. Staff were to remind the resident to follow his plan by avoiding physical contact with others, respecting personal boundaries by not entering others' rooms without permission, and maintaining positive communication.The interventions included administering medications as physician ordered, interacting with the resident in an empathetic and supportive manner and monitoring and documenting each behavioral event. Resident #4's care plan for mental health, initiated 10/17/24 and revised 5/5/25, revealed the resident had an admitting diagnosis of schizophrenia. The resident had a history of an alteration in mood or exhibition of behavioral symptoms related to unwanted touching of others, impulsivity, wandering in other rooms, stealing from others and obsessive behaviors when he fixated on things of interest, such as smoking. Interventions included reporting verbal or physical altercations with other residents to the abuse coordinator immediately so the abuse coordinator could initiate abuse reporting and investigation measures as indicated, and ensuring the resident remained separated from the other resident that was involved until the conflict was resolved. The resident had agreed to a behavior contract, in which he would not engage in unwanted physical contact or verbal altercations with other residents. Staff were to report any inappropriate behavior immediately, after ensuring resident safety. A nurse progress note, dated 5/1/25 at 2:20 a.m. and written by LPN #6, revealed LPN #6 and a CNA heard yelling and went to investigate. Resident #4 was observed walking out of his room and down Hall 300. Resident #22 was observed walking out of Resident #4's room and walking down Hall 200. The CNA went and checked on Resident #22 and LPN #6 spoke with Resident #44. Resident #4 said Resident #22 hit him in the cheek and the police should be called. Resident #4 requested that LPN #6 keep Resident #22 out of his room. Resident #4 was assessed and no injuries were noted. He was given Tylenol, but declined an ice pack for his cheek. Resident #4 was escorted back to his room and ensured that staff would keep Resident #22 out of his room. A head to toe assessment was completed which noted previous scabbed areas to the left side of Resident #4's nose with no new skin issues noted. The DON was notified at 1:15 a.m. The local police department was notified at 1:20 a.m. Resident #4's family was notified at 1:43 a.m. The physician was notified at 2:20 a.m. A nurse progress note, dated 5/2/25 at 12:13 a.m. and written by LPN #3, revealed LPN #3 was sitting at the East nurse's station and heard somebody yell Hey! LPN #3 ran to Hall 300 and observed Resident #4 walking mid-way down the hall. Resident #4 said Resident #22 was in his room. Resident #4 said he yelled at Resident #22 to get out of his room. Resident #4 said Resident #22 hit him in the face and he wanted the altercation reported to the police. A full skin assessment was completed and redness was noted to Resident #4's right upper cheek. Resident #4 denied any pain or discomfort. Resident #4 was instructed to go to the television room. Resident #22 was observed walking out of Resident #4's room. LPN #3 asked Resident #22 what he was doing and he replied that he was looking for a bathroom. LPN #3 escorted Resident #22 to his bathroom and then had him sit at the East nurse's station. Both residents were kept separated and Resident #22 was placed on one-to-one staff supervision. The police were called and the local police department, the NHA, the DON and the physician were notified. The police arrived at approximately 12:05 a.m. and spoke with Resident #4 and provided the facility with a case number. A call was placed to a family member at 12:37 a.m., related to the situation and no concerns were voiced at this time. D. Resident #22 - (assailant) 1. Resident status Resident #22, age greater than 65, was admitted on [DATE] and discharged to the hospital on 5/2/25. According to the May 2025 CPO, diagnoses included Alzheimer's disease, dementia, depression, mood disturbance and anxiety. The 5/2/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident required staff supervision or touch assistance to walk 150 feet once standing down a corridor or a similar space. The resident did not require the use of mobility devices. The MDS assessment indicated the resident had inattention and disorganized thinking that was present and fluctuated (came, went and changed in severity). 2. Record review A wander/elopement risk evaluation, dated 4/30/25 at 2:22 p.m., revealed Resident #22 was at a high risk for wandering. The resident had a diagnosis of Alzheimer's disease or dementia and/or the resident was cognitively impaired. The resident had both short and long-term memory impairment. The resident had impaired decision-making skills. A wanderguard was placed on the resident's right wrist. Resident #22's care plan for being at risk for wandering and an elopement risk was initiated on 4/30/25. The interventions included assessing the resident for physical distress or needs, such as hunger, thirst, pain, discomfort or elimination, assessing the resident for emotional psychological distress, such as anxiety, fear or feeling lost, encouraging the resident to stay in common areas of the building for observation if needed and if the resident wandered, the staff were to redirect the resident to another activity. Resident #22's care plan for impaired cognitive function/dementia or thought related to Alzheimer's disease and dementia was initiated on 4/30/25. The interventions included for staff to use the resident's preferred name and identify themselves at each interaction. The staff were to face the resident when speaking and make eye contact, reduce any distractions by turning off the television, radio and closing the resident's door. The resident understood consistent, simple, directive sentences and Staff were to provide the resident with necessary cues and stop and return if he was agitated. Staff were to discuss concerns about confusion, disease process, nursing home placement with the resident/family/caregivers. Resident #22's care plan for mood and behavior, initiated 5/1/25, revealed the resident had a history of an alteration in mood or exhibition of behavioral symptoms related to Alzheimer's disease, dementia, anxiety, physically aggressive behaviors and inappropriate sexual behaviors. The interventions included administering medications as ordered and allowing the resident time to calm down and reapproach at a later time, evaluating the resident for the need and referring to psychological counseling as recommended by a physician, interacting in an empathetic and supportive manner, monitoring and documenting each behavioral event, monitoring for inappropriate sexual behaviors and redirecting as needed for safety, offering psychosocial support as needed and offering one-to-one staff interaction as needed. A nurse note dated 5/1/25 at 2:35 a.m., by licensed practical nurse (LPN) #6, revealed LPN #6 and a CNA were on duty and heard yelling from down the hall and went to investigate. Resident #4 was observed walking out of Resident #4's room towards LPN #6 and the CNA down Hall 300. Shortly after, Resident #22 was observed walking out of Resident #4's room and he began walking down Hall 200. The CNA went to check on Resident #22 while LPN #6 spoke with Resident #4. Once LPN #6 ensured Resident #4's safety, LPN #6 went to speak with Resident #22 who was working a puzzle on Hall 200. When LPN #6 asked Resident #22 what happened, the resident responded in Italian and went back to doing the puzzle. Staff asked Resident #22 if he wanted to do the puzzle with them and he said yes. Resident #22 was assessed with no injuries noted. Resident #22 demonstrated no signs or symptoms of distress and staff worked on the puzzle with the resident for approximately 20 minutes then assisted the resident back to his room and into bed. LPN #6 notified the DON at approximately 1:15 a.m. and the police were notified at approximately 1:20 a.m. The physician was notified at approximately 1:28 a.m., and the resident's wife was notified at approximately 1:43 a.m. A head to toe skin assessment was performed on Resident #22 with a few scattered scratches/sores and edema to bilateral lower extremities noted. Resident #22 was assisted to his room and back to bed. A behavior progress note, dated 5/1/25 at 2:39 a.m. and written by LPN #6, revealed Resident #22 was self-ambulating around the facility and wandering into other residents' rooms and going through their things. The resident had a physical altercation with another resident (Resident #4) when the resident wandered into the other resident's room and punched the other resident. -Review of Resident #22's progress notes revealed there was no progress note documented by LPN #3 following the 5/1/25 at 11:15 p.m. incident with Resident #4. An event note, dated 5/6/25 at 6:47 p.m. and written by the DON revealed the date of the event was 5/1/25 at 1:10 a.m. The nurse (LPN #6) and a CNA on duty heard yelling from down the hall and went to investigate. Resident #22 was observed walking out of resident #4's room and began walking down Hall 200. The CNA went to check on Resident #22 while LPN #6 spoke with Resident #4. Once LPN #6 ensured Resident #4's safety, the nurse went to speak with Resident #22 near the puzzles on Hall 200. Resident #22 was assessed for injury and none was noted. The police, the NHA, the DON and the physician were notified. The risk factors and root cause identification revealed Resident #22 had a diagnosis of Alzheimer's, dementia, anxiety and depression which would explain his wandering into others' rooms and increased agitation with confrontation. Resident #22 was admitted to the facility on [DATE]. The preventative measures in place prior to the incident were Resident #22 had recently been admitted to the facility, and the resident was identified as a wanderer. The staff interventions were to redirect the resident to another activity, encourage the resident to stay in the common areas, assess the resident for physical distress or needs such as hunger, thirst, pain, discomfort, and/or elimination. The new interventions after the incident (on 5/1/25 at 1:10 a.m.) were to place the resident on one-to-one staff supervision. E. Staff interviews LPN #3 was interviewed on 5/7/25 at 1:46 p.m. LPN #3 said Resident #4 told her he was hit in the face by Resident #22 (on 5/1/25 at 11:15 p.m.). She said Resident #4's face had some redness to his right upper cheek. She said Resident #22 was placed on one-to-one staff supervision. LPN #3 said neither Resident #4 or Resident #22 said they were afraid of each other. She said she kept Resident #22 at the East nurse's station after the incident and Resident #4 stayed in the television room and waited for the police. She said both residents had an additional physical altercation with each other the night before. The DON and RNC #1 were interviewed together on 5/7/25 at 2:15 p.m. The DON said there were two physical altercations between Resident #4 and Resident #22 on 5/1/25. The DON said the nurse note, dated 5/1/25 at 2:35 a.m. and written by LPN #6 in Resident #22's electronic medical record (EMR) only mentioned the two residents yelling at each other and did not mention the physical altercation that took place between them. The DON said it was reported that both altercations involved hitting between Resident #4 and Resident #22. The DON said this was the reason the facility completed two abuse investigations. The NHA, the DON, RNC #1 and the RVPO were interviewed together on 5/7/25 at 3:35 p.m. The NHA said Resident #4 and Resident #22 resided on different halls. The NHA said Resident #4 and Resident #22 had two separate incidents of physical altercations on 5/1/25, approximately 24 hours apart. The NHA said the first altercation was at 1:10 a.m. on 5/1/25 and the second altercation was at 11:15 p.m. on 5/1/25. The NHA said that both altercations occurred in Resident #4's room The NHA said both times, Resident #22 walked (wandered) down the hall to Resident #4's room. The NHA said the facility's initial admission assessment for Resident #22 revealed the resident was at risk for wandering. The NHA said neither Resident #4 or Resident #22 had any injuries from the two physical altercations and neither of the residents went to the hospital. The NHA said this was the first altercation that Resident #22 since admission to the facility. The NHA said in both incidents, Resident #22 hit Resident #4. The NHA said in both incidents, Resident #4 did not hit Resident #22 back. The NHA said Resident #22 had not displayed any form of aggression to any residents before the two incidents. The NHA said the facility concluded that Resident #22 was attracted to Resident #4's room because it was at the end of the hall and Resident #4 played loud music. The NHA said Resident #22 was admitted on [DATE] and discharged to the hospital on 5/2/25 at 3:00 p.m. The NHA said Resident #22 was placed on one-to-one staff supervision and remained on one-to-one staff supervision until his discharge. The NHA said there was a miscommunication from 8:30 p.m. until 11:10 p.m., related to which staff members were to be providing the one-to-one staff supervision for Resident #22. The NHA said it was during this time period that the second physical incident between Resident #4 and Resident #22 occurred. LPN #6 was interviewed on 5/7/25 at 5:47 p.m. LPN #6 said, to her knowledge, there was only one physical altercation between Resident #4 and Resident #22 on 5/1/25 at 11:15 p.m. She said Resident #22 would wander down the hallways, enter into other resident rooms and go through their belongings. She said Resident #22 spoke very little English but he was easy to redirect. She said after she finished resident medication administration, she would have Resident #22 sit at the East nurse's station. LPN #6 said she would give Resident #22 snacks until he became tired and was ready for bed. The DON, RNC #1 and the chief nurse officer (CNO) were interviewed together on 5/8/25 at 9:03 a.m. The DON said there were two physical altercations between Resident #4 and Resident #22 in a 24-hour period. The DON said these incidents were the first and second events since Resident #22 had been in the facility. The DON said Resident #22 was the alleged aggressor both times and Resident #4 did not retaliate during the two altercations. The DON said staff members were disciplined for their actions of a lack of communication on the one-to-one staff supervision for Resident #22. The DON said after conducting the interviews with Resident #22 after the first incident, the facility was unable to determine if physical abuse had occurred, however Resident #4 said he was hit and he had a BIMS score of 15. The DON said Resident #4 did not have any skin issues and did not complain of pain. The DON said Resident #22's target behaviors listed on his Kardex included for staff to monitor/record any occurrences of behavioral symptoms, such as pacing, wandering, disrobing, inappropriate response to verbal communication and violence/aggression towards staff/others. The DON said Resident #4 and Resident #22 were not afraid of each other and the facility was unable to predict that either of the physical altercations would occur. She said Resident #22 was discharged to the hospital for a psychological evaluation at approximately 2:30 p.m. on 5/2/25. The DON said before the first altercation, the staff had Resident #22 sitting at the East nurse's station after admission and engaging him with activities. The DON said staff had helped him get ready and into bed. She said he wandered out of his room and went to Resident #4's room. The DON said Resident #22 escalated by being yelled at and he calmed down by working with puzzles, staff conversation, snacks and beverages. The DON said Resident #22 was easy to redirect. The DON said after the first altercation, Resident #22 was placed on one-to-one staff supervision. She said there was a breakdown in the communication of the one-to-one staff supervision. and that was when the second physical altercation occurred. The DON said both altercations occurred in Resident #4's room. The DON said the one-to-one staff supervision for Resident #22 was put in place after the first incident occurred to prevent any additional altercations with residents. -However, the facility failed to ensure one-to-one staff supervision was in place between 8:30 p.m. and 11:10 p.m. on 5/1/25 (see interview above). The DON said the facility started staff in-services on 5/2/25 which educated staff that to the person that was on a one-to-one staff supervision with a resident could not relinquish this duty until they were relieved by another staff member. The DON said an in-service on abuse and de-escalation techniques was started on 5/6/25 (during the survey). Based on observations, interviews and record review, the facility failed to take steps to protect residents from abuse for four (#9, #7, #8 and #4) of 20 residents reviewed for abuse out of 22 sample residents. Specifically, the facility failed to: -Protect Resident #9 from repeated instances of sexual abuse by a visitor; -Protect Resident #7 and Resident #8 from physical abuse by each other; and, -Protect Resident #4 from physical abuse by Resident #22 in two separate incidents. I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised 4/11/25, was provided by the director of nursing (DON) on 5/6/26 at 12:22 p.m. It read in pertinent part, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include resident-to-resident altercations. It includes sexual abuse and physical abuse. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. II. Incidents of alleged sexual abuse between Resident #9 and Resident #9's visitor on 2/1/25, 4/12/25 and 4/23/25. A. Facility investigation of the alleged sexual abuse on 2/1/25 The 5/13/25 interdisciplinary (IDT) nurse progress note (written during the survey) revealed a certified nurse aide (CNA) reported Resident #9's boyfriend was observed with his hands inside the resident's shirt, touching the resident's breast (on 2/1/25). The CNA asked the boyfriend to move to a common area. The CNA notified the nurse, who said the facility talked to Resident #9's mother and the mother was okay with the interactions. The facility had interviewed the nurse the CNA reported the incident to on 2/1/25. The nurse did not recall the incident or being notified of the incident. The nurse remembered having a conversation with the mom about the boyfriend and his visits. The nurse said the resident was more vocal when the boyfriend was around. The nurse said Resident #9's mother said she was okay with the resident's boyfriend visiting the resident and she had no concerns about him. She said he had been visiting him for a long time and had never had any issues at other visits. The note documented the risk factors and root cause were that Resident #9 had a history of anoxic brain damage, impeding her ability to communicate and express her thoughts and feelings. The visitor was her boyfriend at the time of the incident that caused the resident's brain injury. The resident's parents were her legal representatives and continued to encourage a relationship between the resident and her boyfriend. The resident's parents provided transportation for the boyfriend to visit and he was typically only able to visit on weekends. Resident #9's parents did not stay for the visits and preferred for the staff to manage the interactions between the resident and her boyfriend. The facility was unable to substantiate or unsubstantiated the allegation of sexual abuse because the resident was unable to communicate her side of the incident. The investigation had been turned over to the local police department and adult protective services (APS) for further investigation. The new interventions included that the boyfriend was not permitted to visit at the time (effective 5/13/25). A care conference was set up with both of Resident #9's parents, the ombudsman, APS, the police department and the social services director (SSD). B. Facility investigation of the alleged sexual abuse on 4/12/25 The witness statement, dated 4/12/25 and written by an unknown CNA (per the NHA), documented Resident #9's boyfriend touched Resident #9 in what appeared to be an inappropriate manner. The resident, who was non-verbal, was screaming. The CNA entered the room and advised the boyfriend they needed to go to the television (TV) room. The witness immediately reported the incident to the nurse, and the nurse took over from there. The 4/12/25 nurse incident note revealed the staff reported the incident between Resident #9 and her boyfriend to the NHA. The nursing staff called the police to report Resident #9's boyfriend, as the staff felt there was inappropriate touching happening in the lounge and the resident was not able to consent to the interactions. The resident was deemed safe, as the boyfriend was no longer in the facility. A skin assessment was completed on Resident #9 with no unusual findings. The family was notified of the incident. The 4/14/25 IDT event note revealed the CNA notified the nurse and the NHA, as she felt Resident #9's visitor was touching her inappropriately. The resident did not have the capacity to consent to the advances. The resident's boyfriend denied the interactions, however, he left shortly after the incident. The note indicated the risk factor and root cause identified was the resident had a history of anoxic brain damage, impeding her inability to communicate and express her thoughts and feelings. Her visitor was her boyfriend at the time of the incident leading to the brain injury. The resident's parents were her representatives and continued to encourage a relationship between the resident and her boyfriend. The parents provided transportation for him to visit and he was typically only able to visit on weekends. Resident #9's parents did not stay for the visits and preferred for the staff to manage interactions between the resident and the boyfriend, as they wanted to remain a neutral party. The note indicated the prior interventions were anticipating the resident's needs, encouraging out-of-room activities, encouraging relationships with family and friends, allowing space and limiting touch when able. New interventions were the resident's parents would like visits to continue with the boyfriend as the parents believed the interactions were good for the resident. The staff were to ensure visits happened in line of sight and the boyfriend was not permitted to be in the resident's room without staff or the resident's parents present. The 4/14/25 NHA progress note revealed the NHA spoke to Resident #9's parents[TRUNCATED]

Based on record review and interviews, the facility failed to report alleged violations of sexual and physical abuse to the State Survey and Certification Agency in accordance with state law for four of seven alleged abuse violations. Specifically, the facility failed to: -Submit a final report of the facility's investigation of two separate physical abuse allegations involving Resident #5 and Resident #4 to the State Agency within five calendar days of the incidents; -Submit a final report of the facility's investigation of a physical abuse allegation involving Resident #7 and Resident #8 to the State Agency within five calendar days of the incident; and, -Submit a final report of the facility's investigation of a sexual abuse allegation involving Resident #9 and a facility visitor to the State Agency within five calendar days of the incident. Findings include: I. Facility policy and procedure The Compliance with Reporting Allegations of Abuse/Neglect. Exploitation policy, reviewed on 5/7/25 (during the survey), was provided by the chief nurse officer (CNO) on 5/8/25 at 10:55 a.m. The policy revealed the facility would ensure all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property were reported immediately to the administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Resident abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which could include staff to resident abuse and certain resident-to-resident altercations. This also included the deprivation by an individual, including a caretaker, of goods or services that were necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, caused physical harm, pain or mental anguish. It included verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Resident sexual abuse was the non-consensual sexual contact of any type with a resident. The facility would report all alleged violations and all substantiated incidents to the State Agency and to all other agencies as required, and take all necessary corrective actions, depending on the results of the investigation. The facility would analyze the occurrences to determine what changes were needed, if any, to policies and procedures to prevent further occurrences. The administrator or designee would report sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified within five working days of the incident. II. Abuse allegations and State Agency reporting A. Physical abuse allegation on 3/10/25 at 10:15 a.m. involving Resident #5 and Resident #4 The facility submitted an initial report of a physical abuse allegation to the State Agency reporting site on 3/10/25 at 11:41 a.m. The final report of the facility's investigation of the incident was due on 3/15/25 at 11:59 p.m. -However, the facility submitted the final report of the investigation on 4/8/25 at 3:22 p.m., which was 24 days after the final report was due. B. Physical abuse allegation on 3/10/25 at 6:00 p.m. involving Resident #5 and Resident #4 The facility submitted an initial report of a physical abuse allegation to the State Agency reporting site on 3/10/25 at 7:23 p.m. The final report of the facility's investigation of the incident was due on 3/15/25 at 11:59 p.m. -However, the facility submitted the final report of the investigation on 4/8/25 at 3:53 p.m., which was 24 days after the final report was due. C. Physical abuse allegation on 4/8/25 at 1:00 p.m. involving Resident #7 and Resident #8 The facility submitted an initial report of a physical abuse allegation to the State Agency reporting site on 4/8/25 at 2:36 p.m. The final report of the facility's investigation of the incident was due on 4/13/25 at 11:59 p.m. -However, the facility submitted the final report of the investigation on 4/24/25 at 5:38 a.m., which was 11 days after the final report was due. D. Sexual abuse allegation on 4/12/25 at 2:45 p.m involving Resident #9 and a facility visitor The facility submitted an initial report of a sexual abuse allegation to the State Agency on 4/12/25 at 4:24 p.m. The final report of the facility's investigation of the incident was due on 4/17/25 at 11:59 p.m. -However, the facility submitted the final report of the investigation on 4/24/25 at 5:56 a.m., which was seven days after the final report was due. III. Staff interviews The nursing home administrator (NHA) and the regional vice-president of operations (RVPO) were interviewed together on 5/8/25 at 10:40 a.m. The NHA said he had to notify the appropriate authorities, including the State Agency, immediately or as soon as possible, but no later than 24 hours, after receiving a report of an abuse allegation. He said in the case of serious bodily injury to a resident, the allegation was to be reported no later than two hours after the incident. The NHA said he had to have the final report of the facility's investigation into an abuse allegation submitted to the State Agency within five days of the incident. The NHA agreed with the final submission reporting dates that were documented in the State Agency's reporting system. He said the investigations of the allegations were completed timely but he submitted the final reports late. He said it was his poor timing skills that resulted in the late submissions and he said he was aware of the five-day time constraints. The NHA said he now reported weekly to the RVPO and the regional clinical nurse (RCN) to ensure that any abuse investigations were completed and reported appropriately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #64 A. Resident status Resident #64, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included type 2 diabetes, history of stroke and hypertension. The 7/28/24 MDS assessment revealed the resident was moderately cognitively intact with a BIMS score of 10 out of 15. The resident required moderate assistance with activities of daily living (ADL). B. Record review The primary care provider note dated 11/8/24 documented that Resident #64 was assessed by the physician as he had been off. The resident was skipping meals and smoke breaks. The physician placed physician's orders to obtain blood work for the resident. The blood work was completed by the lab on 11/8/24 and was submitted to the physician's office and facility for review via the EMR. -There was no documentation in Resident #64's EMR to indicate that the resident's primary care provider reviewed the resident's lab work and provided feedback to the facility. -There was no documentation in Resident #64's EMR to indicate the facility followed up with the resident's primary care provider when the facility did not receive feedback from the physician regarding the resident's lab work. On 11/10/ 24 Resident #64's condition deteriorated and he was sent to the emergency room for further evaluation. C. Staff interviews Licensed practical nurse (LPN) #6 was interviewed on 1/20/25 at 1:30 p.m. LPN #6 said she was working with Resident #64 on 11/8/24. She said the resident stayed in his bed and did not go to his smoke breaks. She said he was offered fluids, but he preferred to drink only coffee. She said she contacted his physician who ordered lab work on 11/8/24. She said when lab work was completed by the lab, the lab automatically populated residents' EMRs for providers and for nurses in the facility. She said nurses acknowledged receipt of lab work by writing a progress note when it was received and what the response from the physician was. The DON was interviewed on 1/20/25 at 3:40 p.m. The DON said any changes in a resident's condition should be documented in a change of condition form. She said when lab work results were received, nursing staff should write a progress note and indicate the response from the provider. She said there was not a nursing note for Resident #64's lab work that was completed on 11/8/24. The NHA was interviewed on 1/20/25 at 3:40 p.m. The NHA said she contacted Resident #64's physician's office (during the survey) and the physician's office confirmed that they received a call from nursing staff on 11/9/24 asking for feedback on the resident's 11/8/24 lab work. The NHA said the physician's office was not able to comment if any feedback was provided to the nursing staff on 11/9/24. She said the nursing staff should have contacted the physician's office again to request feedback when they did not hear back from the physician. Based on observations, record review and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for two (#167 and #64) of five residents reviewed for quality of care out of 38 sample residents. Specifically, the facility failed to: -Ensure Resident #167's physician was notified in a timely manner when attempts to start an intravenous (IV) line were unsuccessful and staff could not administer IV fluids per the physician orders; and, -Ensure Resident #64's laboratory (lab) blood work was addressed by the resident's physician in a timely manner. Findings include: I. Facility policy The Change in a Resident's Condition or Status policy and procedure, revised 12/19/16, was received from the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, The nurse supervisor or charge nurse will notify the resident's attending physician or on-call physician when there has been a change in condition, including a significant change in the resident's physical/emotional/mental condition or a need to alter the resident's medical treatment significantly. II. Resident #167 A. Resident status Resident #167, age [AGE], was admitted on [DATE] and discharged to the hospital on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included carotid artery aneurysm (bulge in the artery that supplies brain/head with blood flow), dysphagia (difficulty with swallowing) and depression. The 10/17/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive/maximal assistance with toileting, bathing, hygiene, sit to stand transfers and chair to bed transfers. B. Record review A nursing progress note, dated 11/1/24 at 2:45 p.m., documented Resident #167 had sustained a change in condition related to falls, shortness of breath and decreased urine output. Vital signs documented at the time included an oxygen saturation of 83% (percent) on room air. A nursing note dated 11/1/24 at 3:56 p.m., documented that Resident #167's primary care provider (PCP) gave a physician's order for a stat (immediate) D-dimer (blood test to rule out a blood clot), chest x-ray, two liters per minute of oxygen via nasal cannula, to start a peripheral IV and to administer one liter of 0.9% normal saline solution. It was documented to notify the PCP after completion of the orders and to follow up with any presentation of becoming hemodynamically unstable (unstable movement in blood resulting in inadequate blood flow). A nursing note, dated 11/1/24 at 5:45 p.m., documented that the nurse attempted to start an IV twice on Resident #167 and was unsuccessful. -Review of Resident #167's electronic medical record (EMR) failed to reveal documentation that the resident's PCP was notified when the nurse was unable to start the IV in order to administer the physician ordered normal saline solution (see above). A nursing note, dated 11/2/24 at 6:48 a.m., documented a nurse attempted to start an IV and the resident tolerated it well. However, the IV attempt was unsuccessful and the provider was notified. -However, there was no documentation in Resident #167's EMR to indicate what was recommended by the physician when the IV attempts were unsuccessful. C. Staff interviews The RDQC, the director of nursing (DON) and the nursing home administrator (NHA) were interviewed together on 1/16/25 at 2:35 p.m. The DON said when a resident experienced a change in condition, the nurse on duty was to notify the physician, the DON and the resident's family or medical power of attorney (POA). She said orders from the physician were to be completed right away unless there was another emergency going on. She said if a nurse was unable to get an IV initiated, the process was to have another nurse attempt, notify the DON and call the RDQC to get someone to come in to place the IV. The RDQC said the facility could also call for emergency medical services (EMS) to put an IV in. Nurse practitioner (NP) #1 was interviewed on 1/16/25 at 1:19 p.m. NP #1 said she would expect to be notified right away if a nurse was unable to carry out a treatment order for a resident. She said this would potentially change the treatment plan for the resident. Registered nurse (RN) #2 was interviewed on 1/21/25 at 10:45 a.m. RN #2 said if a resident was experiencing a change in condition, she would assess the resident, call the provider and call the nursing supervisor. She said if she could not follow a provider's order, she would notify the provider right away. Primary care physician (PCP) #1 was interviewed on 1/22/25 at 11:26 a.m. PCP #1 said she was notified of Resident #167's change in condition on 11/1/24 and ordered a peripheral IV with fluids. She said she was not notified by the nursing staff until 11/2/24 that the nursing staff was unable to place the IV. She said if she had been notified earlier, she may have sent Resident #167 to the emergency room if the resident was agreeable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for one resident (#1) out of 38 sample residents. Specifically, for Resident #1, the facility failed to: -Assess the resident for the safe use of bed rails, including assessment for risk of entrapment prior to installing the bed rails; -Create and document a personal care plan for the safe use of bed rails; -Obtain consent from the resident and/or the resident's representative before bed rails installation, including informing them of the risks versus benefits of bed rails; -Obtain a physician's order for the bed rails; and, -Conduct quarterly assessments of the bed rails to evaluate their continued need and safety. Findings include: I. Facility policy and procedure The Side Rail policy, revised on 12/19/16 was received from the nursing home administrator (NHA) on 1/22/25 at 4:15 p.m. It read in pertinent part, An assessment of the resident will be made to include a review of the following: device to be used; indication for use; cognitive status; physical status; pertinent history, as applicable; anticipated benefits; a review of how the device impacts the resident's freedom of movement; a review of whether the resident has the potential to become entrapped or harmed; and, risk factors associated with use of the device. The use of side rails as an assistive device will be addressed in the resident care plan. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks and documented within the assessment. If side rail usage is appropriate, the facility will obtain an order for use from the attending physician. When side rail usage is appropriate, the facility will assess the space between the mattress and side rails to reduce the risk of entrapment. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included generalized idiopathic epilepsy and epileptic syndromes (seizure disorders), cognitive communication deficit, history of traumatic brain injury, sleep apnea, depression and gastro-esophageal reflux disease without esophagitis (GERD). The 12/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required assistance from one person with activities of daily living (ADLs). The assessment documented Resident #1 did not use bed rails. -However, observations revealed the resident had bed rails in place (see below). B. Resident interview and observations Resident #1 was interviewed on 1/13/25 at 9:30 a.m. Resident #1 said she had temporarily moved to a different bedroom because of an issue with the heater. She said she needed bed rails on the bed to help her get up and move around. Resident #1 was lying in her bed and there were no bed rails attached to the bed. Resident #1 was interviewed again on 1/21/25 at 5:30 p.m. The resident was observed in her room in bed. The side rails were present on her bed. She said they were installed last week. C. Record review Review of Resident #1's comprehensive care plan did not reveal documentation regarding the use of a bed rail. Review of Resident #1's electronic medical record (EMR) did not reveal an assessment for the safe use of side rails, a physician's order for the use of the bed rails or a consent for the use of the bed rails. III. Staff interviews The director of nursing (DON) and the NHA were interviewed together on 1/13/25 at 3:00 p.m. They said the resident was moved to a different room while the facility was working on repairing the heater. The NHA was interviewed again on 1/22/25 at 4:45 p.m. The NHA said Resident #1 had been utilizing bedrails She admitted the bedrail assessment should have been completed prior to installing the bed rails.

Based on observations, record review and interviews, the facility failed to ensure the medication administration error was not greater than five percent. Specifically, the facility's medication administration error rate was 8% (percent), or two errors out of 25 opportunities for error. Findings include: I. Manufacturer's recommendations The Novolog medication package insert (February 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.novo-pi.com/novolog.pdf. It revealed in pertinent part, Giving an air shot before injection (after needle application): before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to two units, hold your Novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. the dose selector should return to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. The Humalog medication package insert (July 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/020563Orig1s202,205747Orig1s028Lbl.pdf. It revealed in pertinent part, Priming your insulin pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. II. Observations of medication administration for Resident #18 On 1/14/25 at 10:59 a.m., licensed practical nurse (LPN) #1 was observed during medication administration. She checked Resident #18's blood sugar which was 352 milligrams (mg)/deciliter (dl). She took the Novolog pen out of the medication cart and pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared 22 units of the Novolog solution for Resident #18. She said eight units were for her scheduled insulin and 14 units were the sliding scale order, which was verified correct per the physician's order. She turned the dose to 22 units and went into the resident's room. She did not prime the insulin pen. She wiped Resident #18's lower abdomen with an alcohol wipe and injected the medication into her abdomen. -LPN #1 failed to prime the Novolog insulin pen prior to drawing up the 22 units of insulin. III. Observations of medication administration for Resident #46 On 1/14/25 at 11:12 a.m., LPN #1 was observed during medication administration. She checked Resident #46's blood sugar which was 227 mg/dl. She took the Humalog pen out of the medication cart, pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared eight units of Humalog solution for Resident #46. She said four units were for her scheduled insulin and 4 units were the sliding scale order, which was verified as correct per the physician's order. She turned the dose to eight units and went into the resident's room. She did not prime the insulin pen. She wiped Resident #46's right upper arm with an alcohol wipe and injected the medication into her arm. -LPN #1 failed to prime the Humalog insulin pen prior to drawing up the eight units of insulin. IV. Staff interviews Nurse practitioner (NP) #1 was interviewed on 1/16/25 at 2:33 p.m. NP #1 said it was best practice to prime an insulin pen prior to administration so the resident got the full dose of insulin. The director of nursing (DON) and the regional director of quality and compliance (RDQC) were interviewed on 1/16/25 at 2:35 p.m. The DON said insulin pens should be primed with two units of insulin or whatever the specific manufacturer's recommendation was. Cross reference F760: failure to be free from significant medication errors.

Based on observations, record review and interviews, the facility failed to ensure that residents were free from significant medication errors for two (#18 and #46) of two residents reviewed for medications errors out of 38 sample residents. Specifically, the facility failed to ensure that Resident #18 and Resident #46 were administered the correct dose of insulin by properly priming the insulin pen before insulin administration. Findings include: I. Manufacturer recommendations The Novolog medication package insert (February 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.novo-pi.com/novolog.pdf. It revealed in pertinent part, Giving an air shot before injection (after needle application): before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: turn the dose selector to two units, hold your Novolog flex pen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector should return to zero. A drop of insulin should appear at the needle tip. If not, change the needle and repeat the procedure no more than six times. The Humalog medication package insert (July 2023) was retrieved on 2/3/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/020563Orig1s202,205747Orig1s028Lbl.pdf. It revealed in pertinent part, Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensures that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. II. Observations On 1/14/25 at 10:59 a.m., licensed practical nurse (LPN) #1 was observed during medication administration. She checked Resident #18's blood sugar which was 352 milligrams (mg)/deciliter (dl). She took the Novolog pen out of the medication cart and pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared 22 units of the Novolog solution for Resident #18. She said eight units were for her scheduled insulin and 14 units were the sliding scale order, which was verified correct per the physician's order. She turned the dose to 22 units and went into the resident's room. She did not prime the insulin pen. She wiped Resident #18's lower abdomen with an alcohol wipe and injected the medication into her abdomen. -LPN #1 failed to prime the Novolog insulin pen prior to drawing up the 22 units of insulin. On 1/14/25 at 11:12 a.m., LPN #1 was observed during medication administration. She checked Resident #46's blood sugar which was 227 mg/dl. She took the Humalog pen out of the medication cart, pulled off the cap, wiped the stopper with an alcohol pad and attached the needle. She prepared eight units of Humalog solution for Resident #46. She said four units were for her scheduled insulin and 4 units were the sliding scale order, which was verified as correct per the physician's order. She turned the dose to eight units and went into the resident's room. She did not prime the insulin pen. She wiped Resident #46's right upper arm with an alcohol wipe and injected the medication into her arm. -LPN #1 failed to prime the Humalog insulin pen prior to drawing up the eight units of insulin. Cross reference F759: failure to ensure the medication rate was under 5%. III. Staff interviews Nurse practitioner (NP) #1 was interviewed on 1/16/25 at 2:33 p.m. NP #1 said it was best practice to prime an insulin pen prior to administration so the resident got the full dose of insulin. The director of nursing (DON) and the regional director of quality and compliance (RDQC) were interviewed on 1/16/25 at 2:35 p.m. The DON said insulin pens should be primed with two units of insulin or whatever the specific manufacturer's recommendation was.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of two medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart; and, -Ensure all medications were labeled with resident information. Findings include: A. Professional references The United States Food and Drug Administration (USFDA) (10/31/24) Don't Be Tempted to Use Expired Medicines, was retrieved on 1/23/25 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It documented in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. The National Institutes of Health (NIH) (July 2017) Strengthen Your Resolve: No Unlabeled Containers Anywhere, Ever, was retrieved on 1/23/25 from https://pmc.ncbi.nlm.nih.gov/articles/PMC5481289/#:~:text=Discard%20unlabeled%20medications,event%20as%20a%20hazardous%20condition. It documented in pertinent part, Discard unlabeled medications. Don' t assume that you know what is contained in an unlabeled syringe, cup or basin. Discard any unlabeled solution or medication found in the perioperative area or procedural areas and report the event as a hazardous condition. B. Facility policy and procedure The Medication Labeling and Storage policy, revised 2001, was provided by the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices. The medication label includes at minimum: medication name, prescribed dose, strength, expiration date, resident's name, route of administration and appropriate instructions and precautions. C. Observations On 1/15/25 at 5:30 p.m. the medication cart and treatment cart on the secure unit were observed with licensed practical nurse (LPN) #3. The following items were found: -One bottle of nitroglycerin lingual spray with an expiration date of June 2023; and, -One container of nitroglycerin sublingual tablets with no label indicated which resident it belonged to. IV. Staff interviews LPN #3 was interviewed on 1/15/25 at 5:30 p.m. LPN #3 said usually the night shift nurse would audit the medication carts for expired medications. She said she was going to let the director of nursing (DON) know about the expired medication and the unlabeled medication. She said she would dispose of the medications properly. The DON and the RDQC were interviewed together on 1/16/25 at 2:35 p.m. The DON said the medications carts and storage rooms were reviewed weekly. She said this was done by herself or a unit manager. She said if a nurse found an expired medication, the nurse should have removed the medication and destroyed it. She said medications that come from the pharmacy come with resident labels.

Based on observation, record review and interviews, the facility failed to establish an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and healthcare associated infections. Specifically, the facility failed to: -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP); and, -Ensure sanitary conditions related to the ice box Findings include: I. Failure to ensure staff followed EBP when providing care to a resident with a wound A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) About Enhanced Barrier Precautions (EBP) In Nursing Homes (6/28/24) retrieved on 1/27/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, EBP are an infection control strategy that involves wearing gowns and gloves during high-contact resident care activities. Enhanced Barrier Precautions are recommended for residents with any of the following: infection or colonization, or a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a multi drug resistant organism (MDRO). B. Facility policy and procedure The Infection Prevention and Control Program policy and procedure, revised 12/19/16, was received from the regional director of quality and compliance (RDQC) on 1/22/25 at 4:55 p.m. It documented in pertinent part, The infection prevention and control program bases standards of practice and protocols on recommendations from appropriate government agencies such as the center for disease control (CDC) and the occupational safety and health administration (OSHA). The facility will utilize practices with employees to reduce the risk that employees will expose residents to infection including taking precautions to reduce the risk for spread of infection from employees to residents by utilizing standard precautions. C. Observations Registered nurse (RN) #1 was observed on 1/15/25 at 12:30 p.m. while completing wound care for Resident #10. She gathered the supplies and walked into the resident's room. There was a sign on the door that indicated the resident was on EBP. There was a caddy hanging on the inside of the door with gowns, masks and gloves. RN #1 was wearing a mask prior to entering the resident's room. She applied clean gloves. She did not put a gown on. She cleaned the wound and applied medicated ointment to the wound. She removed a stat lock (device to hold catheter in place) because she said it was not in the correct location. She removed the gloves and washed her hands. She said Resident #10 was on EBP due to his foley catheter. She said she should have put on a gown and did not think about it when entering the room to complete wound care. D. Staff interviews The infection preventionist (IP), the RDQC, the director of nursing (DON) and the assistant director of nursing (ADON) were interviewed together on 1/22/25 at 3:00 p.m. The IP said Resident #10 was on EBP for his foley catheter. She said any resident that had chronic wounds, a foley catheter, history of (MRSA), ostomies and nasogastric tubes qualified a resident to be on EBP. She said the nurse providing wound care to Resident #10 should have put on a gown while providing care to the resident. II. Failure to ensure sanitary conditions related to the ice box A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities (July 2019) retrieved on 1/27/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/infection-control/media/pdfs/Guideline-Environmental-H.pdf, Ice and ice-making machines also may be contaminated via improper storage or handling of ice by patients and/or staff. Suggested steps to avoid this means of contamination include: minimizing or avoiding direct hand contact with ice intended for consumption, using a hard-surface scoop to dispense ice and installing machines that dispense ice directly into portable containers at the touch of a control. B. Observations On 1/15/25 at 12:15 an unidentified resident She opened the white and blue ice box that was in the dining room and used her personal cup to scoop the ice directly from the ice box. The resident did not use an ice scoop. An unidentified certified nursing assistant (CNA) was present in the dining room. C. Staff interviews The IP, the RDQC, the DON and the ADON were interviewed together on 1/22/25 at 3:00 p.m. The IP said the residents were not allowed to scoop their own ice from the ice boxes. She said the staff were supposed to help them use a designated scoop to get them ice. She said the staff and the residents should not use their personal cups to scoop ice directly from the ice box.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe, functional and comfortable environment on two of five units. Specifically, the facility failed to: -Ensure the utility door room near the dining room, between the 300 and 400 units, was closed and not accessible to residents; and, -Ensure room [ROOM NUMBER] on the 500 unit, which was under construction, was not accessible to residents. Findings include: A. Observations On 1/13/25 at 11:35 a.m. the door to the utility room near the dining room between the 300 and 400 units was slightly open. Multiple computer servers and cables were visible in the room. On 1/14/25 at 10:30 a.m. the door to the utility room near the dining room between the 300 and 400 units was open again and had a medication cart next to the room. -The door to the room had not been closed by staff when the medication cart had been placed next to the doorway. On 1/15/25 at 3:40 p.m. the door to the utility room near the dining room between the 300 and 400 units was slightly open again and there was a two-wheel walker folded up and leaning against the wall outside the open door. -The door to the room had not been closed by staff when the walker had been placed next to the doorway. On 1/22/25 at 1:50 p.m. the door to room [ROOM NUMBER] was unlocked. Upon opening of the door, the room revealed there were mechanical tools in the room, such as a drill, nails and screws. The dry wall panel was removed from one of the walls and revealed exposed plumbing. The door to the room was not locked and the unsafe contents in the room were accessible to residents on the 500 unit. B. Staff interviews The maintenance director (MTD) was interviewed on 1/16/25 at 3:54 p.m. The MTD said the utility room with the computer equipment had always had the door open since he had worked at the facility. He said he was told it was because the room got too hot and so it needed ventilation. The nursing home administrator (NHA) was interviewed on 1/22/25 at 5:20 p.m. The NHA said all utility room doors should be closed and should not be accessible to residents for safety reasons. She said she was not aware that room [ROOM NUMBER] had tools in it and was still accessible to residents. She said she would contact the MTD to ensure the tools were not accessible to residents.

Based on observation, record review and interviews, the facility failed to serve food that was palatable and attractive. Specifically, the facility failed to ensure that the resident's food was palatable in taste, texture and appearance. Findings include: I. Resident interviews Resident #39 was interviewed on 1/13/25 at 11:49 a.m. He said that the food did not taste good and was not presentable. Resident #59 was interviewed on 1/13/25 at 2:10 p.m. He said that the food was not good. He said the taste of the food depended on who was cooking and what staff was working. Resident #44 was interviewed on 1/13/25 at 3:23 p.m. She said that the food tasted horrible and that the food does not look presentable. Resident #217 was interviewed on 1/13/25 at 3:37 p.m. She said the facility did not have an alternate menu. She said the kitchen would often close by the time she got her meal, so if she did not like what was served she could not get something else. Resident #50 was interviewed on 1/14/25 at 9:43 a.m. He said the food was not good. He said the food did not taste good. He said the facility did not have an alternative menu., Resident #46 was interviewed on 1/14/25 at 10:21 a.m. He said the meat and vegetables were served over cooked. He said the canned fruit tasted like the can. He said he would like some fresh fruit. II. Resident group interview The resident group interview was conducted on 1/15/25 at 1:04 p.m. The group consisted of five residents (#2, #37, #51, #39 and #58) who were interviewable based on assessment by the facility. All of the residents in the group interview said the food was not palatable. Some of the comments were as follows: -The food was questionable at best; -The food did not look good; -Some of the food was too spicy; and, -The dietary manager (DM) did not listen to the residents or fix the issues. III. Record review The food committee meetings from October 2024 through January 2025 were reviewed. The 10/7/24 food committee minutes documented that the residents wanted more fruit added to the menu and that some of the food was too salty. The 12/2/24 food committee minutes documented that they would like brussel sprouts and some other vegetables off the menu. -The minutes did not mention what actions were taken regarding expressed concerns and if residents were satisfied with resolution. IV. Observations On 1/15/25 at approximately 12:30 p.m. a test tray of a regular diet was immediately evaluated by four surveyors after the last resident was served their room tray for lunch. The test tray was not served palatable and consisted of white rice pilaf, white gravy, four meatballs, steamed brussel sprouts, white bread roll and a slice of angel food cake with canned peaches over the top. The rice pilaf was crunchy and under cooked. The gravy was salty. -The outside of the meatballs were crunchy and hard to bite through. The brussel sprouts were slightly yellow and greyish in color, the consistency was mushy and were overcooked. The angel food cake and the peaches that were on tope were sweet. V. Staff interview The DM was interviewed on 1/22/25 at 4:30 p.m. He said he met with residents every month to discuss food feedback and choices. He said to his knowledge residents were satisfied with food choices they had. The DM said he did taste the rice pilaf on 1/15/25 lunch time and he did not think it was undercooked.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse that rose to the level of immediate jeopardy. Findings include: I. Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies. F600 Abuse prevention During a recertification survey on 7/13/23, F600 was cited at a G level scope and severity, isolated, actual harm. The facility had identified and corrected the deficient practice prior to the survey and therefore F600 was cited at past non-compliance. -However, the facility failed to maintain compliance. During a recertification survey on 1/15/25, F600 was cited at K level scope and severity, pattern, immediate jeopardy to residents health and safety. Failure to monitor sexually inappropriate behavior for the resident with a history of such behaviors. F759 Medication administration error rate above five (%) percent During a recertification survey on 7/13/23, F759 was cited at a D level scope and severity, isolated, no actual harm with potential for more than minimal harm. During a recertification survey on 1/15/25, F759 was cited at a D level scope and severity, isolated, no actual harm with potential for more than minimal harm. II. Staff interviews The nursing home administrator (NHA) was interviewed on 1/15/25 at 5:30 p.m. The NHA said Resident #50 was admitted to the facility prior to change of ownership. She said the resident's history of sexually inappropriate behavior was mentioned in his medical records, however he did not display any inappropriate behaviors until the incident on 1/1/25. She said the facility reviewed all of the residents who might have had a history of sexually inappropriate behaviors to ensure proper interventions were put in place. The medical director (MD) was interviewed on 1/16/25 at 9:50 a.m. The MD said he was not aware that Resident #50 had a history of sexually inappropriate behaviors. He said it was brought to his attention this week. He said primary care and mental health providers were involved in identifying the best course of treatment for this resident. The NHA was interviewed a second time on 1/22/25 at 5:30 p.m. The NHA said QAPI meetings were conducted monthly. She said sexually inappropriate behaviors and Resident #50 were not brought up in the meetings and have not been identified as a problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the kitchen provided food that accommodated resident preferences for one (#22) of five residents of 36 sample residents. Specifically, the facility failed to ensure Resident #22 was receiving their menu choices. Findings include: I. Resident status Resident #22, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included gout (inflammation of joints that cause swelling and pain in joints) and irritable bowel syndrome (IBS). The 5/22/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was independent and required only set up assistance with bed mobility, transfers, dressing, toilet use and personal hygiene II. Resident interview and observation Resident #22 was interviewed on 7/10/23 at 12:05 p.m. She said she ate every meal in her room. She said she was served tomatoes on her chicken today as part of lunch and could not eat them because she had gout. She said her food preferences were often not honored. She said meal tickets for the following day were filled out every evening. She said meal tickets were provided and collected by a staff member. She said staff members provided assistance with filling out tickets if needed. She said she gave up on informing staff of discrepancies as nothing improved or she was not provided with correct food until an hour later. Resident #22 said she ate what she could from meals she was served. The daily use meal ticket, to be filled out by Resident #22, revealed she was not to have tomatoes, juice and gravy on the side if it was a red sauce; allergies were listed as tomato and milk. Resident #22 was interviewed on 7/11/23 at 11:35 a.m. She said she had not received extra gravy for pork chop or margarine for dinner roll as requested. Resident #22 said she would not eat the pork chop without gravy as the pork chop was dry. Resident #22 said she would not eat the dinner roll without margarine as the dinner roll was dry. The lunch plate for Resident #22 was observed to have a pork chop, green beans, dinner roll and cubed cantaloupe. Gravy was not observed on pork chop or on tray, nor was margarine observed. The meal ticket for Resident #22 indicated extra gravy and margarine was a preference. Resident #22 was interviewed on 7/11/23 at 5:12 p.m. Resident #22 said she ordered chicken fajitas and a hot dog. She said she ordered a hot dog in case she did not like the chicken fajitas, she was concerned it might have tomato on it. She said she indicated no rice on her meal ticket. The dinner tray for Resident #22's was observed to have shredded chicken on top of tortilla, white rice, corn and lettuce. -There was no hot dog on the plate. The meal ticket for Resident #22 indicated a hot dog as preference and no white rice. III. Record review The nutrition care plan dated 6/13/23 revealed Resident #22's food preference was to avoid sauces, tomatoes, high acidic foods and drinking milk. IV. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/12/23 at 12:32 p.m. She said evening staff (2:00 p.m. to 10:30 p.m.) presented residents with meal tickets to be filled out for the next day. She said residents were to cross off or add items according to food preference, then tickets went to the kitchen. She said CNAs and people who prepare food were responsible to check that food on plate matched food on ticket. She said if food did not match the ticket it went back to the kitchen for corrections. CNA #2 was interviewed on 7/12/23 12:36 p.m. He said the evening CNAs or resident aides were responsible for assisting residents to fill out meal tickets for the following day. He said once a meal ticket was filled out they were brought to the kitchen. He said he did not check if the food on the plate matched the food on the ticket. CNA #3 was interviewed on 7/12/23 at 1:11 p.m. She said the evening staff went room to room with meal tickets, took the resident food orders and brought meal tickets to the kitchen for next day preparation. She said residents could write in alternative food options if they did not want the main dish. She said she personally checked the food on the plates matched the ticket. She said if there was a discrepancy she took it back to the kitchen for corrections. The regional chef (RC) and the dietary manager (DM) were interviewed on 7/12/23 at 2:54 p.m. The DM said evening CNAs went to each resident room, obtained their food orders for the next day and brought meal tickets to the kitchen. The RC said meal tickets were reconciled nightly (to make consistent) with physician orders and care plans for accuracy. The DM said Resident #22 should have received a hot dog if it was written in on meal ticket and if there was any question about her wanting both then Resident #22 should have been asked. The director of nursing (DON) was interviewed on 7/12/23 at 3:18 p.m. She said the kitchen staff preparing meals and CNAs delivering meals would check that food ordered on meal tickets matched food being delivered to residents and any discrepancies would be returned to the kitchen for correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and observations, the facility failed to ensure one (#19) of five out of 36 sample residents received food and fluids prepared in a form designed to meet his or her needs per speech therapy recommendation, physician orders and the resident's care plan. Specifically, the facility failed to provide meals to Resident #19 according to the prescribed diet order. Findings include: I. Facility policy A Modified Texture Diet policy was requested on 7/11/23 at 2:00 p.m. The district dietary manager provided a Texture Modification Inservice from the dietary departments contracted service company, undated, on 7/11/23 at 3:00 p.m. It read in pertinent part, Policy statement: the company promotes the health and safety of all employees as well as that of the clients and residents we serve. Some residents have problems chewing or use multiple swallows to swallow one bite, pocket food (holding food in cheeks), or cough frequently during meals and should be evaluated by the facility speech and language pathologist. They may suggest a texture modified consistency to decrease the risk of choking and make eating easier. Proper preparation and delivery of texture-modified diets is critical for resident safety and wellness. Four levels of texture modification are offered that utilize both pureed and mechanically soft foods to meet residents' needs. Consistency options as outlined in the contracted service company's diet manual are as follows for the dysphagia advanced consistency: required meat to be ground and moistened; raw fruits must be without skins and seeds. Now raw vegetables permitted except for shredded lettuce, cannot receive hard, dry meats such as bacon, bread with hard crusts, toasts, whole kernel corn, or any hard, dry snack items that do not easily crumble into small pieces. A completion report or paper copy of this inservice must be placed in the employee's file and should be updated annually. II. Resident #19 A. Resident status Resident #19, age [AGE], was admitted to the facility on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included bipolar disorder, heart failure, chronic obstructive pulmonary disease, protein-calorie malnutrition and dysphagia (difficulty swallowing). The 4/25/23 minimum data set (MDS) assessment documented the resident was cognitively intact as evidenced by a brief interview for mental status (BIMS) with a score of 15 out of 15. She required oversight, encouragement or cueing and set up help with eating. Coughing or choking during meals or when swallowing medications was marked. The resident was on a therapeutic, modified diet. III. Observations On 7/11/23 at approximately 11:05 a.m., Resident #19's meal service ticket was observed. The meal ticket had Advanced Dysphagia at the top and hand written on the ticket was toast. At 12:03 p.m. a dietary aide removed the toast from the toaster and placed it on plate with the remainder of Resident #19's food order. The plate was on a tray with Resident #19's meal ticket. The plate was then covered, placed on a cart and delivered to Resident #19. The dietary manager (DM) said Resident #19 was educated and approved to have toast instead of bread. -The menu for advanced dysphagia documented bread should be served instead of toast. IV. Record review Resident #19's physician ordered diet was CCD (carbohydrate controlled) two gram sodium (restricted) diet, dysphagia advanced texture with regular/thin consistency (liquids) ordered 1/5/23. Resident #19 had a care plan due to her difficulty swallowing related to her coughing or choking during meals or when swallowing medications. Resident #19 had an incident where she choked on chips, and was able to cough and clear her throat on her own, initiated 4/24/23 and revised 6/5/23. Pertinent interventions included all staff were to be informed of Resident #19's special dietary and safety needs, and diet to be followed as prescribed; initiated 4/24/23. Referred to speech therapy for evaluation 6/5/23. The 3/8/23 nutrition evaluation documented Resident #19 was on a CCD two gram sodium diet, dysphagia advanced diet with thin liquids. The evaluation documented the resident was non-compliant with her diet and frequently ordered food from outside the facility. The resident was educated on sugar and sodium content in foods. The resident stated she usually just ate a grilled cheese for lunch. -No additional education on textures was documented as provided to the resident since the resident was on an advanced dysphagia diet and grilled cheese was not appropriate (see Textured Modified diet inservice above). A 4/28/23 IDT (interdisciplinary team) note written 1:11 p.m. documented Resident #19 had a regular texture diet. -However, according to the physician's order she was ordered an advanced dysphagia diet (see above). A 5/2/23 nutrition evaluation documented Resident #19 was on a CCD two gram sodium diet, dysphagia advanced diet with thin liquids. The evaluation documented the resident was non-compliant with her diet, frequently ordered food from outside the facility and was educated on her diet. -It was not clear on what education was provided to the resident regarding her diet and if the appropriate texture of food on her current diet was provided. A speech therapy evaluation for Resident #19 was provided by the nursing home administrator on 7/12/23 at 9:00 a.m. The document revealed Resident #19 had a swallow function test performed on 6/5/23. Resident #19 was referred to speech therapy for dysphagia service due to new onset of coughing or choking during oral intake, safety and signs and symptoms of dysphagia. Resident #19 had an episode of choking on a potato chip on 6/3/23. Resident #19's prior level of function as reported by the resident was documented as patient was tolerating a regular diet with thin liquids, and the resident was edentulous (lacking teeth). Resident #19 was assessed using the international dysphagia diet regular and easy to chew level seven (which included regular texture and soft foods). Education was presented to the resident regarding a safe PO (by mouth) intake of solids such as potato chips to decrease the risk of choking and aspiration. The modified diet that was recommended for the patient to swallow solids safely was regular textured. The document was signed by the speech therapist on 6/14/23 and by a physician on 6/19/23. -However, the diet order reflected in the resident's chart was still advanced dysphagia. -The resident was not supposed to be provided potato chips due to the resident being on an advanced dysphagia diet. The resident was not changed to regular diet texture until after treatment with the speech therapist on 6/14/23. -The NHA said there was no diet requisition or documentation to change the resident's diet from advanced dysphagia to regular texture. No additional information was provided as to why the diet was not upgraded to regular. -Observations at lunch and based on record review revealed the facility was not following the diet orders ordered by the physician and the diet tickets did not match the correct diet orders. V. Staff interviews The dietary manager (DM), regional chef (RC), district dietary manager (DDM) and NHA were interviewed on 7/12/23 at 2:00 p.m. The DM said she did go to see Resident #19 after her lunch was delivered on 7/11/23 explained her diet to her. She said she could follow up with the speech therapist and if needed could cut the crust off the toast as Resident #19 liked eating the toast and had ordered it previously. She said when Resident #19 came to the dining room the resident sometimes chose a grilled cheese sandwich or toast with her meal. The DM said she did not know for certain if the speech therapist did do education with Resident #19. She said she had previously receive a list of what residents could and could not have but had not received a diet requisition order for those items for Resident #19. The regional chef said if an order was received for a menu item that was not part of the residents diet, the associate should ask a nurse before the item was served. He said their menu program the meal tickets were printed from should be reconciled daily as it was connected to the resident's electronic health record. That way any diet changes can be updated immediately. The updates could include adaptable equipment, room changes, texture changes and diet order changes. He said nurses could bring an order directly to them. The NHA said staff should all have been educated on diets and reading and understand the meal tickets. He said if an associate was unsure about an item a resident ordered be allowed on the prescribed diet, the associate should go to the nurse first. If a resident was non-compliant with their diet he said the item should not be served right away and the associate should go to the nurse and ask them to intervene and speak to the resident. The NHA said that if a diet change was recommended a diet requisition slip should be completed. VI. Facility follow-up A 7/11/23 resident/family education record for Resident #19 was completed at 2:24 p.m. The documentation revealed Resident #19 was provided a verbal diet instruction that read, We encourage you to eat your ordered diet, however if you choose to eat other foods not ordered, you do understand that this can be dangerous to your health. Under the resident signature section, Resident #19's signature was not present. In the signature of family/other box, another resident's name was present.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for two residents (#45 and #38) of five out of 36 sample residents. Specifically, the facility failed to: -Ensure resident refrigerator temperatures were monitored for refrigerated food storage; and, -Provide the resident and/or resident representative with information on their right to store food and the process for doing so. Findings include: I. Facility policy The Safe Handling for Foods from Visitors policy, revised July 2019, was provided by the nursing home administrator (NHA) on 7/11/23 at 5:00 p.m. It read in pertinent part, Residents will be assisted in properly storing and safely consuming food brought into the facility for residents by visitors. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and equipped with thermometers, have temperature monitored daily for refrigeration less then or equal to 41 degrees fahrenheit, daily monitoring for refrigerated storage duration and discard of any food items that have been stored at for at least seven days and cleaned weekly. II. Resident interviews and observations Resident #38 was interviewed on 7/10/23 at 11:00 a.m. He said his personal refrigerator had not worked for at least 30 days and broke when facility staff tried to fix his bed plugged into the wall. He said no staff checked his refrigerator and the food inside needed to be thrown out. The refrigerator was observed to be plugged in but not running and had an internal temperature of 78 degrees Fahrenheit (F). The refrigerator had a dry, sticky substance on the bottom shelf, an opened package of hot dogs and an opened package of sliced american cheese. He said no staff had provided him with education on food storage in his room. Resident #45 was interviewed on 7/10/23 at 11:30 a.m. He said he did not have a thermometer in his personal refrigerator and no staff checked the temperature. He said he monitored the dates on the food inside his personal refrigerator himself. There was no internal refrigerator thermometer observed inside. He said no staff had explained proper food storage to him. Resident #45 said on 7/11/23 at 2:15 p.m. he received a new thermometer in his refrigerator. On 7/12/23 at 2:00 p.m. a new personal refrigerator was observed in Resident #38's room. III. Record review Temperature logs for Resident #38 and Resident #45's refrigerator were requested but none were provided. IV. Staff interviews Certified nurses aide (CNA) #1 was interviewed on 7/13/23 at 10:50 a.m. She said the overnight staff checked the temperatures of the resident's personal refrigerators. The unit manager (UM) was interviewed on 7/13/23 at 11:44 a.m. She said temperature logs had been placed on all resident personal refrigerators. She said the logs were not there previously and temperatures were not being monitored but it should be corrected going forward and the overnight staff would monitor the temperatures. The temperatures would then be verified as completed the following day. The social services director (SSD) was interviewed on 7/13/23 at 10:45 a.m. She said she was unsure if any proper food storage education was provided to the residents who had personal refrigerators.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey Agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents. Findings include: I. Resident group interview The group interview was conducted on 7/12/23 at 3:09 p.m. with six residents (#64, #53, #23, #5, #47 and #44) identified by assessment and facility as interviewable. All six residents said they did not know where the facility posted information in regard to pertinent State Agencies' contact information and it was not reviewed in the resident council meeting. III. Staff interviews and observation On 7/12/23 at 4:36 p.m. observation of the mandatory posting for the State Agency was made in the administrative offices hallway of the facility. An eight inch by 11 inch frame was hung on the wall next to the administrative offices hallway, and was hung approximately seven feet up from the floor. The frame contained a paper with the names, addresses and phone numbers of State Agencies. The font of the contact information was approximately size 10 font with some areas that were bold but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. The posting was in an area that was not easily accessible to residents that were not mobile. On 7/13/23 at 9:45 a.m. the posting was moved down to approximately four feet up from the floor, however, the email address was not included on the posting. The social service assistant (SSA) was interviewed on 7/13/23 at 10:30 a.m. She said she was uncertain where the State Agencies' contact information was located. Registered nurse (RN) #1 was interviewed on 7/13/23 at 10:47 a.m. She said she did not know where the State Agencies' contact information was located.

Based on observations, and interviews, the facility failed to ensure medication error rate was not greater than five percent. Specifically, the facility's medication error rate was 12 percent with three errors out of 25 opportunities. Findings include: I. Medication administration to Resident #15 On 7/12/23 at 11:50 a.m. licensed practical nurse (LPN) #4 was observed during medication administration. She pulled out a bottle of medication, the label on the bottle read Ibuprofen 200 milligrams (mg). She opened the bottle and poured two tablets in the cup and was getting ready to administer the medication. When she reviewed the physician order, she identified that the order read to administer one tablet of Ibuprofen, not two. She removed one tablet from the cup. LPN #4 was interviewed on 7/12/23 at 12:01 p.m. She said she did not pay attention and confused it with other medication that the resident was receiving two tablets. II. Medication administration to Resident #20 On 7/12/23 at 12:10 p.m. registered nurse (RN) #1 was observed during medication administration. She pulled out a bottle of medication, the label on the bottle read Tylenol 325 mg. She opened the bottle and poured two tablets in the cup and was getting ready to administer the medication. The order on the medication administration record (MAR) read Tylenol 500 mg two tabs for pain. RN #1 stated she confused the bottles as they looked alike and did not check the dose on the bottle. She replaced medications with appropriate strength. At 12:15 p.m. she drew Humalog (insulin) into the syringe and the dose on the syringe was closer to 15 units. The order on the MAR read Humalog 13 units for diabetes. RN #1 said the dose was closer to 15 units. She corrected the dose to 13 units. III. Staff interviews The director of nursing (DON) was interviewed on 7/12/23 at 4:30 p.m. She said nurses were to administer medications accurately as it read on the physician orders. She said she would provide education to the nurses on proper administration of medications to make sure medications were given correctly.

Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to: -Maintain kitchen sanitation and prevent potential cross contamination during the meal preparation and meal delivery; and, -Label, date and discard expired foods appropriately. Findings include: I. Kitchen sanitation A. Professional reference The Food and Drug Administration (FDA) Food Code 2022, last reviewed 1/18/23 and retrieved on 7/19/23 from https://www.fda.gov/food/retail-food-protection/fda-food-code, read in pertinent part, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and cleaned at a frequency necessary to preclude accumulation of soil residues. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Light fixtures and vent covers and other attachments shall be easily cleanable. B. Observations The following observations were made on 7/9/23 at 10:15 a.m.: -The walls under the dishwashing machine table had several food splatters and drips down the wall. -Darkened debris and food crumbs were observed on the floor in the dish room. The debris was under the dish table, on the floor tiles and against the edges of the walls. -A piece of a rectangular light cover was broken and missing over the clean side of the dish machine table. The light was over a tray of inverted drinking cups and a tray of inverted soup cups used for resident meal service. A second light cover over the stove had visible grease and dust build up. A third light cover in the prep area of the kitchen was broken and a piece was missing. -The stove top had a build-up of black matter and food crumbs that were blackened and charred. There was a build-up of black grease on the side of the flat top grill. -The wall behind the stove and grill had built-up grease and streaks of grease running down from the hood. -Two ceiling vent covers above the steam table had build up of grease and dust. Plate covers were set on the steam table top shelf, not inverted and the food contact side was exposed to possible contamination by the dust and grease. -On 7/11/23 at 11:10 a.m. the two ceiling vent covers had been cleaned by the facility staff, however grease and dust build-up were still present approximately two inches across. Debris half an inch long was hanging from the vent cover over covered hot food in the steam table. The plate covers were not inverted and the regional chef (RC) turned the plate covers over so the food contact side was facing down and not exposed to potential physical contamination. -On 7/12/23 at 9:15 a.m. the nursing home administrator (NHA) was present, grease was found pooled in the ledge of the hood above the stove top and flat top grill running a hand inside the ledge. The district dietary manager (DDM) then cleaned the hood ledge with a towel. II. Food dating and labeling A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 7/24/23 from https://cdphe.colorado.gov/environment/food-regulations, read in pertinent part, Refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit or less for a maximum of seven days. The day of preparation shall be counted as Day one. B. Facility policy The Food Storage Retention Guide, undated, was provided by the district dietary manager (DDM) on 7/11/23 at 3:00 p.m. The pertinent use by food dating guidelines were as follows: Ready to eat or prepared foods: food in a form that is edible without additional preparation to achieve food safety (examples: leftovers, deli salads, cut produce); up to seven days and day one is the day of preparation. Raw meat/poultry/seafood: ground meat and all poultry; one to two days once thawed. C. Observations The following observations were made on 7/9/23 at 10:15 a.m in the walk-in refrigerator: -A five pound package and a ten pound package of raw ground beef were in a pan labeled with an expiration date of 7/3/23. -A container of minestrone soup with a prepared date of 7/1/23 and expiration date of 7/15/23. -A container of marinara with a prepared date of 6/2723 and expiration date of 7/10/23. -A container of cooked broccoli with a prepared date of 7/3/23 and expiration date of 7/11/23. -A container of fresh diced onion with a prepared date of 7/5/23 and an expiration date of 7/14/23. -The above items that were marked with an expiration date were past seven days (see reference above). III. Record review The kitchen cleaning schedule was provided by the dietary manager (DM) on 7/11/23 at 3:30 p.m. The cleaning schedule listed the following items to be cleaned daily by the end of each shift by the morning cook and the evening cook (twice a day total): grill including the drip tray, stove top and spider (burner) tops clean. The kitchen cleaning schedule listed hood and vents to be cleaned inside and out weekly by the evening cook. The kitchen cleaning schedule documented the entire floor to be mopped after lunch by the a.m. dietary aide and at the end of the shift by the p.m. dietary aide. A review of the completed cleaning schedule for June revealed the following: -The floor was marked as mopped twice every day for 24 days in June 2023 and at least once a day the remaining days. -The grilled, stove top and stove top spiders were cleaned at least once a day every day in June 2023 and twice a day 19 days in June 2023. -The hood and vents were marked as cleaned weekly in June 2023. The Food and Nutrition Services Food Safety and Sanitation audit was provided by the DDM on 7/11/23 at 3:30 p.m. The audit was marked as completed by the DM on 7/7/23. The audit documented the following: -Tomato paste was expired and discarded immediately. -There was no leftover food in the walk-in refrigerator. -However, there was no mention of the expired ground beef and the cooked and cooled broccoli (see observations above). IV. Interviews The DM, DDM and RC were interviewed on 7/11/23. The DM said the ground beef she thought was labeled incorrectly by taking all the product from the box it was delivered in and placing it in the pan. The DM and DDM said the ground beef that expired 7/3/23 should not be served and it was discarded. The regional chef (RC) said it was part of the daily walk through of the DM to check products in the walk-in, remove and discard expired products if needed. The DDM said the dating guidelines for food were on the door to the walk-in refrigerator and prepared foods had a seven day shelf life. The DM, DDM, RC and nursing home administrator were interviewed on 7/13/23 at 2:00 p.m. The DM said a cleaning list was posted on the board in the kitchen, dietary staff check off completed tasks. There was a deep cleaning by shift, and they have daily, weekly and monthly tasks. She said the hood filters were cleaned monthly and on the deep clean list and the floor was cleaned once a day after the dinner shift, unless something like a spill happens and they mopped more than once a day. The dietary staff cleaned the floor by mopping and using a scrub brush and deep cleaned the floor was done once a month. She said the dietary staff used a floor wash cleaning product provided by their chemical vendor and Orange Force. Both the DM and DDM said they had not read the instructions for use on the floor wash cleaning product that indicated to leave the chemical on the floor to penetrate before mopping. The DM said she was unsure how long the lights had been cracked in the kitchen. The DDM and DDM both said the lights needed to be cleaned. The DM said the dietary staff tried to clean up the grease that dripped from the hood when they noticed it. She said maintenance requests were written in the maintenance book or it was verbal communication with the maintenance supervisor (MS) or the NHA. A verbal request was reviewed at the morning meeting where she let the NHA know the issue. and they could follow up. She said she did report to the maintenance director that the ceiling vents needed to be cleaned and wrote it in the maintenance log. The DM said she tried to walk through the walk-in every day to review products in the refrigerated walk-in and when she did the Friday walk through (7/7/23) she probably missed the expired ground beef and she would do a better job. She said a five pound package of ground beef could take in one to two days to thaw and a 10 pound package can take a little longer to thaw. The RC said ceiling vents were not assigned to be cleaned by the dietary department but should have been looked at on kitchen walk throughs and any time that a vent was heavily soiled it should have been reported to the maintenance department. The RC said the floor wash cleaner instructions were to add the diluted cleaning product to the floor, let it sit, then mop or squeegee and allow it to air dry. The RC said the hood was not pulling air as strongly as it should that contributed to the grease drips on the wall. The RC said for meats the staff should pull frozen meat 72 hours ahead of the day it was to be used and it was on their production sheets. The NHA said the facility management reviewed the work order list in every morning meeting. The NHA said the facility maintenance department cleaned the kitchen ceiling vents if needed and it was something the dietary staff could complete. He said he did not think the maintenance team did a regularly scheduled kitchen walk through but it was going to be done in the future. The NHA said the maintenance director was not aware the ceiling vents needed to be cleaned. The DDM was interviewed on 7/13/23 at 9:30 a.m. He said the cleaning list documented what to clean but not how to clean it and he and the DM would work on that detail going forward. He said the stove top spiders looked like they had built up and had not been cleaned. He said he had looked for any written maintenance requests but was unable to find them. V. Facility follow-up Staff in-services were completed on 7/11/23 for the dietary department on the topics of cleaning and sanitizing and dating and labeling. The cleaning and sanitizing in-service read in pertinent part, Cleaning is the physical removal of solid and food matter from a surface. When you clean a surface you remove all visible debris. On 7/12/23 at 9:15 a.m. the floor in the dish room was observed to have been cleaned and debris removed. The grease build-up on the side of the flat top grill was still present however some of the build-up had been cleaned and removed. The broken light covers were replaced with new ones and the other light covers were cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure two (#63 and #60) out of 45 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide resolutions to food concerns voiced by Resident #63 and Resident #60. Findings include: I. Resident #63 A. Resident status Resident #63, younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included hyperkalemia (high potassium), seizures, anxiety, end stage renal disease, depression, chronic pain syndrome, and dependence on dialysis. The 5/31/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervision for all activities of daily living (ADLs). B. Resident interview Resident #63 was interviewed on 6/13/22 at 4:51 p.m. She said when she was admitted to the facility, the staff took all of her clothes to have them labeled, even though she told them on multiple occasions that the facility would not be doing her laundry. She said the staff took her clothes to label them. She said she did not receive all of her clothes back and was still missing a few items. Resident #63 said she had reported the missing items to the environmental services director (ESD). She said her clothing items had not been replaced since she was admitted to the facility three months ago. C. Record review The 4/26/22 grievance form, filed by Resident #63 documented the resident reported she had been missing a sweatshirt. The follow-up was documented on the grievance form by the environmental services director (ESD) that the sweatshirt was not found and needed to be replaced. The grievance form revealed the resident had not been notified her sweatshirt was not found and would be replaced. The nursing home administrator (NHA) did not sign the grievance form to approve the resolution. The resident did not receive a replacement sweatshirt. II. Resident #60 A. Resident status Resident #60, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 CPOs, the diagnoses included sepsis (blood infection), diabetes mellitus type two, obesity, and depression. The 5/26/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one person for bed mobility, dressing, toileting, and personal hygiene. B. Resident interview Resident #60 was interviewed on 6/13/22 at 5:11 p.m. She said her close friend gifted her a dress that meant a lot to her. She said she sent the dress to the laundry services and never received the dress back. Resident #60 said she reported the missing dress to the ESD several weeks ago. She said the facility had not located the missing dress. C. Record review The 5/31/22 grievance form filed by Resident #60 documented the resident had a missing black and white dress. The follow-up was documented on the grievance form by the ESD that the dress was not found and needed to be replaced. A purchase order was provided alongside the grievance form that a replacement dress was purchased. -However, according to the interview with Resident #60 she was not aware the dress had been replaced, nor received the replacement dress. The grievance form revealed the resident had not been notified her dress was not located and or replaced. -The NHA did not sign the grievance form to approve the resolution. III. Staff interviews The social services director (SSD) and NHA were interviewed on 6/15/22 at 5:23 p.m. She said residents were able to fill out grievance forms for any concerns they had. She said residents were also able to report grievances verbally and a staff member would assist the resident in filling out a form. The SSD said all grievance forms were given to her and placed in the grievance log. She said she then gave the grievance to the department manager it pertained to. She said each department manager was responsible for speaking with the resident and finding a solution to the concern. She said all grievances should be reviewed with the resident, who filed the grievance, to ensure their satisfaction with the resolution. The SSD said grievances should be resolved with the resident within three to five days of the resident filing the grievance. The SSD said when the department manager resolved the grievance, it was then given to the NHA for approval. The SSD said the facility received one to two grievances per week regarding missing clothing items. She said the majority of the time the facility was able to locate the missing items. The SSD said the ESD was responsible for handling grievances regarding missing clothing items. She said if the facility was unable to locate the item, the business office would replace the item. The ESD was interviewed on 6/16/22 at 11:25 a.m. She said the residents had recently filed a lot of missing clothing item grievances. She said when residents were admitted to the facility she took all of their clothing items and labeled them. She said she put this process into place to prevent clothing items from being lost. She said several residents had been admitted over the weekend recently, which resulted in their clothing items not being labeled. She said she was the only staff member that was able to label the residents clothing items. She said several grievances had been filed by residents recently regarding missing clothing items related to not being able to label their clothing items upon admission. She said Resident #63 had filed a grievance regarding a missing sweatshirt on 4/26/22, which was over two months ago. She said the sweatshirt was not located. She said she had requested the business office to replace the sweatshirt. The ESD said Resident #63's grievance was not followed up on in a timely manner. The ESD said Resident #60 filed a grievance regarding a missing dress on 5/31/22. She said the residents ' friend gifted her the dress. She said the resident placed the dress in the laundry hamper prior to it being labeled, which was why the dress went missing. She said the dress was unable to be located and thought the business office replaced the dress. She said she had not followed up with the resident to ensure a resolution was made. She said she understood why Resident #60 was upset, since her friend purchased the dress for her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#38) of four out of 45 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #38 was kept free from abuse by Resident #62. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/13/22 at 2:00 p.m. It revealed, in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting and kicking. It also includes controlling behavior through corporal punishment. II. Failure to keep residents free from abuse A. Resident #38 1. Resident status Resident #38, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included multiple sclerosis and major depressive disorder. The 4/30/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. She required extensive assistance of one person with bed mobility, dressing, toileting and personal hygiene and total dependence of two people with toileting. 2. Record review The behavior care plan, initiated on 1/22/21 and revised on 8/11/21, documented the resident had the potential to be involved in a resident to resident altercation related to her mood. The interventions, in pertinent part, included accepting staff interventions, notifying staff when she is frustrated by other residents, receiving visits as needed from the social services department to evaluate her mood and behavior, removing herself from negative interactions, coping with her frustrations with a counselor, and allowing the resident to verbalize her feelings and frustrations. B. Resident #62 1. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the June 2022 CPOs, the diagnoses included non-displaced fracture of the left clavicle. The 5/24/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting, and personal hygiene. She had verbal and physical behaviors toward others one to three days during the assessment period. 2. Record review The behavior care plan, initiated 6/1/21 and revised on 5/2/22, documented the resident had the potential to be verbally aggressive related to her diagnosis of dementia. The resident would provide mothering to others, which had the potential for her to have negative interactions with others. When agitated, the resident would strike out at others. It indicated the resident would camp out at the back door, waiting for her husband and was difficult to redirect. She would bang on the door and yell out. The interventions read in pertinent part administering medications as ordered; analyzing key times, places, circumstances, triggers and what deescalates the resident's behavior and document; assessing the resident's needs for food, thirst, toileting, position and comfort; assessing the resident's understanding of the situation and allowing time for the resident to express herself and her feelings toward the situation; encouraging the resident not to answer the phone; giving the resident as many choices as possible about care and activities; and when the resident became agitated, intervene before the agitation escalates, guiding the resident away from the source of distress, engaging in calm conversation and if the resident's response is aggressive, the staff should walk away calmly when the resident is in a safe position and approach the resident at a later time. C. Incident of physical abuse The 4/3/22 incident report documented Resident #38 had scratches to the right arm and the bridge of her nose. The nurse reported Resident #62 was heard arguing with her husband on the phone before she entered the dining room and began a physical altercation with Resident #38. Resident #38 said Resident #62 attacked her, scratched her arm and face and pulled her hair. Both residents were separated and injuries were assessed. The NHA, on call manager and the physician were notified. Treatment orders were received for Resident #38. Both residents were placed on 15 minute safety checks. The 4/9/22 abuse investigation documented the assailant (Resident #62) was upset that her husband was not visiting and went toward the victim (Resident #38). As she passed Resident #38 in her wheelchair, she reached out and scratched the victim. The victim pulled away and threw juice on the assailant. The investigation concluded Resident #62 physically assaulted Resident #38 by scratching her and pulling her hair. III. Staff interviews The NHA was interviewed on 6/16/22 at 10:55 a.m. He said Resident #38 was sitting in the dining room on 4/3/22. He said Resident #62 entered the dining room, agitated and targeted Resident #38. Resident #62 grabbed Resident #38 by the hair and scratched her arm and nose. Resident #38 threw juice on Resident #62 in retaliation. He said the facility staff intervened and separated both residents. He said the facility moved Resident #62 to another part of the facility, into a private room and have increased the resident's interactions with staff. He said, during the investigation, the facility had substantiated that Resident #62 had physically assaulted Resident #38. He said Resident #62 was easily agitated after her husband would visit her. He said she would get upset when he would leave and did not understand why she could not go with him. He said Resident #38 was not fearful of Resident #62. He said the facility determined Resident #62 had become agitated following a phone call with her husband and that led to the incident with Resident #38.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure three (#32 ,#9 and #39) of five residents reviewed out of 45 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #32, Resident #9 and Resident #39 were assisted with personal hygiene including nail care and facial hair. I. Resident #32 A. Resident status Resident #32, younger than 65, was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included epilepsy (seizure disorder), speech disturbances, lack of coordination, dysphagia (swallowing difficulty), need for assistance with personal care, and gastro-esophageal reflux disease (GERD). The 4/9/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required limited assistance of one person for bed mobility, transfers and extensive assistance of one person for dressing, eating, toileting, and personal hygiene. B. Resident interview and observations Resident #32 was interviewed on 6/14/22 at 10:13 a.m Resident #32 said he had uncontrolled movements in his upper extremities that caused him to cut his forehead because his fingernails were long. His fingernails were half inch extended past the tip of his finger. There were dried blood stains observed on his pillow case. The resident said the dried blood was from him accidently cutting himself with his fingernails. Resident #32 said he preferred to have his fingernails cut short to prevent him from hurting himself with involuntary movements. He said he often had to ask the facility staff multiple times before they would cut his nails. C. Record review The activities of daily living (ADL) care plan, initiated on 7/14/18 and revised on 3/10/21, documented Resident #32 had an ADL self-care performance deficit related to an anoxic brain injury (lack of oxygen to the brain), asthma, seizure disorder, and decreased mobility. The interventions included, in pertinent part, checking the resident's nail length, trimming and cleaning on the resident's bath days or as necessary and providing extensive assistance with showers and personal hygiene. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 6/16/22 at 11:15 a.m. She said the CNAs were responsible for trimming resident's fingernails on each resident's shower days. She said CNAs were not able to cut a resident's nails who was diabetic. She said Resident #32 required total assistance with personal hygiene, such as trimming his fingernails. She said the CNAs were responsible for trimming Resident #32's nails on his shower days or as needed. She said Resident #32 had reported to her that he did not like his fingernails long, as he was afraid of cutting himself with them. CNA #3 said she trimmed Resident #32's nails in the last few days as she noticed they were long (which was attended to during the survey process). Licensed practical nurse (LPN) # 5 was interviewed on 6/16/22 at 1:25 p.m. She said CNAs typically trimmed the resident's nails. She said all nursing staff members were responsible to ensure the resident's nails were trimmed and filed. The director of nursing (DON) was interviewed on 6/16/22 at 1:50 p.m. She said CNAs were responsible for trimming resident's fingernails. She said the nurses were responsible for trimming resident's fingernails of residents who were diabetic. II. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the June 2022 CPO, the diagnoses included heart failure, chronic obstructive pulmonary disease (COPD), diabete mellitus type two, and weakness. The 3/28/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of two people for bed mobility, transfers and extensive assistance of one person for dressing, toilet use, and personal hygiene. B. Resident interview and observations On 6/14/22 at 11:20 a.m. Resident #9 was sitting in a mechanical wheelchair in her room. She had one inch long hairs on her chin and neck. On 6/15/22 at 10:45 a.m. Resident #9 was sitting in her mechanical wheelchair in her room. She had one inch long hairs on her chin and neck. Resident #9 said she needed assistance from staff to complete personal hygiene tasks. C. Record review The ADL care plan, initiated on 1/10/17 and revised on 8/10/21, documented Resident #9 required assistance with ADLs related to weakness, decreased mobility, a left below the knee amputation, and obesity. The interventions included, in pertinent part, providing extensive assistance of one person for washing the resident's face, performing oral care and combing the resident's hair. D. Staff interviews CNA #3 was interviewed on 6/16/22 at 11:5 a.m. She said it was the CNAs responsibility to trim female facial hair for the residents. She said Resident #9 was able to complete personal hygiene with set up assistance. She said Resident #9 often had facial hair. She said Resident #9 needed encouragement and assistance to trim her facial hair. The director of nursing (DON), regional clinical director (RCD) #2, and the nursing home administrator were interviewed on 6/16/22 at 1:50 p.m. The DON said the CNAs were responsible for assisting residents with facial hair. The DON said Resident #9 needed encouragement and set-up assistance to perform personal hygiene, such as grooming her facial hair. She said female facial hair should be kept groomed. III. Resident #39 A. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included Parkinson ' s disease, and chronic heart failure. The 4/29/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 13 out of 15. She required extensive assistance of one person with bed mobility, transfers, dressing, toileting, and personal hygiene and bathing. B. Resident interview and observations Resident #39 was interviewed on 6/13/22 at 1:20 p.m. The resident had greasy shoulder length hair and about one inch long facial hair on her chin. She stated the certified nurse aides (CNAs) were supposed to assist her with facial hair during the showers but it did not happen regularly. She said she had tremors and was not able to do so herself. C. Staff interviews CNA #1 was interviewed on 6/16/22 at 12:15 p.m. She said she was working with Resident #39 today but she did not recall giving her showers. She said she did not notice any facial hair on the resident. She said she would check with the resident and if she did have facial hair she would offer her assistance with the removal. RN #2 was interviewed on 6/26/22 at 2:10 p.m. She said all residents offered assistance with facial hair removal. She said Resident #39 should be assisted with her facial hair removal if this was her preference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#21) of two residents reviewed for visual problems out of 45 sample residents. Specifically, the facility failed to investigate Resident #21's broken glasses and fix them timely. Findings include: I. Facility policy and procedure The Hearing and Vision Services policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/17/22 at 4:58 p.m. It revealed, in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. Employees should refer any identified need for hearing or vision/appliances to the social worker/social services designee. The social worker/social services designee is responsible for assisting residents, and their families, in locating and utilizing any available resources for the provision of the vision and hearing services the resident needs. Employees will assist the resident with the use of any devices or adaptive equipment needed to maintain vision or hearing. II. Resident #21 status Resident #21, age younger than 65, was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included multiple sclerosis, hemiplegia (paralysis) to the left non-dominant side, speech disturbances and major depressive disorder. The 4/12/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of two people with bed mobility, transfers, dressing and personal hygiene and total dependence of two people with toileting. It indicated the resident used corrective lenses. A. Resident #21's interview and observations Resident #21 was interviewed on 6/14/22 at 10:31 a.m. He said his glasses were falling apart. He said his glasses had been broken for three months and the staff did not offer or attempt to fix his glasses. He said he was told, since he needed new glasses, they would not assist him in getting his current glasses fixed and he would have to wait for his new pair. He said he used his glasses every day and needed them to be able to see clearly. The resident's glasses were observed to be broken on the right arm. The resident was only able to wear them with the missing arm, however they kept slipping off his nose. On 6/14/22 at 5:30 p.m. the resident was observed sitting in the dining room. The resident's glasses had tape on them at the right arm of the glasses. B. Record review The impaired visual function care plan, initiated on 5/18/18 and revised on 2/4/2020, documented the resident had impaired visual function due to a diagnosis of multiple sclerosis and cataract surgery in November 2018. The interventions included, in pertinent part, ensuring appropriate glasses were available to support the resident's participation in activities, reminding the resident to wear his glasses when up, and ensuring the resident's is wearing glasses which are clean, free from scratches and in good repair. The 1/6/22 social services progress note documented the resident had a vision exam completed and resulted in the resident requiring eye surgery for cataracts. It indicated the facility was working on obtaining details from the eye center to schedule the resident's eye surgery. The 3/21/22 vision progress note documented the resident was scheduled to be seen on 3/21/22 for broken glasses. The resident was unable to be seen because he was out of the facility. It indicated the resident would be seen in April 2022 to reattempt the visit, however the resident's medical record did not have documentation to indicate the resident had been seen. The additional vision notes documented in the resident's medical record on 5/4/22 did not indicate his glasses had been attempted to be fixed, however just indicated the resident was seen for double vision. III. Staff interviews The social services director (SSD), social services assistant (SSA) and the NHA were interviewed on 6/15/22 at 5:25 p.m. The SSD said the social services department was responsible for ensuring resident's received ancillary services such as vision, dental, podiatry and audiology. She said a vision provider came to the facility approximately every six weeks. She said if 10 or more residents needed to be seen, he would come to the facility sooner. She said any residents who needed to be seen were placed on a list and would be seen when the optometrist would come to the facility. The SSD said the social services department could assist in fixing glasses. She said they kept a variety of screws in the social services office for replacement and could assist with fixing any broken glasses. The SSA said she was aware Resident #21's glasses were broken. She said she did not know how long she had been aware they had been broken, but it had been a while. She said she had never looked at the resident's broken glasses or offered to try and get them fixed. She said she did not know if the glasses had broken or were missing a screw. She said she did not know who had taped the resident's glasses on 6/14/22, during the survey process. She said she was not involved. She said Resident #21 had surgery coming up and would end up with a different eye glasses prescription. She said she did not attempt to get his glasses fixed because he would be getting new glasses. She said she had not spoken with him regarding his broken glasses. She said she thought the resident's glasses had been broken for a few months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#63 and #42) of three out of 45 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to: -Ensure Resident #63 was served a therapeutic diet to meet her nutritional needs; and, -Ensure Resident #42 was re-weighed in a timely manner after a significant weight gain. Findings include: I. Professional reference According to the Nutrition Care Manual website, General Renal Diet Properties, https://www.nutritioncaremanual.org/auth.cfm (Retrieved 6/26/22). Definition: Renal diets restrict specific nutrients based on the severity of renal failure and current treatment methods. Nutrients that are restricted in renal diets include protein, sodium, potassium, phosphorous, and water (and, thus, fluid in general). These additional restrictions must be specified to accompany the renal diet order. Assessment by the registered dietitian nutritionist (RDN) will determine the need for modification in protein, sodiu, potassium, phosphorus, and fluid based on individual needs, stage of renal failure, and treatment methods. Despite the intentional, individual restrictions of a renal diet, these meal plans can still have adequate energy, macronutrients, and micronutrients. For patients who must eliminate an extensive number of foods from the diet, diet intervention and customization by an RDN is needed to ensure the diet is nutritionally adequate. This diet is appropriate for long-term use and meets the Recommended Dietary Allowances/Dietary Reference Intakes for all ages. Communication between the facility and dialysis center is essential for the patient to achieve nutrition goals. This may routinely include review of laboratory data, diet acceptance, diet tolerance, and need for diet modifications. II. Facility policy and procedure The Nutritional Management policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/17/22 at 10:00 a.m. It revealed, in pertinent part, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition. Acceptable parameters of nutritional status refers to factors that reflect that an individual's nutritional status is adequate, relative to his/her overall condition and prognosis, such as weight, food/fluid intake, and pertinent laboratory values. Care plan implementation: The resident's goals and preferences regarding nutrition will be reflected in the resident's plan of care, interventions will be individualized to address the specific needs of the resident. Examples include, but are not limited to: diet liberalization unless the resident's medical condition warrants a therapeutic diet, altered-consistency food/liquids after underlying causes of symptoms are addressed, weight-related interventions, environmental interventions, disease-specific interventions, physical assistance or provision of assistive devices, interventions to address food-drug interactions or medication side effects. Real food will be offered first before adding supplements. Monitoring/revision: monitoring of the resident's condition and care plan interventions will occur on an ongoing basis. Examples of monitoring include: interviewing the resident an/or resident representative to determine if their personal goals and preferences are being met; directly observing the resident; interviewing the direct care staff to gain information about the resident, the interventions currently in place, what their responsibilities are for reporting on those interventions, and possible suggestions for changes if necessary; reviewing the resident-specific factors identified as part of the comprehensive assessment to determine if they are still relevant of if new concerns have emerged such as new diagnoses or medications; and, evaluating the care plan to determine if current interventions are being implemented and effective. The Weight monitoring policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/17/22 at 10:00 a.m. It revealed, in pertinent part, based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutrition status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended loss over a period of time) may indicate a nutritional problem. A weight monitoring schedule will be developed upon admission for all residents: weights should be recorded at the time obtained. Mathematical rounding should be utilized; newly admitted residents - monitor weights for four weeks; residents with weight loss-monitor weight weekly; if clinically indicated - monitor weights daily; and, all others- monitor weight monthly. Weight analysis: the newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: 5% change in weight in one month (30 days); 7.5% change in weight in three months (90 days); and, 10% change in weight in six months (180 days). III. Resident #63 A. Resident status Resident #63, younger than 65, was admitted on [DATE] and remitted on 5/26/22. According to the June 2022 computerized physician orders (CPO), the diagnoses included hyperkalemia (high potassium), seizures, anxiety, end stage renal disease, depression, chronic pain syndrome, and dependence on dialysis. The 5/31/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervision for all activities of daily living (ADLs). The 3/1/22 MDS assessment documented that the resident received dialysis. B. Resident interview and observations Resident #63 was interviewed on 6/13/22 at 4:51 p.m. She said the physician had prescribed her a renal diet as she received dialysis three times a week. She said the facility was unable to provide her with foods that accommodated the renal diet that was ordered by the physician. Resident #63 said she often received foods that were so salty, she was unable to finish consuming the items. She said she recently stopped ordering food from the kitchen as she often received the wrong menu item that did not meet her dietary restrictions and the food was served cold. -Cross reference: F804 the failure to serve palatable food. Resident #63 said she bought a refrigerator and a microwave for her room. She said she ordered low sodium food options that she was able to heat herself. She said the facility removed the microwave from her room and said it was a fire hazard. She said she ordered in microwavable macaroni and cheese that the nursing staff would help her cook. She said she had filed grievances with the facility regarding the food, but the facility did not resolve the grievances and she still received inedible food that was not part of her renal diet. Resident #63 said her dry weight was 130 lbs to 140 lbs. She said the facility RD did not listen to her when she reported her dry weight. At the time of Resident #63's interview, she had microwavable macaroni and cheese, bread, peanut butter, jelly, animal crackers, and a variety of other packaged snacks observed in her room. C. Record review 1. Nutritional care plan The nutrition care plan, initiated 5/4/22 and revised 5/13/22, documented the resident had a nutritional problem related to end stage renal disease (ESRD) with renal replacement therapy (dialysis), depression, Clostridium difficile (a germ that causes diarrhea), epilepsy (seizure disorder), chronic pain, ascites (accumulation of fluid in the abdomen), hypertension (high blood pressure). The resident went to dialysis on Monday, Wednesday, and Friday. The resident had a desired significant weight gain in May 2022. The interventions included: determining the resident's likes and dislikes, obtaining dry weights after dialysis treatments, inviting the resident to activities that promote additional intake, observing the resident for signs and symptoms of dysphagia (difficulty swallowing), observing for signs and symptoms of malnutrition such as weight loss, obtaining lab work as ordered by the physician, providing and serving supplements as ordered by the physician, eight ounces of Nepro (nutritional supplement) once per day, providing the diet as ordered; the registered dietitian (RD) to monitor and make recommendations as needed and providing the resident a calm and quiet setting at meal times. 2. Nutritional assessments/progress notes The 2/23/22 nutrition data collection assessment documented that the resident weighed 160 lbs upon admission. Her usual body weight was 150 to 160 lbs and the resident had not had any recent weight changes. The resident had ascites and bilateral lower extremity edema and a dialysis port. The resident received dialysis three days per week. The resident was able to feed herself independently and accepted snacks. The physician ordered for the resident to receive a renal diet and had varying meal intakes. The resident was ordered to receive a nutritional supplement twice a day. The RD recommended providing the resident a before or after dialysis meal and diet education related to dialysis as needed. The nutrition goals were to maintain the resident's current weight without any significant weight changes. The 2/23/22 nutrition progress note documented the RD recommended continuing the resident's current diet, monitoring the resident's fluid intake, encouraging meal intake, offering support during meals, offering snacks between meals, monitoring the resident's weekly dry weights, providing before or after dialysis meals, and providing education related to ESRD and dialysis. The resident said she had been on dialysis for four years and was aware of which foods she was able to consume. The 3/14/22 nutrition progress note documented that the resident weighed 139.4 lbs on 3/14/22 with a BMI of 21.8, indicating the residents ' weight was normal to underweight. She sustained a significant weight loss of 7.6% (11.4 lbs) in one week (from 2/25/22 to 3/3/22) and weight changes were expected related to dialysis. The resident reported frequent gastrointestinal (GI) issues, such as nausea and low appetite. The resident had snacks in her room to consume as she desired. The RD recommended decreasing the nutritional supplement to once a day as the resident was frequently refusing. -Resident #63 sustained a significant weight loss of 7.6% (11.4 lbs) in one week (from 2/25/22 to 3/3/22). The RD did not assess the weight change until 3/14/22, 12 days after the resident sustained a significant weight loss. -The RD did not put nutritional interventions in place to address Resident #63's significant weight loss on 3/3/22. The 4/13/22 nutrition progress note documented the resident weighed 136.8 lbs on 4/7/22 with a BMI of 21.4, which indicated the resident was at a normal weight. The resident sustained a significant weight loss of 8.4% (12.6 lbs) in two months (from 2/25/22 to 4/7/22). The resident continued on a renal diet with variable meal intakes and meal refusals. The RD recommended the resident needed to increase her caloric intake. The RD documented the resident could have sustained the weight loss related to increased nutrient needs with dialysis treatments, inconsistent meal intake, dialysis refusals, supplement refusals, and a paracentesis (removal of fluid from the amdoment). The RD visited quickly with the resident and encouraged increased meal and supplement intake. It indicated the resident said she preferred her own food. -Resident #63 sustained a significant weight loss of 8.4% (12.6 lbs) in two months (from 2/25/22 to 4/7/22). The RD did not assess the weight change until 4/13/22, eight days after the resident sustained a significant weight loss. The 5/13/22 nutrition progress note documented the resident weighed 145.2 lbs on 5/5/22. The resident consumed 75% of meals, but had multiple refusals. The resident sustained a significant weight gain of 6.1% (8.4 lbs) in one month (from 4/7/22 to 5/5/22). The resident had snacks ordered after dialysis such as peanut butter and jelly sandwiches, Nepro, and desserts. The RD documented the weight gain and was unsure if the weight gain was from fluid shifts or good intakes. It documented the resident was meeting her nutrition needs when she consumed food. There were no new interventions recommended. The 5/18/22 nutrition progress note documented that the residents' electronic medical chart was updated with dry weights from dialysis. The dry weights should be documented to monitor the residents ' lean body mass. Weight fluctuations were anticipated related to dialysis treatments. The 5/31/22 nutrition progress note documented that the resident was readmitted to the facility after a hospitalization due to fluid overload. The RD recommended continuing the current diet, monitoring the resident's fluid intake, encouraging meal intake, offering snacks in between meals, continuing the nutritional supplements as ordered, monitoring the resident's dry weights, and providing diet education as needed. D. Staff interviews The RD and the NHA were interviewed on 6/15/22 at 1:45 p.m. The RD said Resident #63's weight should be monitored closely due to her diagnosis. She said since the resident was on dialysis, she could have weight changes related to fluid shifts. The RD said the physician had prescribed Resident #63 to be on a renal diet, since she received dialysis treatment. The RD said a renal diet should be low in potassium, sodium, and phosphorus. The RD said packaged snacks and delivery food were high in nutrients that the resident should not consume. The RD said she was not aware that Resident #63 was receiving food items from the kitchen that did not fall within the residents ' physician ordered renal diet restrictions. The RD said the facility was not meeting the resident's nutritional needs as the facility failed to provide the resident food that met her dietary restrictions. The RD said she had not spoken with the RD at the dialysis center regarding the resident's weights and nutritional needs. She said she should have collaborated and documented with the RD at the dialysis facility regarding Resident #63's nutritional status and needs. The dining account manager (DAM) and the regional dining director (RDD) #1 were interviewed on 6/15/22 at 2:15 p.m. The DAM said the kitchen changed the menu for the renal diet occasionally. She said she was not aware that Resident #63 was often served foods that did not meet her dietary restrictions. She said the facility was not meeting the resident's nutrition needs. IV. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the June 2022 CPO, the diagnoses included muscle weakness, intellectual disabilities, and anxiety. The 4/30/22 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required supervision for transfers and limited assistance of one person for dressing, toileting, and personal hygiene. It documented the resident had a weight gain of 5% or more in the last month or weight gain of 10% in the last six months that was not physician-prescribed. B. Record review 1. Nutritional care plan The nutrition care plan, initiated 11/26/21 and revised on 5/16/22, documented the resident was at risk for unintended weight change related to physiologic causes as evidenced by heart failure, pain, metabolic encephalopathy (chemical imbalance in the brain), hypomagnesemia, pneumonia, weakness. The resident was at risk for fluid deficit related to diuretic and laxative use. The interventions included monitoring signs or symptoms of dysphagia (swallowing difficulties,; monitoring signs and symptoms of malnutrition such as significant weight loss, obtaining and monitoring lab work, providing education related to weight gain, providing a regular diet and monitoring meal intakes, and providing education regarding diet change recommendations as needed. The nutrition at risk care plan, initiated on 5/16/22, documented the resident had a nutritional problem related to metabolic encephalopathy, heart failure, hypertension (high blood pressure), weakness, magnesium infusion, and obesity. The resident had progressive weight gain since her admission to the facility. The interventions included administering medications as ordered, determining the resident's food preferences, developing an activity program that included exercise and mobility to help divert the resident from food, obtaining monthly weights, observing for signs and symptoms of dysphagia, observing for signs and symptoms of malnutrition, providing the diet as ordered by the physician, and evaluating the resident as needed by the RD. 2. Resident #42's weights Resident #42's weights were documented in the resident's medical record as follows: -On 11/19/21, the resident weighed 111 lbs. This weight was struck out on 12/16/21, related to a reweigh. -On 12/1/21, the resident weighed 159.8 lbs. The resident's weight was obtained with a wheelchair scale. -On 12/8/21, the resident weighed 159 lbs. The resident's weight was obtained with a standing scale. -On 1/10/22, the resident weighed 158.6 lbs. The resident's weight was obtained with a standing scale. -On 2/15/22, the resident weighed 167.2 lbs. The resident's weight was obtained with a standing scale. -On 3/4/22, the resident weighed 172 lbs. The resident's weight was obtained with a wheelchair scale. -On 5/12/22, the resident weighed 188.2 lbs. The resident's weight was obtained with a wheelchair scale. -On 5/15/22, the resident weighed 187.8 lbs. The resident's weight was obtained with a standing scale. -On 6/1/22, the resident weighed 193 lbs. The resident's weight was obtained with a wheelchair scale. -On 6/15/22, the resident weighed 191.6 lbs. The resident's weight was obtained with a standing scale. -The resident had a 5.4% (8.6 lbs) weight gain, which was considered significant, from 1/10/22 to 2/15/22 in one month. -The resident had a 8.2% (13 lbs) weight gain, which was considered significant, from 12/8/22 to 3/4/22 in three months. -The resident had a 12.3% weight gain, which was considered significant, from 2/5/22 to 5/15/22 in three months. -The resident had a 12.2% (21 lbs) weight gain, which was considered significant, from 3/4/22 to 6/1/22 in three months. -The resident had a 21.4% (34 lbs) weight gain, which was considered significant, from 12/8/21 to 6/1/22 in six months. 3. Nutritional assessments/progress notes The 11/26/21 nutrition data collection assessment documented the resident's weight on 11/19/21 was 111 lbs. The resident's usual body weight was unknown at time of admission. The resident's body mass index (BMI) was 18.5. The resident had not had any significant weight changes. The resident was independent at meals and was on a regular diet with thin liquids. The assessment summary documented that the resident reported a poor appetite upon admission related to her recent illness. The resident was consuming 38% of her meals and was unsure of her usual weight. The resident was at risk for fluid deficit related to the use of diuretic and laxative medications. It documented that the RD would be available as needed. The 11/26/21 RD assessment documented the resident required 1500-1600 calories per day, 51-61 grams of protein per day, and 1500 milliliters of fluids per day. The assessment summary documented the resident was at risk for unintended weight change related to physiological causes as evidenced by heart failure, pain, metabolic encephalopathy, hypomagnesemia, pneumonia, and weakness. The resident was at risk for fluid deficit related to the use of diuretic and laxative medications. The 2/25/22 nutrition note documented the resident weighed 167.2 lbs on 2/15/22 and had a BMI of 27.8. The resident consumed 50-100% of meals and snacks. The resident sustained a significant, undesired and unplanned weight gain of 5.4% (8.6 lbs) in one month, from 1/10/22 to 2/15/22. The RD requested nursing to obtain a reweigh for the resident. The nutrition goals were to maintain current weight without significant change. The RD visited with Resident #42. The resident said she did not notice any recent weight changes. -Resident #42 was weighed on 2/15/22 and the RD did not assess the weight change until 2/25/22, 10 days after the resident sustained a significant weight gain. The reweigh was not obtained until 3/4/22, eight days after the RD made the request. The 3/17/22 nutrition progress note documented the resident weighed 172 lbs and had a BMI of 28.6. The resident sustained a significant, undesired and unplanned weight gain of 8.2% (13 lbs) in three months (from 12/8/21 to 3/4/22). It indicated the resident may have had a weight gain related to fluid retention from heart failure and medication infusions, excessive caloric intake, and decreased physical activity. The interventions included continuing the resident's current diet, monitoring the resident's fluid intake, offering the resident snacks in between meals, monitoring the resident's weight weekly, and providing education related to fluid intake and heart failure as needed. The nutrition goals included maintaining the resident's current weight without a significant change. -The resident had a significant weight gain of 8.2% (13 lbs) in three months (from 12/8/21 to 3/4/22). The RD did not assess the resident's weight change until 3/17/22, 14 days after the documented significant weight gain. -The RD recommended the resident to be weighed weekly as a nutritional intervention. The resident was not weighed again until 5/12/22, two months after the resident was placed on weekly weights. The 5/13/22 nutrition progress note documented that the RD requested the resident to be reweighed as the resident sustained a 16 lbs weight gain in two months. The resident had a steady weight gain since her admission to the facility. The 5/16/22 nutrition progress note documentetd the resident weighed 187.8 lbs on 5/15/22 and had a BMI of 31.2, which was now considered obese. The resident sustained a significant weight gain of 12.3% (20.6 lbs) in three months (from 2/5/22 to 5/15/22). It indicated the resident may have sustained a significant weight gain related to excessive caloric intake from meals, snacking, and getting meals and snacks at medication infusions on Monday, Wednesday, and Fridays, decreased physical activity, and possible fluid retention related to heart failure. -These potential weight gain factors had been documented in the nutritional progress notes and assessments since her admission to the facility, however the facility continued to fail to intervene to prevent the resident's excessive weight gain. The interventions did not include any additional interventions that had not already been documented in the resident's medical record during previous nutritional assessments. The physician was notified of the residents ' significant weight gain and said the weight gain was likely from excessive caloric intake. The 5/18/22 interdisciplinary (IDT) note documented that the resident had a significant, undesired and unplanned weight gain in three months. The resident's weight fluctuations were expected due to the resident's diagnosis of heart failure. The resident did not display signs of symptoms of fluid overload. The IDT recommended the RD was to provide a snack list to encourage fruit and vegetable intake. -The IDT did not provide any additional interventions to combat the resident's significant weight gain. The 6/13/22 nutrition progress note documented the resident weighed 193 lbs on 6/1/22 with a BMI of 32.1, which was still considered obese. The resident sustained a 12.2% (21 lbs) weight gain in three months (from 3/4/22 to 6/1/22) and a 21.4% (34 lbs) weight gain in six months (from 12/8/21 to 6/1/22). The RD requested a reweigh to verify the resident's weight gain. It indicated the resident may have sustained a significant weight gain related to excessive caloric intake from meals and snacking, obtaining meals during medication infusions, decreased physical activity, and possible fluid retention related to heart failure. -The RD did not evaluate the interventions in place to determine their effectiveness to prevent the resident's continued significant weight gain or put other effective interventions into place. -The resident sustained a significant weight gain of 12.2% (21 lbs) in three months (from 12/8/21 to 6/1/22) and a 21.4% (34 lbs) weight gain in six months (from 12/8/21 to 6/1/22). The RD did not assess the resident's weight change until 6/13/22, 13 days after the resident sustained a significant weight gain. The rewigh was not obtained until 6/15/22, which was during the survey process. C. Staff interviews The RD and the NHA were interviewed on 6/15/22 at 1:45 p.m. The RD said weights should be obtained upon each resident's admission to the facility and then weekly for four weeks. The NHA said the restorative nurse aides (RNA) were responsible for obtaining admission, weekly, and monthly weights. The RD said she expected reweighs to be done within 24 hours of the request. She said had noticed reweighs were taking a long time to be completed. He said the facility had noticed reweighs were not being completed in a timely manner, so the RD started communicating directly with the RNAs to obtain reweighs as recommended. The RD said she had discussed Resident #42's weight gain with the resident's physician. The physician said the residents ' weight gain was likely related to the resident's decreased physical activity and excessive caloric intake. The RD said she recommended the resident be placed on an activity program to increase physical activity to help maintain weight balance on 5/16/22, but the program had not been developed. The RD said she documented, to provide diet education to the resident regarding heart failure and weight gain, however the actual education provided to the resident was not documented in the medical record. The RD confirmed Resident #42's weights were not assessed in a timely manner. She said the facility did not obtain reweighs in a timely manner to assess the residents' nutritional status. The director of nursing (DON), NHA, and the regional nurse consultant (RNC) #2 were interviewed on 6/16/22 at 1:50 p.m. The DON said all residents should be weighed the day they were admitted to the facility. The DON said obtaining weights and reweighs in a timely manner was important to monitor the residents ' nutrition status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observations, the facility failed to assist a resident to obtain routine or emergency dental services, as needed, for one (#58) out of two of 45 sample residents. Specifically, Resident #58 lost his dentures at the hospital and the facility did not assist the resident in finding the lost dentures or obtaining new dentures. Findings include: I. Facility policy and procedure The Dental Services policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/17/22 at 4:58 p.m. It revealed, in pertinent part, It is the policy of this facility to assist residents in obtaining routine and emergency dental care. The social services director (SSD) maintains contact information for providers of dental services that are available to facility residents at a nominal cost. The facility will assist the resident with making dental appointments and arranging transportation to and from the dental services location. For residents with lost or damaged dentures, the facility will refer the resident for dental services within three days. Direct care staff are responsible for notifying supervisors or the SSD of the loss or damage of the dentures during the shift that the loss or damage was noticed, or as soon as practicable. The SSD, or designee, shall make appointments and arrange transportation. The resident and/or resident representative shall be kept informed of all arrangements. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record. II. Resident #58 status Resident #58, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included secondary malignant neoplasm (cancer) of the brain, heart failure and ischemic cardiomyopathy (decreased function of the heart). The 5/25/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required limited assistance of one person with transfers and supervision with bed mobility, dressing, eating, toileting and personal hygiene. It indicated the resident did not have any broken or loosely fitted full or partial dentures. A. Resident #58 interview Resident #58 was interviewed on 6/13/22 at 4:33 p.m. He said his dentures had been lost when he was at the hospital six months ago. He said the social worker was aware his dentures had been lost, however had not assisted him in obtaining new dentures. He said he was not aware the facility should assist him in obtaining new dentures. He said he was given a list of three dentists by a facility staff member but neither of them took his insurance to be able to get new dentures. He said he did not know what else to do to get new dentures. B. Record review The 12/28/21 social services progress note documented that the resident had upper and lower dentures when he was admitted to the facility. The 1/18/22 social services progress note documented the resident was edentulous. The resident had upper and lower dentures, however they went missing while he was in the hospital. -The resident's medical record did not contain any further documentation regarding the process of ensuring the resident received new or replacement dentures. III. Staff interviews The SSD, social services assistant (SSA) and the NHA were interviewed on 6/15/22 at 5:25 p.m. The SSD said the social services department was responsible to arrange dental services for the residents. She said the dentist came to the facility every month and maintained a list of residents to be seen annually. When a resident needed to be seen, she said they placed the resident on the list and provided the list to the dentist prior to coming to the facility. The SSA said she was assigned to the resident and was not aware the resident had any dentures. She said she thought he had natural teeth. She said she had not made arrangements for the resident to be seen by the dentist to obtain new dentures or contact the hospital for the policy of replacing the lost dentures. The SSD said she was aware Resident #58 had lost his dentures at the hospital. She said she had called the local hospital and they could not locate the resident's dentures. She said she had not pursued it any further and did not know the hospital's policy for replacing the lost dentures. She said she did not document that information in the resident's medical record. The SSD said she did not assist the resident in obtaining new dentures.

Based on interviews and record review, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents ' concerns regarding meals that were brought up by the resident council and food committee. Findings include: I. Resident interviews Residents were identified by the facility and assessment as interviewable. Resident #41, #12, #14, #9 and #2 were interviewed on 6/15/22 at 9:56 a.m. They said during resident council meetings, they were told not to share food concerns. They said the facility staff told the residents they could attend food committee meetings held on the fourth Tuesday of each month to voice concerns regarding their meals. They said the food committee meetings were often canceled or rescheduled without notice. They said they found the food committee to be a waste of their time, as the concerns voiced were never addressed or resolved. They said they had notified the facility regarding late meals, cold food, not receiving what they ordered, small portions, and not enough variety on the menu through menu chat or with staff members, but the facility had failed to address these concerns. They said they preferred the department heads to attend the resident council meeting, so the concerns brought up by the residents could be heard and addressed by the staff. II. Record review The December 2021 resident council meeting minutes revealed that the food committee meeting would be held in two weeks. The December 2021 food committee minutes revealed the residents reported the biscuits and gravy needed more gravy, the scrambled eggs needed more cheese, and they did not like the corned beef that was served. They requested chili dogs, bratwurst, soups (corn chowder and potato), beef stem, smothered burritos, broccoli rice casserole, and jello to be placed on the upcoming menu. The January 2022 resident council meeting minutes revealed the food committee meeting would be held in two weeks. One resident requested condiments to be served with her meals. The January 2022 food committee minutes revealed the resident would like more breakfast meat, fresh fruit, burritos, jello and more ice cream to be on the upcoming menus. -It did not document the result of the concerns that were brought up in the December 2021 food committee meeting. It did not address the resident ' s menu requests or a conclusion if they would be added to the menu. The February 2022 resident council meeting minutes revealed the residents voiced a concern in the month of January regarding their meal tickets. The minutes documented dietary questions would be shelved until the food committee held on the fourth Tuesday of the month at 2:00 p.m. in the bisto. -There was no documentation regarding the meal tickets in the January 2022 resident council minutes or if the residents felt their concern was addressed. The March 2022 resident council meeting minutes revealed food comments were to be shelved until the food council meeting on the fourth Tuesday of the month. A representative from the dining department was not present at the meeting. -The facility was unable to provide March 2022 food committee notes during the survey process. The April 2022 resident council meeting minutes revealed the director of the dining department resigned and tablecloths were planned to return to the dining room. A representative from the dining department was not present at the meeting. The April 2022 food committee minutes revealed the residents wanted more options and the menu to be changed. They requested chili macaroni, fried chicken, and a variety of desserts to be put on the upcoming menu. The May 2022 resident council meeting minutes revealed the director of dining services was meeting with residents regarding their food preferences and presented the new menu to the residents. The May 2022 food committee minutes revealed the residents wanted less fish and for the kitchen to work on food presentation. They requested fresh fruit to be placed on the menu. -The food committee minutes failed to address if the residents' felt their concerns and requests were addressed and implemented. The residents requested fresh fruit, jello and burritos in two of the four food committee meetings. Cross reference F803: the facility failed to follow the menu and provide the documented portion sizes to meet the residents nutritional needs. Cross reference F804: the facility failed to ensure food was palatable. III. Staff interviews The activities director (AD) and the nursing home administrator (NHA) were interviewed on 6/15/22 at 5:09 p.m. She said resident council was held on the second Tuesday of every month at 2:00 p.m. in the dining room. She said the meeting was documented on the activities calendar and she went room to room encouraging all residents to attend. She said she began each meeting by asking the residents if the department managers could attend the meeting. She said the residents preferred when the department managers attended the meeting, so they could hear the concerns the residents expressed. She said she then would read the minutes from the previous month's meeting and ask the residents if they had any ongoing concerns. She said if a resident had a concern that arose during the meeting, she would complete a grievance form and give it to the social services director (SSD) to place on the grievance log. She said the grievance would be assigned to the appropriate department to conduct an investigation. She said the residents had not had a group concern since she started working at the facility eight months prior. She said residents were able to bring up food concerns in the resident council meeting, but were encouraged to attend the food committee meeting to raise those concerns. The NHA said the facility had three different directors of dining in the last six months, which led to missed food committee meetings. He acknowledged the residents had several concerns regarding their meals and meal service that were not discussed in the resident council meeting. -The residents expressed wanting to discuss food concerns in the resident council meeting and were told by staff not to share their concerns. The resident council meeting was organized by the residents with staff participation by invitation, therefore the staff should not impede on their meeting. The dining account manager (DAM) and the regional dining director (RDD) were interviewed on 6/16/22 at 12:46 p.m. The DAM said the food committee was held on the fourth Tuesday of every month. She said all residents were welcome to come, but the same residents typically attended. She said the residents should be able to voice their concerns related to food during the resident council meeting. The DAM said she was responsible for addressing and resolving grievances related to food and meal service. The DAM said she had not received any group grievance forms regarding meals since she started one month ago.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#25) of four residents reviewed for abuse out of 45 sample residents. Specifically, the facility failed to report incidents of alleged abuse to the State Agency made by Resident #25. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/13/22 at 2:00 p.m. It revealed, in pertinent part, The facility will have written procedures that include: Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies within specified time frames: immediately, but not later than two hours after the allegation is made, if the events of that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours after the allegation is made do not result in serious bodily injury. The administrator will follow up with government agencies, during business hours, to confirm the initial report was received and to report the results of the investigation when final within five working days of the incident, as required by state agencies. II. Resident #25 status Resident #25, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included delusional disorder, dementia without behavioral disturbance, bipolar disorder and psychotic disorder with delusions due to known physiological condition. The 4/14/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. She required supervision with all activities of daily living. It indicated the resident did not exhibit any behaviors during the assessment period. It indicated the resident wandered one to three days and her wandering significantly intruded on the privacy or activities of others. A. Incidents of alleged abuse 1. Alleged incident of abuse on 2/14/22 The 2/14/22 behavior progress note documented the resident claiming another resident kicked her three times in the dining room, she had called the police and she was told she was no longer allowed in the dining room. It indicated that none of the above statements contained any truth and there was no evidence of the resident being kicked. Another progress note, also dated 2/14/22, documented Resident #25 said a specific resident at the facility sucker punched her in the middle of the back during the dinner meal service. The staff in the dining room said it did not occur and the two residents had not been within arm's reach of one another. -It did not indicate the allegations had been reported to the State Agency. 2. Alleged incident of abuse on 3/8/22 The 3/8/22 behavior progress note documented the resident wheeled her wheelchair up to another resident in the dining room. She said to the other resident, Get out of my way, you (expletive language). Resident #25 told the nurse that the other resident started it. -It did not indicate the incident had been reported to the State Agency. 3. Alleged incident of abuse on 3/22/22 The 3/22/22 behavior progress note documented Resident #25 said another specific resident kicked her in the leg seven times. She then said she had been kicked in her head. The registered nurse (RN) informed Resident #25 that the resident she accused of kicking her, was unable to get out of bed. Resident #25 then said another specific resident kicked her in the head 10 times. The nurse told the resident to stay away from that specific resident if she was afraid. -It did not indicate the allegation had been reported to the State Agency. 4. Alleged incident of abuse on 4/19/22 The 4/19/22 behavior progress note documented Resident #25 said six people on the other side of the facility threatened to kill her. It indicated the RN completed an investigation which revealed another resident reporting that Resident #25 blocked the hallway, yelled at her and told her she was not allowed in that area. A certified nurse aide (CNA) intervened and brought Resident #25 back to the nursing station where she resided. Resident #25 became highly agitated and began to tell the facility staff that the people on the other side of the facility threatened to kill her. The nurse indicated she notified the NHA. -It did not indicate the allegation had been reported to the State Agency. 5. Alleged incident of abuse on 5/26/22 The 5/26/22 behavior progress note documented Resident #25 said she was hit by a specific resident. Resident #25 told the nurse to ask another resident who witnessed the incident. The other resident said she did not see anyone hitting Resident #25. -It did not indicate the allegation had been reported to the State Agency. -The facility was unable to provide documentation the allegations of abuse made by Resident #25 on 2/14/22, 3/8/22, 3/22/22, 4/19/22, and 5/26/22 were reported to the State Agency during the survey process (6/13/22-6/16/22). -A review of the State Agency abuse reporting system on 6/14/22 at 2:30 p.m. did not reveal documentation that the facility had reported the allegations of abuse to the State Agency. III. Staff interviews The NHA was interviewed on 6/16/22 at 10:55 a.m. He said the incidents reported by Resident #25 on 2/14/22, 3/8/22, 3/22/22, 4/19/22 and 5/26/22 were not reported to the State Agency. He said he only reported incidents that required reporting to the State Agency system. He said he did not report the incidents because he did not think they actually occurred. He said the resident had a history of making false allegations of abuse and was delusional. He said the resident would talk in circles and there was never a way to determine if the allegation actually happened. He said the resident did not have any physical marks after each incident she reported. He said all incidents of abuse should be reported to the State Agency within two hours of the incident occurring. He acknowledged, according to federal guidelines, any and all allegations of abuse should be reported to the State Agency. He acknowledged the investigation stage was where it was to be determined if the allegation was substantiated or unsubstantiated.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, appearance and temperature. Findings include: I. Facility policy and procedure The Therapeutic Diets policy and procedure, dated September 2017, was provided by the dining account manager (DAM) on 6/16/22 at 2:41 p.m. It revealed, in pertinent part, Therapeutic diet is defined as a diet ordered by a physician, or delegated registered or licensed dietitian, as part of the treatment for a disease or clinical condition. The purpose of a therapeutic diet is 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 that a resident is able to eat (e.g. mechanically altered diet.). II. Group interview A group interview was conducted on 6/15/22 at 10:00 a.m. with five alert and oriented residents (resident #4, #12, #14, #9, and #2), per the facility and assessment. All the residents in the group interview said the food was not palatable. Some of the comments were as follows: -The food was always cold; -The portion sizes were too small; -The food appeared to be slopped on the plate without any attention to detail; -The food had no flavor; -They often did not receive the menu items they requested; -The menu was often changed without notification; -Residents were served food items they could not eat due to diet restrictions, did not order, or did not like; and, -The kitchen frequently ran out of food on the alternative menu. III. Resident interviews Resident #14 was interviewed on 6/13/22 at 3:56 p.m., who was identified as interviewable by the facility and assessment. He said the food had no flavor or taste. He said they were able to order food off the alternative menu, but it did not taste good either. He said he would rather consume the wood off his dresser than the hamburger meat that was served to him. He said the food was often cold. He said when he ordered ice cream it was delivered to him melted. Resident #14 said the kitchen staff often forgot to provide him a meal. He said the nursing staff would use their own money to have food delivered to the facility for him. Resident #58 was interviewed on 6/13/22 at 4:26 p.m., who was identified as interviewable by the facility and assessment. He said the kitchen often changed the menu without notifying the residents. He said he preferred to eat his meals in his room. He said his meals were always delivered late and cold. He said the food was extremely bland and tasteless. Resident #29 was interviewed on 6/13/22 at 4:46 p.m., who was identified as interviewable by the facility and assessment. He said the food had no taste and was always cold. He said the meat was often too tough to chew. Resident #63 was interviewed on 6/13/22 at 4:51 p.m., who was identified as interviewable by the facility and assessment. She reported that she stopped eating the food the facility provided. She said she was prescribed a renal diet by her physician. She said the facility often changed the menu without notice to food items she was unable to consume due to her dietary restrictions. She said the kitchen frequently makes salisbury steak. She said she had filed grievances regarding the food, but nothing had been changed. Resident #60 was interviewed on 6/13/22 at 5:16 p.m., who was identified as interviewable by the facility and assessment. She said her physician had prescribed her to be on a diabetic diet. She said the facility did not follow the physician ordered diabetic diet. She said she had been a diabetic for many years and knew what she could and could not eat. She said the food was always cold and tasteless. Resident #47 was interviewed on 6/14/22 at 9:51 a.m., who was identified as interviewable by the facility and assessment. She said she often did not receive the food items that she had requested. She said the food did not taste good. Resident #32 was interviewed on 6/14/22 at 9:53 a.m., who was identified as interviewable by the facility and assessment. He said the food was always cold. He said the kitchen served the same meals over and over again. He said they often were served salisbury steak at least once a week. He said the food was tasteless. He said he purchased his own frozen waffles to have at breakfast everyday, because the kitchen often ran out of food. Resident #21 was interviewed on 6/14/22 at 10:28 a.m., who was identified as interviewable by the facility and assessment. He said the kitchen prepared the same menu items on repeat, which he grew tired of. He said the kitchen would often run out of food and substitute different items that were not originally on the menu. Resident #13 was interviewed on 6/14/22 at 10:34 a.m., who was identified as interviewable by the facility and assessment. She said she had ordered scrambled eggs and a biscuit for breakfast, but received a biscuit and gravy. She said she frequently did not receive the food items she ordered. IV. Observations During a continuous observation during the lunch meal on 6/15/22 beginning at 11:12 a.m. and ending at 12:05 p.m,. the following was observed: -Cook #1 said the alternate menu item for the day was salisbury steak, mashed potatoes with gravy, and braised cabbage. He said there was not enough pork loin to make the parsley pork loin, so the menu was changed. The menu was posted in the hallway by the common area, but the residents were not notified of the change. (see interview below) -Cook #1 said the buttered noodles were not made, therefore the residents who were ordered to receive a renal diet were served mashed potatoes. A test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for breakfast on 6/16/22 at 8:40 a.m. The test tray was not served at palatable food temperatures and consisted of oatmeal, sausage, and pancakes. -The oatmeal was very thick and tasteless. There were no condiments served with the oatmeal. -The sausage was cold at 102 degrees fahrenheit (°F) -The pancakes were crusted on the edges and chewy in the middle. The thermometer read 116.3°F. V. Record review The 6/12/22 to 6/18/22 week at a glance renal diet spreadsheet indicated the lunch meal for 6/15/22 was parsley pork loin, buttered noodles, zucchini and onions, a dinner roll, and sliced pears. VI. Staff interviews The registered dietitian (RD) and the nursing home administrator (NHA) were interviewed on 6/15/22 at 1:45 p.m. The RD said Resident #63 was on a renal diet as she had chronic kidney disease and received dialysis. She said it was important for Resident #63 to follow the renal diet prescribed by the physician. The RD said since the facility often changed the menu for the renal diet to items Resident #63 could not eat, the facility was not meeting the resident ' s nutrition needs. Cross reference F692: the failure to meet the nutritional needs of the Resident #63 who required a renal diet. The dining account manager (DAM) and regional dining director (RDD) #1 were interviewed on 5/15/22 at 2:15 p.m. The DAM said the menus were posted in the hallways three days in advance. She said when a menu item was substituted it was placed on the substitution log and updated on the menu in the hallways (A copy of the substitution log was requested, but not provided during the survey). She said the only way she notified the residents of the menu change was by updating the menu posting. RDD #1 said the parsley pork with buttered noodles should have been made to ensure the residents on a renal diet had the appropriate nutrition. The DAM said since the kitchen was often changing the menu items on the renal diet to items Resident #63 could not consume due to her dietary limitations; the facility was not meeting her nutritional needs. The DAM, RDD #1 and the RDD #2 were interviewed on 6/16/22 at 12:46 p.m. The DAM said she had recently conducted an in-service with all of the staff on professionalism. She said if residents requested an alternative food item they should receive it. The DAM said she started at the facility a month ago. She said she was working on meeting all of the residents to develop their food preferences. RDD #2 said the facility used a four week menu cycle that ran for six months. RDD #1 said she had conducted test tray audits once a month. She said she took the temperatures of the food in the kitchen and did not replicate meal service (due to the temperature of the food items decreasing once served from the kitchen). RDD #1 said the facility only had one hot holding box to deliver food to the five units. She said most of the residents preferred to eat in their rooms. She said she was working with the nursing home administrator to purchase additional hot holding boxes. The DAM said she had been attending the food committee recently. She said the residents had reported they were tired of chicken. She said she sampled the food after the cooks made it. She said the menu could use improvement and more options. The director of nursing (DON) and NHA were interviewed on 6/16/22 at 1:50 p.m. She said therapeutic diets were ordered to help manage certain diseases. The NHA said the facility had begun working with a nurse practitioner a few weeks ago to ensure the therapeutic diets' menus aligned with standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19. Specifically, the facility failed to initiate isolation precautions timely to control a scabies outbreak. Findings include: I. Professional reference The Centers for Medicare and Medicaid Services (CMS) (September 1, 2020) Scabies Frequently Asked Questions (FAQS), retrieved on 6/21/22 from https://www.cdc.gov/parasites/scabies/gen_info/faqs.html, read in pertinent part, Scabies is an infestation of the skin by the human itch mite. The microscopic scabies mite burrows into the upper layer of the skin where it lives and lays its eggs. The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies. Scabies is found worldwide and affects people of all races and social classes. Scabies can spread rapidly under crowded conditions where close body and skin contact is frequent. Institutions such as nursing homes, extended-care facilities, and prisons are often sites of scabies outbreaks. Institutional outbreaks can be difficult to control and require a rapid, aggressive, and sustained response. II. Facility policy and procedures A. The Infection Prevention Program policy, which was not dated, was provided by the nursing home administrator (NHA) on 6/17/22 at 4:58 p.m. It read in pertinent part, The goals of the infection prevention program are to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection by: decreasing the risk of infection to residents and personnel; monitoring for occurrence of infection, implementing appropriate control measures, and incorporating antibiotic stewardship practices; identifying and correcting problems relating to infection prevention practices; and, maintaining compliance with state and federal regulations relating to infection prevention. The infection prevention program is comprehensive, based on the individual facility assessment and accepted national standards, in that it addresses identification, detection, prevention, investigation, control, and reporting of communicable diseases and infections among residents and personnel. Systems are in place to facilitate recognition of increases in infections as well as clusters and outbreaks. B. The Outbreak Investigation policy, which was not dated, was provided by the NHA on 6/17/22 at 4:58 p.m. It read in pertinent part, Purpose: To delineate a process for outbreak investigation should an outbreak be suspected. An outbreak is defined as the occurrence of more cases over the usual or expected (endemic) number of cases of healthcare associated infections in a given area or among a specific group of people over a particular period of time, usually produced by the same organism. Any personnel recognizing a possible epidemic will immediately report this to the Director of Nursing and/or Infection Preventionist through which the facility management and medical director will be notified. Reasonable immediate control measures will be put into effect. Such measures might include but are not limited to transmission-based precautions, removal of common suspected sources of personnel from patient contact, or immediate inservice training in certain infection prevention techniques. C. The Head Lice and Scabies Exposure and Treatment policy, which was not dated, was provided by the NHA on 6/17/22 at 4:58 p.m. It read in pertinent part, It is the policy of this facility to ensure that residents who contract scabies or head lice are treated according to current standards of practice to eradicate the infestation and prevent further exposure and transmission. Human scabies is caused by the human itch mite. It is contagious and can be transmitted by direct, prolonged skin to skin contact with an affected person. Proper treatment and infection control measures should be utilized to prevent outbreaks within the facility. The infested resident will be placed in a single occupancy room away from other residents to avoid transmission. Staff will follow appropriate transmission-based precautions, including PPE, when providing care to the affected resident(s). III. Resident #41 (roommate of Resident #371) A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included cognitive communication deficit, unspecified dementia without behavioral disturbance, polyneuropathy, and need for assistance with personal care. The 4/30/22 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of seven out of 15. The resident required supervision with bed mobility, transfers, and personal hygiene. He required one-person limited assistance with dressing and toilet use. B. Record review The facility's Scabies Surveillance Form was provided by the director of nursing (DON) on 6/16/22 at 2:42 p.m. The form documented Resident #41 presented with itching, a rash and scabs on his entire body on 11/18/21. The resident received treatment for scabies on 12/9/21. -The resident did not receive treatment for scabies until 21 days after the appearance of the rash. Review of Resident #41's electronic medical record (EMR) revealed the following progress notes, documented in pertinent part: 11/18/21: Resident presents with generalized dryness and reddened rash to bilateral upper and lower extremities, and posterior aspect of back. Self scratches noted to areas of concern. Hardened lesion to the left lower lumbar. 11/19/21: Spoke with the resident's son who gave verbal consent for the wound doctor (WD) to complete a skin biopsy if deemed necessary. 11/23/21: Resident seen by WD for possible rash. The skin was evaluated and it was noted that he has multiple scabs and excoriation to his legs, arms, back and abdomen. There is no notable rash in the groin, webbing of fingers or armpits. The resident states that he is itchy, worst in his abdominal fold. The area to the abdominal fold has been cleansed and prepared for biopsy by the WD. 11/24/21: The interdisciplinary team (IDT) met to review resident: resident saw WD, punch biopsy was done on abdominal fold, WD diagnosed xerosis (abnormally dry skin)/neurotic excoriation (self-inflicted skin lesions produced by repetitive scratching). Biopsy will confirm, no new orders at this time, will continue treatments that are in place. 12/3/21: Resident and his roommate to be on contact isolation pending final biopsy skin results obtained several days ago. -Despite the facility experiencing a previous scabies outbreak in the facility one year earlier, Resident #41 was not placed on isolation until 15 days after his rash first appeared on 11/18/21. 12/8/21: IDT met to review the resident's skin. The resident was previously seen by the WD and a biopsy was completed to diagnose the rash. The biopsy results were inconclusive but did not exclude arthropod (an invertebrate animal which includes mites) bite reaction, seborrheic keratosis (a common noncancerous skin growth), immunobullous disease (blistering skin condition) or medication reaction. The WD did complete the immunofluorescence (a technique done to investigate pathophysiology of biopsy samples to help further diagnose skin disorders). The report is pending at this time. The resident was seen at dermatology to assess the rash further. The resident was diagnosed with scabies after a scraping was completed. All scabies precaution initiated. 12/9/21: Resident's son notified of temporary room change and treatment orders in place, son voiced understanding and had no questions. 12/9/21: Scattered rashes and scabs to entire body due to scabies. Treatment administered, resident continues on isolation. Review of Resident #41's EMR revealed the following documentation from the wound doctor: 11/23/21: Resident has been noted to have a diffuse rash for over a month that seems to wax and wane. There is no rash noted along intertriginous areas and skin folds including the interdigital web spaces, wrists, antecubital fossa, axillae and groin. He did have a few scattered slightly raised patches along the anterior abdominal fold. A punch biopsy was obtained of one of these lesions. A verbal consent was obtained from the power of attorney (POA). Diffuse scratch marks, excoriation, and scabs of his torso and all extremities. Diagnoses: xerosis and neurotic excoriation. Treatment: Aquaphor to the whole body twice daily, excluding skin folds and web spaces; Triamcinolone 0.1% cream twice daily for 14 days to the affected area. 12/3/21: Dermatitis/eczema no change. Punch biopsy of right hand for establishment of pathologic diagnosis. Tissue preserved and sent for pathologic examination. Resident tolerated the procedure well. Review of Resident #41's EMR revealed a punch biopsy report dated 11/27/21. It documented, in pertinent part, Skin biopsy, lower abdomen: arthropod bite reaction in association with seborrheic keratosis, early lesion. Note: the differential diagnosis could include a drug reaction and an immunobullous disease. Direct immunofluorescence studies are recommended and an immunofluorescence kit is being sent. -Despite the diagnosis of an arthropod bite reaction, the facility did not place Resident #41 on isolation precautions until 12/3/21. A note dated 12/7/21 from Resident #41's visit to a dermatology office documented the following, in pertinent part: Resident presents today for a rash that is on his back, arms, waist band, and legs that has been going on for approximately three weeks. The resident states it's very itchy. The resident was prescribed Triamcinolone cream for eczema and he says they rub it all over. Spoke with the resident's primary nurse and was told the Triamcinolone works until they stop applying it. Resident lives in a nursing care facility and his roommate has the same rash. No one else in the care facility has a rash, and the last scabies outbreak was last spring per nurse. Physical Exam: Linear tracks and burrows, involving head, neck, chest, abdomen, back, pelvis, upper extremities, lower extremities, right anterior lower leg. Scabies prep performed. No ectoparasite noted, but feces seen. Assessment: Scabies Plan: Medications - Ivermectin 3 milligram (mg) tablet. Take five five tablets at one time with food. Can be repeated in two weeks if symptoms persist. The resident's room should be thoroughly cleaned and all bedding/clothing washed; non washables need to be sealed in a plastic bag for one week. Counseled driver/caregiver that resident's roommate will need to be treated as soon as possible to prevent recurrence. Review of Resident #41's December 2021 CPO revealed a physician's order for Ivermectin tablet 3 mg. Give five tablets by mouth one time for scabies. The order date was 12/7/21. Review of Resident #41's December 2021 medication administration record (MAR) revealed the Ivermectin medication was administered to the resident on 12/9/21 (21 days after appearance of the rash). -Review of Resident #41's comprehensive care plan history did not reveal a care plan for isolation or contact precautions due to the diagnosis of scabies in December 2021. IV. Resident #371 (roommate of Resident #41) A. Resident status Resident #371, age [AGE], was admitted on [DATE], and passed away at the facility on 4/2/22. According to the April 2022 CPO, diagnoses included cognitive communication deficit, unspecified dementia without behavioral disturbance, post polio syndrome, and need for assistance with personal care. The 2/21/22 MDS assessment revealed that the resident had severe cognitive impairment with a BIMS of three out of 15. The resident required one-person extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. He required two-person extensive assistance with transfers. B. Record review The facility's Scabies Surveillance Form documented Resident #371 presented with itching, a rash and scabs on his entire back, arms, and legs on 11/8/21. The resident received treatment for scabies on 12/10/21. -The resident did not receive treatment for scabies until 32 days after the appearance of the rash. A nurse practitioner's note dated 11/8/21 documented the following in pertinent part, Resident complains of rash that itches. It is located on his waistline. Rash appears to be in a band like fashion with some eruptions all in the same stage. Assessment and Plan: Rash and other nonspecific skin eruption: Appears to be contact dermatitis. Will need to avoid irritating detergents. Requested nurse to apply moisturizing lotion. Review of Resident #371's EMR revealed the following progress notes, documented in pertinent part: 11/19/21: Resident has scattered dry red patchy areas across legs, ankles, groin, arms. Last week resident complained of excessive itching, not complaining of itching as much. 11/22/21: Call out to resident's POA for permission to see WD. No answer at this time. Message left to call back. 11/22/21: Contact made with POA and verbal consent given to be seen by WD. 11/23/21: Received verbal consent from POA for skin biopsy if necessary. 11/23/21: At this time there are no scratches or rash noted to arms, legs or stomach. Large dry, flaky patch noted to lower back. Biopsy completed on this area after being cleansed and prepped by WD. 11/24/21: IDT met to review resident for skin: resident had biopsy completed to area on back, has dermatitis and eczema to lower back, has new right buttock and right lateral buttock trauma wound probably from scratching, new order for barrier cream, has order for Triamcinolone cream. 12/1/21: IDT met to review resident at At Risk meeting for skin: has wound to right buttock, trauma from scratching, wound is improving, no rash seen, waiting on biopsy results. 12/3/21: Resident and his roommate on contact isolation until final skin biopsy results on roommate. This nurse instructed both residents, however this resident was non-compliant and argumentative. He has not remained in his room through the shift. -Despite the facility experiencing a previous scabies outbreak in the facility one year earlier, Resident #371 was not placed on isolation until 25 days after his rash first appeared on 11/8/21. 12/9/21: POA notified of temporary room change and treatment orders. POA voiced understanding and had no questions. -12/15/21: IDT met to review resident skin. The resident was seen on 12/14/21 by WD and assistant director of nursing (ADON). The resident has been treated for scabies and has not complained of severe itching. He will return to his previous room as soon as the room has been deep cleaned. Review of Resident #371's EMR revealed the following documentation from the wound doctor: 11/23/21: Patient was noted to have this rash on his lower back 2 weeks ago which has been treated with triamcinolone cream without improvement and seems to have spread to both lower extremities. There was no involvement of his upper extremities. He did have diffuse dry and scaly skin. No rashes noted in his skin folds including the interdigital spaces, wrists, antecubital fossa, axillae, abdominal folds and groin. Because the rash has spread, a punch biopsy was obtained from his lower back. Verbal consent obtained from POA. Diagnosis: dermatitis/eczema. Treatment: Triamcinolone 0.1% cream twice daily for 7 days to the affected area. Review of Resident #371's EMR revealed a punch biopsy report dated 12/1/21. It documented, in pertinent part, Skin biopsy, lower back: urticarial (raised itchy rash that appears on the skin) allergic reaction in association with seborrheic keratosis, early lesion. Note: the differential diagnosis could include a urticaria, drug reaction and arthropod bite reaction. -Despite the differential diagnosis of an arthropod bite reaction, the facility did not place Resident #371 on isolation precautions until 12/3/21. Review of Resident #371's December 2021 CPO revealed a physician's order for Ivermectin tablet 3 mg. Give five tablets by mouth one time only for rash. The order date was 12/9/21. Review of Resident #371's December 2021 MAR revealed the Ivermectin medication was administered to the resident on 12/10/21 (32 days after appearance of the rash). -Review of Resident #371's comprehensive care plan history did not reveal a care plan for isolation or contact precautions due to the diagnosis of scabies in December 2021. V. Resident #22 A. Resident status Resident #22, age younger than 70, was admitted on [DATE]. According to the June 2022 CPO, diagnoses included epilepsy, muscle weakness, and need for assistance with personal care. The 4/12/22 MDS assessment revealed the resident was cognitively intact with a BIMS of 14 out of 15. The resident required one-person extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. She required two-person extensive assistance with transfers. B. Record review The facility's Scabies Surveillance Form documented Resident #22 presented with itching and a rash to her chest and arms on 12/14/21. The resident received treatment for scabies on 12/21/21 (however, the December 2021 MAR documented the medication was administered on 12/23/21 - see Ivermectin administration below). -The resident did not receive treatment for scabies until nine days after the appearance of the rash. Review of Resident #22's EMR revealed the following progress notes, documented in pertinent part: 12/14/21: Spoke with POA regarding rash. Verbal consent given for resident to be seen by WD and for punch biopsy if needed. 12/16/21: Skin check done with WD. Rash on left thumb healing scratches to right upper extremity and scratches to right forearm. Biopsy taken from right forearm. Covered with silvasorb and sterile gauze and coban. 12/21/21: Spoke with POA regarding new medication and treatment plan regarding rash. POA voiced understanding and had no questions or concerns. -There was no documentation regarding the resident being placed on isolation precautions. Review of Resident #22's EMR revealed the following documentation from the wound doctor: 12/15/21: Was asked to evaluate a rash and perform a biopsy to determine the etiology. The resident has had itching on and off. However on evaluation the only area that had a small patch of resolving erythematous lesions was on the left upper chest. It was pretty much cleared. Otherwise she did have dry skin with fine scaling of both upper and lower extremities. I would be happy to see her again if her rash recurs. Diagnosis: xerosis. Treatment: Aquaphor twice daily to dry skin. 12/16/21: Erythematous papular rash of upper extremities for two weeks. Diagnosis: dermatitis/eczema. Punch biopsy of left forearm for establishment of pathologic diagnosis. Tissue preserved and sent for pathologic examination. Resident tolerated the procedure well. Review of Resident #22's EMR revealed a punch biopsy report dated 12/22/21. It documented, in pertinent part, Skin biopsy, left forearm: intracorneal pustular dermatitis. Note: the differential diagnosis could include psoriasis or impetigo. -Despite the biopsy report being negative for arthropod bite, the facility treated the resident with Ivermectin on 12/23/21. Review of Resident #22's December 2021 CPO revealed a physician's order for Ivermectin tablet 3 mg. Give five tablets by mouth one time only for rash. The order date was 12/21/21. Review of Resident #22's December 2021 MAR revealed the Ivermectin medication was administered to the resident on 12/23/21 (nine days after appearance of the rash). -Review of Resident #22's comprehensive care plan history did not reveal a care plan for isolation or contact precautions due to the possible scabies in December 2021. VI. Resident #368 A. Resident status Resident #368, age [AGE], was admitted on [DATE], and passed away at the facility on 12/30/21. According to the December 2021 CPO, diagnoses included cognitive communication deficit, unspecified dementia without behavioral disturbance, Parkinson's disease, and need for assistance with personal care. The 12/26/21 MDS assessment revealed that the BIMS was not assessed. The resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The resident required two-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. B. Record review The facility's Scabies Surveillance Form documented Resident #368 presented with a rash to her abdomen on 12/10/21. The resident received treatment for scabies on 12/23/21. -The resident did not receive treatment for scabies until 13 days after the appearance of the rash. An SBAR Communication assessment dated [DATE] documented Resident #368 had a small area of rash to her left lower back and hip which started on 12/10/21. The resident was to be seen by the WD. Review of Resident #368's EMR revealed the following progress notes, documented in pertinent part: 12/14/21: Resident seen by WD. Verbal consent from family to complete biopsy to rash noted on right and left abdomen and left breast. The area was evaluated by the WD and a biopsy was completed on the left abdomen. The resident did not display any signs of discomfort or pain during the biopsy. A fungal rash was noted under the right breast. Orders for fungal rash received. Biopsy to be sent to the lab by WD. 12/15/21: IDT met to review resident at A Risk meeting for skin: Resident has yeast under right breast and areas of rash to left breast and abdomen, has treatment in place for yeast rash. Seen by the wound care doctor and biopsy was completed, is currently on contact precautions, until results of biopsy. -Despite the resident's rash being observed on 12/10/21, there was no documentation to indicate the resident was placed on isolation precautions until 12/15/21. 12/21/21: Spoke with sister regarding new medication order and plan of care regarding rash. The sister voiced understanding and had no questions or concerns. Review of Resident #368's EMR revealed the following documentation from the wound doctor: 11/23/21: Erythematous (red) papulo-vesicular rash of the left side of her torso. Diagnosis: folliculitis (a common skin condition in which hair follicles become inflamed). Punch biopsy of left abdomen for establishment of pathologic diagnosis. Tissue preserved and sent for pathologic examination. Resident tolerated the procedure well. Review of Resident #368's EMR revealed a punch biopsy report dated 12/19/21. It documented, in pertinent part, Punch biopsy, left lateral abdomen: urticarial allergic reaction. Note: the differential diagnosis could include a urticaria, drug reaction and arthropod bite reaction. -Despite the differential diagnosis of an arthropod bite reaction, there was no documentation to indicate the facility placed Resident #368 on isolation precautions until 12/15/21. Review of Resident #368's December 2021 CPO revealed a physician's order for Ivermectin tablet 3 mg. Give five tablets by mouth one time only for rash. The order date was 12/21/21. Review of Resident #368's December 2021 MAR revealed the Ivermectin medication was administered to the resident on 12/23/21 (13 days after appearance of the rash). -Review of Resident #368's comprehensive care plan history did not reveal a care plan for isolation or contact precautions due to the diagnosis of possible scabies in December 2021. VII. Resident #369 A. Resident status Resident #369, age younger than 70, was admitted on [DATE] and discharged home on [DATE]. According to the December 2021 CPO, diagnoses included chronic respiratory failure, muscle weakness, and need for assistance with personal care. The 12/3/21 MDS assessment revealed that the resident had moderate cognitive impairment with a BIMS of eight out of 15. He required supervision with bed mobility, transfers, dressing, toilet use, and personal hygiene. B. Record review The facility's Scabies Surveillance Form documented Resident #369 presented with itching and scabs on his legs on 12/10/21. The resident was discharged home with his sister on 12/17/21, prior to receiving treatment for scabies. -There was no documentation in the resident's EMR to indicate the facility had informed the resident's sister of the potential scabies outbreak or that the resident had been given a prescription for Ivermectin medication at the time of his discharge. Review of Resident #369's EMR revealed the following progress notes, documented in pertinent part: 12/13/21: Spoke with POA and verbal consent received for resident to see wound care doctor and for biopsy if necessary. 12/13/21: Registered nurse (RN) reminded resident that he is on isolation and is to remain in his room because of his rash. Resident verbalized understanding and returned to his room. 12/14/21: Resident's legs assessed this morning by WD. A biopsy was obtained after verbal content from the resident and the family. A biopsy was obtained from the right lateral leg. There were no complaints of pain or discomfort with biopsy. 12/15/21: IDT met to review resident for skin: resident has rash to lower legs, saw wound care doctor and biopsy was completed, is on contact precautions. Review of Resident #369's EMR revealed the following documentation from the wound doctor: 12/14/21: Rash on both lower extremities that was first noted about a week ago. At this time there are some scattered excoriations, scratch marks on the anterior, medial and lateral aspects of both legs. I was asked to biopsy this rash to determine the etiology. Punch biopsy of right shin for establishment of pathologic diagnosis. Tissue preserved and sent for pathologic examination. Resident tolerated the procedure well. Review of Resident #369's EMR revealed a punch biopsy report dated 12/1/21. It documented, in pertinent part, Skin biopsy, right lateral shin: urticarial allergic reaction, excoriated. Note: the differential diagnosis could include a urticaria, drug reaction and arthropod bite reaction. -Review of Resident #369's December 2021 CPO revealed no physician's order for Ivermectin. -Review of Resident #369's December 2021 MAR revealed the Ivermectin medication was not administered to the resident prior to his discharge home with his sister on 12/17/21 (7 days after appearance of the rash). -Review of Resident #369's comprehensive care plan history did not reveal a care plan for isolation or contact precautions due to the diagnosis of scabies in December 2021. VIII. Resident #19 A. Resident status Resident #19, age [AGE], was admitted on [DATE]. According to the June 2022 CPO, diagnoses included cognitive communication deficit, bipolar disorder, polyneuropathy, and need for assistance with personal care. The 4/9/22 MDS assessment revealed that the resident had moderate cognitive impairment with a BIMS of 12 out of 15. The resident required one-person extensive assistance with bed mobility and dressing. She required one-person limited assistance with transfers, toilet use, and personal hygiene. B. Record review The facility's Scabies Surveillance Form documented Resident #19 presented with itching and a rash under her left breast and on her back on 12/9/21 (however, the resident's progress notes documented the rash was identified on 12/7/21-see 12/7/21 weekly skin assessment below). The form further documented the resident received treatment for scabies on 12/23/21 and 12/30/21 (however, the resident's December 2021 MAR documented the medication was administered on 12/24/21 and 12/31/21-see Ivermectin administration below). -The resident did not receive treatment for scabies until 17 days after the appearance of the rash. Review of a weekly skin assessment dated [DATE] documented the resident had a new rash to the left side of her back. Review of Resident #19's EMR revealed the following progress note, documented in pertinent part: 12/9/21: Resident continues to be monitored related to new onset of rash. The resident is resting with eyes closed through shift between rounds. Resident denies discomfort and initially refused ordered treatment to site. Following education/encouragement, resident accepted. Vital signs within normal limits. Bed in lowest position, call light in reach. Will continue to monitor. -There were no other progress notes regarding the resident's rash, and there were no progress notes to indicate the resident was placed on isolation precautions. Review of Resident #19's EMR revealed the following physician notes, documented in pertinent part: 12/8/21: Chief complaint: rash below breasts and left back, lateral left breast. Atopic dermatitis, unspecified- no evidence of shingles, scabies. denies burning, pain. diffuse area. denies new lotions, foods, detergents. Yesterday the on-call physician had ordered benadryl topical cream, uncertain if staff administered it. No fever, chills, or signs/symptoms of infection. Discontinue benadryl cream. start 0.1% triamcinolone topical twice daily times two weeks. Close monitoring. Encouraged to call if unresolved, discussed with nursing. 12/22/21: Chief complaint: skin follow up, new areas to arms. Scabies. multiple scattered bites to bilateral upper extremities, facility is currently under a scabies outbreak. Resident reports arms feel sore, trying not to itch, worse at night. Assessment and plan: scabies: discussed with nurse. Isolation per facility protocol. Oral Ivermectin per facility protocol. -There was no documentation in Resident #19's EMR that the resident was placed on isolation precautions, despite the physician documenting she should be placed on isolation. 12/29/21: Chief complaint: skin follow up; new areas to arms and chest. Now scabies areas have spread to trunk and chest. Not on legs. Assessment and plan: scabies: discussed with nurse. Isolation per facility protocol. Placed order for round two of oral Ivermectin per facility protocol. -There was no documentation in Resident #19's EMR that the resident was placed on isolation precautions, despite the physician documenting she should be placed on isolation. -The POA did not give consent for WD visit or biopsy, so biopsy was not conducted on the resident. Review of Resident #19's December 2021 CPO revealed two physician's orders for Ivermectin tablet 3 mg. Give five tablets by mouth one time only for rash. The order dates were 12/23/21 and 12/30/21. Review of Resident #19's December 2021 MAR revealed the Ivermectin medication was administered to the resident on 12/23/21 (17 days after appearance of the rash). The resident received a second dose of the medication on 12/31/21. -Review of Resident #19's comprehensive care plan history did not reveal a care plan for isolation or contact precautions due to the diagnosis of scabies[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to: -Ensure residents were served the correct diets; and, -Follow correct portion sizes to ensure adequate nutrition was provided to the residents. Findings include: I. Facility policy and procedure The Therapeutic Diets policy and procedure, dated September 2017, was provided by the dining account manager (DAM) on 6/16/22 at 2:41 p.m. It revealed, in pertinent part, All residents have a diet order, including regular, therapeutic, and texture modification, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines. Mechanically altered diet means one in which the texture of the diet is altered. When the texture is modified, the type of texture must be specific and part of the physicians' or delegated registered or licensed dietitian's orders. The Texture Modification policy and procedure, undated, was provided by the DAM on 6/16/22 at 2:41 p.m. It revealed, in pertinent part, Importance of texture modification: Some residents have problems chewing or use multiple swallows to swallow one bite, pocket food ([NAME] food in cheeks), or cough frequently during meals and should be evaluated by the facility Speech and Language Pathologist. They may suggest a texture modified consistency to decrease the risk of choking and to make eating easier. Proper preparation and delivery of texture modified diets is critical for resident safety and wellness. Regular consistency: Requires no modification. Can receive all items and garnishes. Mechanical soft consistency: requires meat to be ground and moistened. All cold vegetable salads should be shredded or ground as determined on the diet guids/tickets. Cannot receive hard, dry meats such as bacon, large pieces of raw fruits or vegetables, bread with hard crusts, or any hard, dry snack items that do not easily crumble into small pieces. Dysphagia ground consistency: Requires meat to be ground and moistened. All other food items (example: breads, starches, fruits, vegetables, and desserts) must be pureed to a mousse-like texture. Cannot receive hard, dry meats such as bacon, raw fruits or vegetables, or any breads, starches, fruits, vegetables and desserts that cannot be pureed into a smooth mousse-like texture. Puree consistency: All Foods (example: meats, breads, starches, fruits, vegetables, or foods that cannot be pureed to a mousse-like texture. Cannot receive hard, dry meats such as bacon, raw fruits, or vegetables, or foods that cannot be pureed into a smooth mousse-like texture. II. Failure to ensure residents were served the correct diets During a continuous observation during the lunch meal on 6/15/22 beginning at 11:12 a.m. and ending at 12:05 p.m., the following was observed: -The DAM plated Resident #66's plate. She placed a whole piece of pork loin, a scoop of zucchini and onions, and a scoop of braised cabbage onto the plate. -The DAM placed the meal tray into the service window to be served to the resident. -Upon prompting, the DAM reviewed Resident #66's meal ticket and said Resident #66 was ordered to receive a dysphagia diet and should have been served ground pork loin. The DAM corrected the resident's plate with the appropriate diet texture. -However, without prompting Resident #66 would have been served a regular texture meal. III. Failure to follow correct portion sizes to ensure adequate nutrition was provided to residents. During the lunch meal on 6/15/22 beginning at 11:12 a.m. and ended at 12:05 p.m., cook #1 used the following scoop sizes: A #16 scoop (0.25 cup) for the zucchini and onions for the regular diet; and, A #16 scoop (0.25 cup) for the braised cabbage for the regular diet. -The #16 scoop (0.25 cup), measuring 2 ounces (oz), was 2 oz less than the 0.5 cup (4 oz) specified on the menu extension sheet for the zucchini and onions and the braised cabbage for the regular diet. At 11:30 a.m. the regional dining director #1 (RRD) changed the #16 scoop used for the zucchini and onions to a #12 scoop (0.33 cup). -The #12 scoop (0.33 cup), measuring 2.67 oz, was 1.33 oz less than the 0.5 cup (4 oz) specified on the menu extension sheet. The residents in room [ROOM NUMBER]A and room [ROOM NUMBER] had double portions documented on their meal tickets. These residents received the same amount of food as the residents who did not have double portions documented on their meal tickets. During the breakfast meal on 6/16/22 beginning at 7:30 a.m. and ended at 9:03 a.m., cook #1 used the following scoop sizes: A #8 scoop (0.5 cup) of oatmeal cereal for the regular diet; and, Two #30 scoops (2.4 tablespoons each) for the pancakes for the pureed diet. -The #8 scoop (0.5 cup), measuring 4 oz, was 2 oz less than the 0.75 cup (6 oz) specified on the menu extension sheet for the oatmeal cereal. -The two #30 scoops (4.8 tablespoons total), measuring 2.14 oz, was 1.86 oz less than the 0.5 cup (4 oz) specified on the menu extension sheet for the pancakes. IV. Staff interviews The DAM, regional dining director (RDD) #1 and the nursing home administrator (NHA) were interviewed on 6/15/22 at 2:15 p.m. The DAM said the certified nurse aides (CNAs) were responsible for obtaining the resident's meal orders. The DAM said it was important for the dining staff to ensure residents received the correct mechanically altered diet. She said if residents did not receive the correct texture, it could have led to choking. The DAM, RDD #1, and RDD #2 were interviewed on 6/16/22 at 12:46 p.m. The DAM said it was important to use the correct scoop sizes when serving the residents. She said since the scoop sizes were smaller than the recipe documented, the residents were not receiving adequate nutrition. The DAM said the cooks should follow each meal ticket as it was documented. She said a resident should be served double portions if it was documented on the meal ticket. The DAM said she had not provided the dietary staff any education regarding diet types or the importance of following the recipes. The director of nursing (DON) was interviewed on 6/16/22 at 1:50 p.m. She said each resident had a prescribed diet by the physician. She said mechanically altered diets were often ordered when residents had difficulty chewing or swallowing. She said if a resident was served the incorrect mechanically altered diet, there was a potential negative outcome of choking. She said the correct portion sizes should be served to residents, to ensure they were being provided adequate nutrition. VI. Facility follow-up The RDD #1 provided a copy of education on 6/16/22 regarding portion sizes, therapeutic diets, and mechanically altered diets provided to the dietary staff. She said she had begun educating all dietary staff members, during the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated; -Ensure the kitchen was clean and sanitary; and, -Ensure holding temperatures of food were within the correct range. Findings include: I. Failure to ensure food was labeled and dated correctly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. (Retrieved 6/24/22). B. Facility policy and procedure The Labeling and Dating policy and procedure, undated, was provided by the nursing home administrator (NHA) on 6/16/22 at 11:34 a.m. It revealed, in pertinent part, Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out (FIFO) manner. This will minimize waste and ensure that items that are passed their due date are discarded. Guidelines for Labeling and Dating: -All foods should be dated upon receipt before being stored. -Foods labels must include: the food item name; the date of preparation/receipt/removal from freezer; and, the 'use by' date as outlined in the attached guidelines. -Items that are removed from a labeled case in the freezer and placed in the refrigerator for thawing should be labeled with the date of removal from the freezer and an appropriate 'use by' date as outlined in the Retention Guide attached. -Leftovers must be labeled and dated with the date they are prepared and the 'use by' date. 'Use by' Dating Guidelines: -The manufacturer's expiration date, when available, is the 'use by' for unopened items. -The manufacturer's instructions for the discarding of opened items supersedes the general guide below. -Day of preparation or opening is considered Day one when establishing the 'use by' date. -Guidelines assume that food is properly stored, covered and handled. -Guidelines apply, regardless of storage location (e.g., kitchen, panties, etc.). -All Ready-to-Eat, Time/Temperature Control for Safety (TCS) foods that are to be held for more than 24 hours at a temperature of 40°F (fahrenheit) or less, will be labeled and dated with a 'prepared date' (Day one) and a 'use by date' (Day seven). C. Observations On 6/13/22 at 9:39 a.m. the initial kitchen tour was conducted and the following was observed: -In the main walk-in cooler, there were three cooked chicken breasts covered in plastic wrap on a plate, an opened bottle of Italian dressing, a ziploc bag of fried chicken, a large container of coleslaw, a container of ketchup, two opened bags of shredded cheddar cheese, one opened bag of mozzarella cheese, a pan of prepared watermelon, one opened package of salad greens, and a bottle of barbeque sauce were not labeled with a received, prepared, or use by date. There was a box of nutritional shakes in the refrigerator without a pull or use by date, a container of chicken base was labeled 5/19/22, a large container of salad that expired on 6/12/22, and three blocks of sliced cheese were opened and wrapped in plastic wrap, dated 6/11/22. There was a previously opened bag of chicken thighs wrapped in plastic wrap and thawed in a container in the refrigerator. The chicken did not have a label with a pulled from freezer date or use by date. There was a container of pre-baked muffins left open to air and did not have a use by date on them. -In the dry storage, there were three packages of opened pasta and one package of opened marshmallows undated. -In the main kitchen, there were two opened containers of brown sugar, one opened box of cornstarch, four opened bags of bread, a container of peanut butter and two opened bags of hamburger buns that did not contain received date, prepared date, or use by date. There was a prepared individual serving of Cheerios labeled 5/26/22. -In the walk-in freezer, there were two boxes of frozen waffles, a box of fried chicken patties, a box of beef patties, and a box of rolls that were open to the air. The boxes had been opened, but were not closed leaving the food open to air. During a continuous observation, on 6/16/22 beginning at 7:33 a.m. and ended at 9:00 a.m., the following was observed: -In the main part of the kitchen where the preparation tables and service line was, a prepared container of honey was labeled 5/15/22, a prepared container of brown sugar was labeled 6/16/22, prepared and individually packaged fortified puddings were labeled 6/14/22 and a prepared container of cereal was labeled 6/14/22. Three opened bags of sliced bread, an opened bag of potato chips, an opened bag of country gravy mix, an opened bag of hamburger buns, a container of peanut butter all without expiration dates. An opened box of cream of wheat was dated 6/14/22 and an opened box of hollandaise sauce powder was dated 2/10/22 (see interview below regarding preparation and use-by dates) -In the dry storage, the three packages of opened pasta and one package of opened marshmallows were left undated. -In the main walk-in cooler, the opened package of muffins, four prepared unwrapped fruit bowls, an opened carton of liquid eggs, a container of jam, a container of prepared scrambled eggs with cheese, one bottle of caesar dressing and two bottles of barbeque sauce were opened and unlabeled without an expiration date. -In the main walk-in freezer, the frozen waffles remained open to air. An opened box of cinnamon rolls was also left open to air. II. Failure to ensure the kitchen was clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view Revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved 6/28/22) B. Facility policy and procedure The Cleaning and Sanitizing policy and procedure, undated, was provided by the NHA on 6/16/22 at 11:34 a.m. It revealed, in pertinent part, Resident safety in a healthcare environment is a top priority. Cleaning and sanitizing properly is one of the most important things we continually do in our kitchens to prevent harm. When to Clean and Sanitize: Surfaces that comes in contact with food, such as a cutting board or utensil, must be cleaned and sanitized after each use. Other scenarios that require cleaning and sanitizing include: -When switching between food and preparation tasks. Special care is needed between raw food and read to eat food preparation. -Anytime you are interrupted during a task and the tools or items you have been working with [NAME] have been contaminated. Busy rush periods or receiving deliveries are examples. -At four hour intervals if the food contact surfaces and equipment are in constant use. Examples are deli slicers, knives or cutting boards. Sanitizing: -Sanitizing follows cleaning. Sanitizing is the application of heat or chemicals to a properly cleaned (and thoroughly rinsed) food-contact surface. This reduces the number of microorganisms on a clean surface to safe levels. -When you sanitize a surface you remove most harmful bacteria from the area. -Sanitizer solution must be kept in an easily identifiable bucket that is not used for food storage. -Santizier solution should be tested for correct PPM (parts per million) frequently. Consult manufacturer's directions for proper dilution rate for the chemical in use at your facility. -You must change your sanitizing solution every two hours or when it becomes soiled. Follow manufacturer instructions for the specific chemical used in your facility. C. Observations During the initial kitchen walk through on 6/13/22 beginning at 9:39 a.m. and ended at 10:10 a.m. the following was observed: -The kitchen floor had piles of food debris in the preparation area. A soiled face mask was on the floor in the dry storage and five empty boxes were on the ground underneath the handwashing sink. When walking, shoes were sticking to the floor. -An unidentified dishwasher unloaded dirty dishes from a cart and placed them into the dish room. He then grabbed a towel that was sitting on a preparation table and wiped the cart off. He then placed the cart back into the dining room to be used to serve room trays for lunch. III. Failure to ensure holding temperatures of food were within the correct range A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. (Retrieved 6/28/22) B. Facility policy and procedure The Food: Preparation policy and procedure, dated September 2017, was provided by the NHA on 6/16/22 at 11:34 a.m. It revealed, in pertinent part, The Dining Services Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F (fahrenheit) and/or less than 135 degrees F (fahrenheit), or per state regulation. When hot pureed, ground, or diced food drops into the danger zone (below 135 degrees fahrenheit), the mechanically altered food must be reheated to 165 degrees fahrenheit for 15 seconds if holding for hot service. C. Observations During a continuous observation, on 6/16/22 beginning at 7:33 a.m. and ended at 9:00 a.m., the following was observed: Cook #2 began removing food from the steam table. [NAME] #2 obtained temperatures of the food after the meal services had ended. Food items not within acceptable temperature range included: -Pureed sausage 115°F; -Ground sausage 122°F; and, -Country gravy 124.8°F -The mechanically altered food items were stored in metal pans that were then placed into a larger metal pan and placed into the steam table. The larger metal pan did not have direct contact with the hot water in the steam table. IV. Staff interviews Cook #2 was interviewed on 6/16/22 at 9:05 a.m. She said they only took temperatures of the food before meal service. She said she had not been instructed to take temperatures after the meal had finished. She said she placed the mechanically altered food items into a metal pan and then into a larger pan, because she did not have the correct equipment to place the smaller pans into the hot holding table. Regional dining director (RDD) #2 was interviewed on 6/16/22 at 9:06 a.m. She said she would order the kitchen the correct equipment and provide education to the staff members on how to assemble the hot holding table to ensure food was held at the correct temperature for meal service. The dining account manager (DAM), RDD #1, and RDD #2 were interviewed on 6/16/22 at 12:46 p.m. The DAM said when food was delivered to the facility it should be labeled with a received by date. She said when an item was opened it should be labeled with a prepared or opened date and a use by date. RDD #1 confirmed there were several items, including ketchup, salad dressing, liquid eggs, and cheeses that were not labeled properly in the refrigerator. She also confirmed there were items in the dry storage and the main kitchen that did not contain prepared dates or use by dates. The DAM said all dining staff members were responsible for ensuring all food items were properly labeled and dated. The DAM said when the cooks were preparing individual portioned items, such as honey, cereal, or fortified puddings each container was being labeled with the prepared date. She said their current process did not include labeling these items with a use by date. She said they should be labeled with the use by date, so the staff were aware of when the item needs to be discarded. The DAM said the cooks were responsible for ensuring food was discarded when past the expired date. She said she should have taken the initiative to ensure all foods were labeled, dated, and disposed of when necessary at the end of each day. RDD #1 said when meat was thawed in the refrigerator it should contain a label with the date it was pulled from the freezer. RDD #1 confirmed there was not a cooling log in use. She said the cooked chicken and scrambled eggs that were in the fridge, should have been documented on the cooling log. The DAM said the dishwashers should be using a yellow peroxide sanitizer on the carts used for meal trays. She said after the dirty dishes were removed from the cart, the sanitizer should be sprayed on the cart and let sit for three minutes before wiping. The DAM said the floors in the kitchen should be clean and free of debris. She said the floor should not be sticky. She said boxes should be disposed of and not stored on the ground. The DAM and RDD #2 said the facility did not take temperatures of the food at the end of each meal service. They said it would be a good idea to take the temperatures to ensure the food was held at the correct temperature during meal service. RDD #2 confirmed cook #2 had placed the mechanically altered breakfast items in metal pans within a larger metal pan. She said the larger metal pan was not touching the water in the hot holding table, which was why the temperatures of the food were within the temperature danger zone. RDD #2 said when food was held at the improper temperature the food was susceptible to growing bacteria that could cause food borne illnesses. The DAM, RDD #1, and RDD #2 said they would review the facility policy to educate themselves on the correct temperatures for holding foods. V. Facility follow up The RDD #1 provided a copy of education on 6/16/22 regarding labeling and dating; and, kitchen sanitation provided to the dietary staff on 6/16/22. She said she had begun educating all dietary staff members, during the survey process.