**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide blood pressure monitoring to meet the needs of a resident, and failed to assess the accuracy of medication administration, for 1 of 3 sampled residents (Resident #1). The Findings included: A review of the facility's policy on Medication Administration, dated 01/27/2025, revealed medications are administered in accordance with the prescribers orders, and number 11 revealed vital signs are checked and verified for each resident prior to administering medications. 1) Resident #1 was admitted on [DATE] and was discharged on 11/08/24. A review of diagnoses included Atrial Fibrillation, Pneumonia with Shortness of Breath, Coronary Artery Disease, and Heart Failure. A review of the Minimum Data Set (MDS) dated [DATE] under Section C for Brief Interview of Mental Staus (BIMS) revealed a score of 15 indicating good mental cognition. A review of orders dated 11/6/24 at 4:47 PM revealed Spironolactone oral tablet 25 MG, give 0.5 tablet by mouth one time a day for edema, hold if Systolic Blood pressure (SBP) is less than 120. A review of orders dated 11/5/24 at 1:00 PM revealed to obtain and document vital signs every shift for 72 hours, then re-assess for continued monitoring. A review of the Medication Adiministration Record (MAR) dated 11/7/24 at 9:00 AM revealed Spironolactone was given by Staff D, Licensed Practical Nurse (LPN), when she took and recorded Resident #1's blood pressure reading of 86/62 on 11/7/24 at 8:55 AM . A review of Resident #1's docuemnted blood pressire (BP) measurement revealed the following : on 11/7/25 at 8:55 AM, it was 86/62, on 11/7/25 at 10:44 PM, it was 87/68, and on 11/8/25 at 6:54 AM, it was 85/42. A further review of documented BP revealed there was no BP recorded between 8:55 AM and 10:44 PM on 11/7/24, revealing no reassessment for continuing monitoring was done per doctor's order. There was no BP documentation on 11/7/24 between 10:44 PM and 11/8/24 at 6:54 AM revealing no re-assessment for continuing monitoring was done per doctor's order. In an interview with Staff B, LPN, on 04/10/25 at 10:35 AM, when asked how she would manage a resident with a blood pressure of 90/50, she responded, I would know by looking at the resident. The resident would have pale lips or darker blue lips, and the skin feels cold. She added that she would check the vital signs. She would also assess the resident's breathing, skin, bowel movement, and if she thinks something is wrong and the resident does not look ok, she will inform the doctor of resident's low BP. In an interview with Staff D, LPN, on 04/10/25 at 11:32 AM, when asked how she would care for a resident if there was a change in condition, she responded, I would check the resident's vital signs and blood pressure. When asked what would she do if the previous BP was 102/70 and now is 90 /60, she responded, I will call the doctor, and I will check the medications. She would make sure the resident is talking, is safe and responsive to questions in bed, then she will go to the nurses station to call the resident's family and call the doctor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure adequate hydration and nutrition for 1 of 3 sampled residents (Resident #1) The findings included: During a record review of the Facility's policy, titled weight assessment and intervention , it was revealed under evaluation that the physician and the multidisciplinary team identify conditions or clinical situations and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss based on the following examples, medication related adverse consequences, fluid and nutrient loss, and inadequate availability of food and fluids. Resident # 1 was admitted on [DATE] and was discharged on 11/08/24. A review of diagnoses included Atrial Fibrillation, Pneumonia with Shortness of Breath, Coronary Artery Disease, Heart Failure. A review of the Minimum Data Set (MDS) section C for Brief Interview of Mental Status (BIMS) revealed a score of 15 indicating good mental cognition. Section N revealed Resident # 1 was on anticoagulant, antiplatelet and diuretics. A review of Dietary progress notes dated 11/7/24 at 2:37 PM revealed Staff G, Registered Dietitian, notified Medical Doctor (MD) that Resident #1 was noted with increased reflux. Resident #1's daughter rrevealed resident is lactose intolerant. The MD was requested to change Ensure supplement to trial of Ensure Clear. An order by MD included: Pepcid increased to 2x/day; Recommend discontinuing Ensure plus and give Ensure clear daily. Continue to monitor per orem (oral intake and follow up as needed). A review of Nursing progress notes did not include Staff D, LPN monitored the fluid intake of resident on 11/7/24 at 8:55 AM when the blood pressure (BP) of 86/62 was documented. There was no recoded progress notes done by Staff D regarding monitoring of fluid intake when resident is on 2 diuretics, had a low BP. A review of progress notes from the facility's multidisciplinary team did not indicate any nutritional evaluation related to resident's medications such as BP medications and diuretics. An additional review of nursing care plan did not include a focus on fluid and nutrition maintenance and any interventions on how to maintain the resident's fluid and nutrition status. In an interview with Staff A, a Licensed Practical Nurse (LPN), when asked if she monitored resident # 1's fluid status, she responded, she does not remember. In an interview with Resident #1's physician ,on 04/10/25 at 5:30 PM, when asked why he waited for the order of Intravenous fluids until 11/8/24 at 9: 00 AM, he responded, I saw the resident on 11/6/24 and 11/7/24 and she was ok.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9) Record review showed that Resident #27 was admitted to the facility on [DATE] with diagnosis of Atrial Fibrillation and Malignant Neoplasm. The Minimum Data Set (MDS)quarterly assessment dated [DATE], documented the resident's Brief Interview of Mental Status (BIMS) score as 15, which indicates no cognitive impairment. In an observation conducted on 12/03/2024 at 10:10 AM, Resident #27 was observed unable to wheel herself out of the bathroom, in her wheelchair due to piles of linen/clothing that was located on the floor of her bedroom. Resident #27 had no way of picking up the bag of clothes from the floor without assistance. In a brief interview conducted on 12/03/2024 at 9:30 AM, Resident #27 stated that she has been asking for paper towel for over 3 days and no staff member ever brought it for her. In this interview, no paper towel was observed in the bathroom. 10) Record review revealed that Resident #86 was admitted on [DATE] and readmitted on [DATE] with diagnosis of Dementia, without behavioral disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. The Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident's Brief Interview of Mental Status (BIMS) score as an 8, which indicates moderate cognitive impairment. In an observation conducted on 12/02/2024 at 10:00 AM, Resident #86 was found standing next to his bed with all the linens from the bed piled up on the floor. In this observation Resident #86 stated that he needs the bed to be made with a new set of linen because the ones that he took off were dirty. At this time. the Surveyor advised a staff member that Resident #86 needed his bed linens changed. In another observation conducted on 12/02/2024 at 2:00 PM, Resident #86 was found seated in his wheelchair at the room door. Resident #86 asked the Surveyor to please have someone fix his bed because he needed to lay down. Upon observation, the bed was still unmade from the prior observation at 10:00 AM. In an interview conducted on 12/02/2024 at 2:05 PM with Staff B, Registered Nurse (RN), stated that she had already asked the Certified Nursing Assistant on two occasions to fix the Resident #86's bed, but she would ask again. In an interview conducted on 12/05/2024 at 10:20 AM with Staff F, Certified Nurse Assistant (CNA), stated that the bed linens are changed daily and upon request or when the bed is observed dirty. And if Staff are busy, the task is redirected to an available staff member. Based on observations, interviews and record review the facility failed to 1) ensure access to call device for 2 of 32 sampled residents (Residents #46 and #94); 2) ensure function of air mattress for 2 of 31 sampled residents provided with air mattress (Residents #80 and #90); 3) provide access to wall light for 7 out of 26 sampled residents on 1 of 2 hallways on the [NAME] unit (Residents #94, #6, #68, #72, #80, #90, #53); 4) provide unobstructed access to bathroom and provide paper towels to 1 of 34 sampled residents (Resident #27); 5) provide clean linen in timely manner for 1 of 34 sampled residents (Resident #86). The findings included: Review of the facility's policy titled, Accommodation of Needs with a revised date of March 2021, included in part, the following: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. In order to accommodate individual needs and preferences, adaptions may be made to the physical environment, including the residents' bedroom and bathroom, as well as the common areas in the facility. Examples of such adaptions may include a) providing access to assistive devices, e) installing longer cords or providing remote controlled overhead or task lighting so that they are easily accessible, f) moving furniture or large items in rooms and common areas that may obstruct the path of a resident using a walker. 1) Record review for Resident #46 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses that included in part the following: Paraplegia, and Neuromuscular Dysfunction of Bladder Review of the Minimum Data Set (MDS) assessment for Resident #46 dated 10/13/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 14, indicating a cognitive response. On 12/02/24 at 10:52 AM, an observation was made of Resident # 46 sitting up in bed with the call bell on the floor, a full Styrofoam cup of water and 2 empty two handled sippy cups on the nightstand out of her reach. She said they (staff) moved the water when her breakfast came and never put it back. On 12/03/24 at 8:40 AM, an observation was made of Resident #46 sitting up in bed with her breakfast tray in front of her with one handled cup with no spill lid containing coffee, a two handled cup with a lid that was not secured containing orange juice. During an interview conducted on 12/02/24 at 10:52 AM, Resident # 46, stated she is supposed to be checked to see if she needs her [adult incontinent brief] changed every couple of hours, she has been in the same brief since 10:00 PM last night. They usually change her the same time as the other resident, but they have not. She said she normally has a private aid, but the aid is on vacation this week. When asked if she could call for assistance she said yes, but she cannot reach the call bell, it is on the floor. She said she has been in a [soiled adult incontinent brief] for a very long time today. 2) Record review for Resident #94 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Vascular Dementia and History of Falling. Review of the Minimum Data Set (MDS) assessment for Resident #94 dated 11/23/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 4, indicating severe cognitive impairment. On 12/05/24 at 9:50 AM, a side-by-side observation with the Director of Nursing (DON) and the Director of Maintenance (DOM) was made of Resident #94, sitting in a wheelchair next to window with the call bell device on her bed and not accessible. The DON attempted to pull the call bell device closer to the resident, but it did not reach, the DOM moved the resident closer to the call device, so it was accessible to the resident. Also observed was the wall light behind the resident's bed with a pull cord of approximately 6 inches long and not accessible to the resident while sitting in the chair or when she is in her bed. 3) Record review for Resident #80 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Dementia and Delusional Disorders. Review of the MDS assessment for Resident #80 dated 11/10/24 documented in Section C a BIMS score of 6, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #80 revealed an order dated 03/24/23 documented, low air loss mattress in use, check placement and function every shift. Review of the Treatment Administration Record (TAR) for Resident #80 from 12/01/24 to 12/03/24, revealed the status of the low air loss mattress function and settings was documented each shift. Review of the Nursing Progress Notes for Resident #80 from 12/01/24 to 12/03/24 revealed no documentation of issues with the low air loss mattress. 4) Record review for Resident #90 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Acute Chronic Diastolic (Congestive Heart Failure), Chronic Kidney Disease Stage 4, and Glaucoma. Review of the MDS for Resident #90 dated 11/04/24 documented in Section C a BIMS score of 8, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #90 revealed an order dated 10/21/24 for low air loss mattress, check function and settings every shift. Review of the TAR from 12/01/24 to 12/03/24 revealed the status of the low air loss mattress function and settings was documented each shift. Review of Nursing Progress Notes for Resident #90 from 12/01/24 to 12/03/24 revealed no documentation of issues with the air mattress. During an in interview conducted on 12/03/24 at 9:00 AM with Staff I, Licensed Practical Nurse (LPN) who was asked if she took care of Resident #80 and Resident #90 yesterday as well as today, she said yes. When asked about the low air loss mattress, she said they are checked every day. When asked what she checks, she stated she checks to make sure it is on, and the machine is functioning properly. When asked if there were any issues with the low air loss mattress for either resident yesterday or today, she said no, not that she is aware of. Staff I LPN and the surveyor then did a side-by-side observation of the low air loss mattress for Residents #80 and Resident #90. She stated Resident #80 and #90's mattress was not working, then said the air mattress was not plugged in and said I did not notice this until just now. 5) Record review for Resident #6 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses that included, in part, the following: Infection and Inflammatory Reaction Due to Other Cardiac and Vascular Devices Implants and Grafts, and Chronic Obstructive Pulmonary Disease. Review of the MDS for Resident #6 dated 11/18/24 documented in Section C, a BIMS score of 15, indicating a cognitive response. On 12/02/24 at 9:30 AM, an observation was made in Resident 6's wall light, shared between her and her roommate, with no access to the light to turn it off or on. The privacy curtain was located in the middle of the wall light. 6) Record review for Resident #68 revealed the resident was admitted to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included, in part, the following: Dementia and Anxiety Disorder. Review of the MDS assessment for Resident #68 dated 10/01/24 documented in Section C, a BIMS score of 0, indicting severe cognitive impairment. On 12/05/24 at 11:30 AM, an observation was made of Resident #68 lying in bed with wall light, with no pull cord. Resident #72 (the roommate) to Resident #68 stated they put my light on in the night, if they need any light to help my roommate. When asked if this bothers her, she said I am not saying anything, I don't want to get into trouble. 7) Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Review of the diagnoses for Resident #72 revealed the resident had a diagnosis of Post-Traumatic Stress Disorder, dated 11/14/24. Review of the Minimum Data Set assessment for Resident #72 dated 08/14/24 documented in Section C a Brief Interview of Mental Status score of 15, indicating a cognitive response. On 12/02/24 11:25 AM, an observation was made of Resident #72 sitting up in bed with the wall light on located at the head of the bed with an approximately 3-inch pull cord. During an interview conducted on 12/02/24 11:25 AM, Resident #72 who was asked if she can put her light on, she stated only if she lays her bed flat, raises her bed height and reaches up behind her. 8) Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with diagnoses including, in part, the following: Dementia, and Inflammatory Spondylopathy Cervical Region. Review of the MDS assessment for Resident #53 dated 09/17/24 documented in Section C a BIMS score of 8, indicating moderate cognitive impairment. On 12/02/24 at 12:40 PM, an observation was made of Resident #53 sitting up on the side of her bed. The wall light behind the head of her bed was noted having a pull chain of approximately 3 inches long. During an interview conducted on 12/02/24 at 12:40 PM with Resident #53 who was asked if she could put the wall light on behind the head of her bed. She stated no, I can't reach it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Record review revealed Resident #88 was admitted to the facility on [DATE] with diagnosis of non-Hodgkin lymphoma and Myelofibrosis. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairments. A review of the care plan dated 11/12/2024 indicated that Resident #88 is prone to side effects related to the use of antidepressant medications, which needs to be observed for potential side effects such as: hypotension, tachycardia, nausea, vomiting, diarrhea, blurred vision, chest pain, rash, drowsiness, lethargy. A review of the physician's orders dated 08/23/24, documented: Sertraline HCl Oral Tablet 25 MG (Sertraline HCl), give 1 tablet by mouth one time a day for depression, give with 100mg tablet to equal a total of 125mg daily. Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) give 1 tablet by mouth one time a day for depression, give with 25 mg to equal total of 125mg daily. A review of the physician orders, the Medication Administration Report (MAR) and the Treatment Administration Report (TAR) indicated that the facility failed to order and implement intervention to monitor side effects related to the use of antidepressant medications for Resident #88. Based on observations, interviews and record reviews, the facility failed to develop a comprehensive care plan for Post-Traumatic Stress Disorder (PTSD), for 2 of 2 sampled residents reviewed for behavior, (Residents #72 and Resident #28); failed to implement care plan interventions for 2 of 5 sampled residents reviewed for unnecessary medications, (Resident #88 and Resident #111); and failed to implement interventions regarding psychotropic medications' side effects for 2 of 2 sampled residents (Resident #111 and Resident #88) reviewed for Psychotropic Medications. The finding included: 1) A review of facility's policy titled, Care Plans Comprehensive, published on 09/25/2024, with document ID # 42867439 revealed the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. It revealed statement #2, under Policy Interpretation and Implementation, explaining the comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (admission, annual or significant change in status), and no more than 21 days after admission Additional review of facility's policy titled, Care Planning IDT, revealed a statement explaining the Interdisciplinary team is responsible for the development of resident care plans. It further explained that resident care plans are developed according to the timeframes and criteria established by §483.21 Resident #28 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Post-Traumatic Stress Disorder (PTSD), Dysphagia Following Cerebral Infarction, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. A review of Minimum Data Set (MDS) assessment Section C revealed a Brief Interview of Mental Status (BIMS) score of 14, indicating good mental cognition. A review of electronic care plans initiated on 09/13/24, 09/16/24 and 12/12/24, revealed no care plan was initiated on these dates regarding Resident #28's PTSD. Interview was conducted with a Social Services Staff member on 12/04/24 at 12:21 PM, who has been working in the facility for one year, when asked about Resident #28's care plan for PTSD, she stated, There is no care plan for PTSD. She added that the reason there was no care plan for PTSD was, First upon admission the resident denied anxiety and depression, and secondly, because the resident was evaluated by the psychiatrist. When asked why she had not created a care plan for Resident #28's PTSD yet, she responded that she planned to keep asking the resident, because she wants to make sure Resident#28 is comfortable with her. She added that she plans to quarterly assess this resident. When this Social Services Staff was asked regarding Resident #28's PTSD diagnosis, she stated it was derived from admission. When asked when is she planning to create a PTSD care plan because three (3) months had passed since resident's admission to the facility, she responded she has not made any evaluation to ask for triggers and insisted that she must make a rapport with the resident first. She added it is a continuous process. In an interview with the MDS Coordinator on 12/04/24 at 4:11 PM, when asked how she demonstrated her knowledge of Resident #28's current behavioral and emotional needs, she stated These are based on care evaluations from Psychiatrist, Psychologist, and Social Services assessments. When asked how often she attends Staff Behavioral in-service training, she stated once a year. When asked about the types of behavioral health training she had completed, she stated it was an annual in-service provided by facility to all Staff. When asked how she demonstrates competent interactions when addressing the resident's behavioral care needs, she responded by providing services based on resident's culture. When asked how she would know if a resident was a trauma survivor, and what would she do differently for that resident, she stated she must create a care plan in the MDS. She added that a section in the MDS has specific space for creating a care plan. She added that baseline care plan for the resident should be done in 2 to 3 days, while the comprehensive care plan should be done in 30 days. When asked regarding PTSD interventions for Resident #28, she stated some examples are approaching resident in a calm manner, assuring resident to prevent him/her from getting anxious. When asked about Resident #28's care plan for PTSD, she responded It must be completed. 2) Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Further review revealed the resident had a diagnosis of Post-Traumatic Stress Disorder (PTSD) Unspecified dated 11/14/24. Review of the Minimum Data Set assessment for Resident #72 dated 08/14/24 documented, in Section C, a Brief Interview of Mental Status score of 15, indicating a cognitive response. Review of the care plan for Resident #72 revealed there was no care plan related to PTSD. During an interview conducted on 12/02/24 at 11:25 AM, Resident #72 stated she has PTSD. The resident stated she is seen by a psychiatrist. During an interview conducted on 12/03/24 at 1:40 PM with the Social Service Director (SSD) she stated she has worked at the facility since December last year. When asked about residents with diagnoses of PTSD the SSD stated upon admission we do a stress for life evaluation, refer to psychology and psychiatry services and do monitoring for behaviors and would create a care plan for the PTSD for the resident. When asked about Resident #72 the SSD stated the resident had a stress for life screening upon admission on [DATE] and was not positive she had a stress for life screening every quarter with the most recent on 11/12/24 and was positive. The SSD also acknowledged there was no care plan for PTSD for Resident #72 until she created one today, (12/03/24) just before talking with this surveyor. During an interview conducted on 12/04/24 at 3:20 PM with the MDS Director she stated she has worked at the facility for 6 years. When asked if a resident is admitted with diagnosis PTSD would she be the person to create a care plan for the resident. She said if the resident was admitted with the diagnosis she would. The MDS Director stated if the resident was diagnosed with PTSD after admission, she would want to find out more before creating a care plan such as why the resident was diagnosed, what the triggers were and what to avoid to be able to help the resident. When asked about Resident #72, she said she believes the resident was diagnosed with PTSD after admission. The MDS Director recalled having a conversation with Social Worker and other staff regarding the PTSD diagnosis for Resident #72, but could not recall when she said it. The MDS Director stated she generally does not create care plans if they are related to mood, psychosocial, discharge planning or advance directives. These issues would most likely be created by the Social Worker. 3) A record review revealed that Resident #111 was admitted to the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Heart Failure, and Type 2 Diabetes. The 5-day Minimum Data Set assessment dated [DATE] revealed that Resident #111 had a Brief Interview of Mental Status (BIMS) score of 14, which is cognitively intact. A review of the Order Summary Report documented an order for Alprazolam 0.25 milligrams, 1 tablet at bedtime for Anxiety which was dated 11/21/24. No order was noted to monitor the side effects of Alprazolam. The pharmacy recommendation from 10/1/24 to 10/31/24 revealed that the guidelines requires that a side effect needs to be monitored every shift to support the use of Alprazolam. The care plan initiated on 11/22/24 revealed to observe for signs and symptoms of Anxiety, as needed. It further documented to observe the resident for potential side effects such as confusion, forgetfulness, nausea, vomiting, diarrhea, appetite changes, lightheadedness, and drowsiness. A progress note dated 10/21/24 revealed that Resident #111 was prescribed Xanax (anxiety medication) at bedtime and continue to monitor the side effects of the psychotropic medication. In an interview conducted on 12/04/24 at 3:04 PM with the Director of Minimum Data Set, she stated that antianxiety medication should be initiated with a care plan that included monitoring it's side effects. She further said all residents on psychotropic medications need to be monitored for side effects.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Record review for Resident #108 revealed that the resident was admitted to the facility on [DATE] with a readmission on [DATE] with the following diagnoses: Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris; Hyperlipidemia; Tremor; Essential (Primary) Hypertension; Parkinsonism. Review of Section C of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #108 had a Brief Interview for Mental Status (BIMS) of 09, which indicated that she had moderate cognitive impairment. Review of Section GG of the same MDS revealed that Resident #108 had functional Range of Motion (ROM) with limitations of the upper and lower extremities. Review of the Physician's Orders showed that Resident #108 had an order dated 11/25/23 for Benztropine Mesylate Oral Tablet 1mg, give 1 tablet by mouth one time a day for Parkinson's disease. Review of the Physician's Orders showed that Resident #108 had an order dated 12/15/23 for Austedo (Deutetrabenazine) Oral Tablet 6 mg, give 1 tablet by mouth two times a day for tardive dyskinesia. Review of the Care Plan dated 10/15/24 documented that Resident #108 has Parkinson's Disease. Goals were to minimize risk of complications though next review date. Interventions were to monitor for risk of falls; Monitor/document/report to doctor as needed sign and symptoms of Parkinsons complications: Poor balance, Constipation, Poor coordination, Insomnia, Dysphagia, Tremors, Gait disturbance, Incontinence, Muscle cramps or rigidity, Decline in ROM, Skin breakdown, Mood changes, Decline in cognitive function. Review of the Care Plan dated 10/15/24 revealed no documentation that Resident #108 was assessed for scissors safety. During the initial tour of the facility conducted on 12/02/24 at 10:10 AM, Resident #108 was observed sitting on her bed using regular size scissors to cut paper towels into squares. When asked if those were her scissors, Resident #108 stated yes and she uses them to cut the paper towels because she does not like waste, so she cuts them into rectangles. An interview was conducted on 12/03/24 at 10:32 AM with the Director of Nursing (DON), in which she stated she was not aware that Resident #108 had scissors in her room. She also stated she will do an assessment of Resident #108 to see whether she is able to safely use the scissors. During an observation conducted on 12/04/24 at 5:24 PM, revealed no scissors in Resident #108's room. During an interview conducted on 12/05/24 at 10:30 AM with Staff M, Certified Nursing Assistant (CNA), she stated she has worked at the facility for 2 years and has cared for Resident #108 before. Staff M stated she has not seen Resident #108 with scissors in the room. She noted that if she finds any sharps in residents' rooms, she is to report it to the nurse manager. During an interview conducted on 12/05/24 at 1:37 PM with Staff K, Activity Aide, she reported she has been working at the facility for 1 ½ years. Staff K was asked if Resident #108 can safely use scissors on her own, she stated we do not allow residents to use regular scissors or any sharps during activities. She stated she has never seen Resident #108 with scissors in her room and acknowledged that residents are not allowed to have scissors in their rooms. On 12/05/24 at 2:00 PM, an interview was conducted with the DON. She stated Resident #108's scissors were probably brought in by the family. She stated an assessment was conducted on Resident #108 and safety was a concern, therefore, the scissors were removed from Resident #108's room. Based on observations, interviews and record review, the facility failed to ensure the resident environment remains free of accident hazards including 1 out of 4 emergency carts containing sharps left unlocked and unattended, 1 out of 7 med carts with a broken sharp disposal container, and 2 out of 32 sampled residents with sharps at the bedside (Resident #88 and #108). The findings included: On 12/05/24 from 7:00 AM to 2:30 PM, the Administrator and Director of Nursing were asked several times for a policy regarding sharps or accident/hazards the only policy provided was the facility policy titled, Sharps Disposal undated (printed dated of 12/05/24). Review of the facility's policy titled, Sharps Disposalundated (printed dated of 12/05/24) included in part the following: 3. During use, containers for contaminated sharps will be handled as follows: c) Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container. 1) On 12/02/24 at 1:10 PM, an observation was made of med cart located between rooms [ROOM NUMBERS]. The sharp's container attached to the med cart was broken, containing unsecured sharps (Photographic Evidence Obtained). Staff I, Licensed Practical Nurse (LPN) and Customer Success Representative present at the med cart. During an interview conducted on 12/02/24 at 1:10 PM with Staff I, LPN and the Customer Success Representative who were present at the med cart were asked about the broken sharp's container containing unsecured sharps. Staff I, LPN and the Customer Success Representative stated it was broken. Staff I, LPN unlocked the sharps container holder and acknowledged it was broken. The Customer Success Representative stated maintenance should be contacted, Staff I, LPN locked the sharps container holder and left the med cart. The Customer Success Representative also left the med cart. 2) On 12/03/24 at 7:18 AM, an observation was made of unlocked emergency cart across from the [NAME] nursing station with several safety razors, 2 pair of scissors, and box of lancets (200 count). A side-by-side observation conducted on 12/03/24 at 8:08 AM with Staff B, Registered Nurse (RN) of unlocked emergency cart across from [NAME] nursing station. Staff B, RN acknowledged the unlocked and unattended emergency cart contained 11 safety razors, 2 pair of scissors, and a box of lancets (200 count). An interview was conducted on 12/03/24 at 8:011 AM with Staff B, RN who stated she has worked at the facility for 1 month. Staff B, RN stated emergency carts should be locked at all times. When asked about residents having razors or scissors at the bedside, she said residents should not have razors or scissors stored at the bedside 3) Record review for Resident #88 revealed the resident was admitted to the facility on [DATE] with diagnoses including, in part, the following: non-Hodgkin lymphoma, Myelofibrosis, Polycythemia, and Recurrent Depressive Disorders. Review of the Minimum Data Set (MDS) assessment for Resident #88 dated 11/04/24 documented in Section C a Brief Interview of Mentals Status score of 15 indicating a cognitive response. On 12/02/24 at 11:07 AM, an observation was made of Resident #88 sitting in a wheelchair in his room, on nightstand there was a safety razor in a Styrofoam cup. On 12/03/24 at 9:00 AM, a second observation was made of the safety razor in the Styrofoam cup on the nightstand in Resident #88's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the drainage bag for a resident with an indwelling urinary catheter is maintained in a manner to prevent infection and maintain dignity for 1 of 1sampled resident reviewed for a urinary catheter (Resident #46). The findings included: Review of the facility's policy titled, Catheter Care Urinary with a revised date of August 2022 included in part the following: Purpose: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Infection Control: 2. Be sure the catheter tubing and drainage bag are kept off the floor. Review of the facility's policy titled, Dignity with a revision date of February 2021 included, in part, the following: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. 1) Residents are treated with dignity and respect at all times. Record review for Resident #46 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE]. The resident's diagnoses included in part the following: Paraplegia, and Neuromuscular Dysfunction of Bladder Review of the Minimum Data Set assessment for Resident #46 dated 10/13/24 documented in Section C a Brief Interview of Mental Status score of 14, indicating a cognitive response. Review of the Physician's Orders for Resident #46 revealed, and order dated 03/08/24 for Foley Catheter (type of indwelling urinary catheter) 16 Fr (size of catheter) DX(Diagnosis): Neurogenic Bladder. Review of the Physician's Orders for Resident #46 revealed an order dated 03/12/24 documented, Maintain Foley Catheter to straight drain, keep foley below the level of the bladder, check placement and function every shift, monitor for any kinks in the tubing, keep the urinary drain bag covered every shift. Review of the Physician's Orders for Resident #46 revealed an order dated 03/12/24 documented, Maintain Foley Catheter to straight drain, keep foley below the level of the bladder, check placement and function every shift, monitor for any kinks in the tubing, and keep the urinary drain bag covered every shift. Review of the Care Plan for Resident #46 dated 10/19/23 with a focus on the resident has a 16 Fr. Foley Catheter for Neurogenic bladder due to paraplegia, potential for infection, catheter related trauma and accidental dislodgement. The goals were for infection to be minimized, risk for accidental dislodgement will be minimized and risk for catheter-related trauma will be minimized through next review date. The interventions included, in part, the following: Catheter care every shift and as needed. Empty drainage bag every shift. Provide dignity cover for drainage bag. On 12/02/24 at 10:52 AM, an observation was made of Resident #46 lying in bed with an indwelling urinary catheter drainage bag lying on the floor (not hanging from bed) with no privacy cover. On 12/02/24 at 1:30 PM, a second observation was made of Resident #46's indwelling urinary catheter drainage bag hanging from the bed with no privacy cover. On 12/03/24 at 7:32 AM, an observation was made of Resident # 46 lying in bed with indwelling urinary catheter drainage bag lying on the floor with no privacy cover in place. During an interview conducted on 12/02/24 at 10:55 AM with Resident # 46, she was asked about her indwelling urinary catheter and she stated they told her originally, they would be changing the catheter every 6 months, but she insisted they change it monthly. During an interview conducted on 12/05/24 at 10:58 AM with Staff E, Certified Nursing Assistant, who stated she has worked at the facility for 1 year. When asked about residents with indwelling urinary catheters, she said the catheter care is done daily and documented in POC (Point of Care) for the resident and the bag needs to be hanging and have a privacy cover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). Record review showed that Resident #98 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Complex Regional Pain Syndrome I and Obstructive and Reflux Uropathy. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score was 8, which indicates moderate cognitive impairment. A thorough review of the weight log for Resident #98 showed the following: 182.2 pounds on 06/13/24 and dropped to 172.0 pounds on 06/27/24. This showed a 5.5% severe weight loss in less than one month. Continued review indicated a weight loss from 172 pounds on 06/27/24 to 161pounds on 07/11/24, which showed an overall severe 12% weight loss in less than 2 months. Resident #98 had an overall trending weight loss of 14% from 06/13/2024 to 11/04/2024 (past 6 months). A review of the Dietary progress note dated 06/28/24 (a day after the 5.5% weight loss was identified) revealed the following: Staff D, Registered Dietitian documented Resident #98 had a non-significant weight loss. Resident #98 received Magic cup (nutritional supplements) once a day and it was recommended to also increase the Ensure Plus (nutritional supplements) from once a day to twice a day. This note revealed that Resident #98 had an intake of meals between 50% to 100% of meals. A review of the Dietary progress note dated 07/12/2024 revealed the following: Staff D, Registered Dietitian documented Resident #98 had significant weight loss. Resident #98 was recommended to increase the Ensure Plus 8 ounces to three times a day (TID) for an additional 1050 calories and 48 grams of protein a day, and the addition of fortified foods at breakfast and lunch meals. A review of Resident #98's Physician's orders showed the following: Ensure Plus 8oz TID was started on 07/13/2024 and discontinued on 09/11/2024. A new order was written for Ensure Plus twice a day and started on 09/11/2024. No orders were noted for fortified meals or Magic Cup. In an observation conducted on 12/04/2024 at 12:35 PM Resident # 98 was observed in the dining room eating. His meal ticket consisted of Mechanically Altered Chopped Orange Glazed Chicken 3oz, Mechanically Altered Chopped Normandy Vegetable blend 4oz, Cream of [NAME] 4oz, Diced Peaches 1/2Cup, Magic Cup 1/2 Cup and Sugar Free Lemonade 8oz. No fortified foods were noted on the meal ticket or on the actual meal tray. Further observation of the meal tray showed the following: a Magic cup noted on the side table and not on the meal tray, and a regular chocolate ice cream on the side table as well. Resident #98, unassisted, picked the regular ice cream chocolate instead of the Magic cup ice cream. Staff in the room did not ensure that Resident #98 was given the correct nutritional supplements as needed or assisted him with the lunch meal. In an interview conducted on 12/04/2024 at 11:30AM with Staff C, Registered Dietitian stated that when a Magic Cup is recommended it is not added as a physician order but placed directly into the meal tracker to auto populate on the meal ticket. The same process applies for any recommended fortified foods. Staff C said that the percent intake of the Magic Cup is not documented better yet the tray is reviewed as a whole. Unlike for Ensure Plus which is ordered and documented for percentage intake in the Medication Administration Record (MAR). According to Staff C the fortified meal for lunch is Mashed Potatoes which was not provided to Resident #98. In an interview conducted on 12/04/2024 at 4:45 PM with Staff D, she stated that the progress note dated 06/28/2024 said no significant weight loss because she was comparing the weight loss from one week to another instead of seeing the overall weight loss in less than a month. When asked how do you assess the effectiveness of the nutritional supplements not documented in the MAR she did not have an answer. In an interview conducted on 12/05/2024 at 10:20 AM with Staff F, Certified Nurse Assistant (CNA), she reported that she did not know what a Magic Cup was and did not know that it was a nutritional supplement. In another interview conducted on 12/05/2024 at 10:45 AM with Staff G, Certified Nurse Assistant (CNA), she reported that she had no idea what a Magic Cup was, and also asked : Is it a cup? Based on observations, interviews and record reviews, the facility failed to monitor intake of nutritional supplements for 2 of 3 sampled residents reviewed for Nutrition (Residents #98 and Resident #53). The findings included: The facility's policy titled, Oral Supplements with a reference date of May, 2023, documented: Policy: The Department shall provide nutritional supplements to residents whose nutritional needs cannot be met through three meals per day, as ordered by the physician. Procedures: Nursing staff documents the resident's acceptance/rejection of supplements by amount. Records the amount of nourishment consumed by the resident in EMR (electronic medical record), and notifies the dietitian if the resident refuses the produce consistently. 1). Resident #52 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, a Medicare 5-day Minimum Data Set (MDS), dated [DATE], Resident #52 had a Brief Interview for Mental Status (BIMS) score of 09, indicating the resident had moderate cognitive impairment. The assessment documented that Resident #52 was dependent upon staff for eating. Resident #52's diagnoses at the time of the assessment included: Heart Failure, Hypertension, Renal Insufficiency, Non-Alzheimer's Dementia, Malnutrition, Chronic Lung Disease, Acute Embolism and Thrombosis, Thryotoxicosis, Atrial Fibrillation, speech and language deficits following cerebrovascular disease, Dysphagia following cerebrovascular disease, Diverticulosis of intestine, Osteoarthritis, and Disorder of Kidney and Ureter. Resident #52's dietary orders dated 11/12/24 included: Regular diet, Puree texture, Nectar Thickened Liquids consistency - 11/08/24 Ensure Plus one time a day - 11/08/24 Weekly weight times one time a day every Tuesday for monitoring. Resident #52's Care plan for nutrition documented, Resident at high nutrition risk diagnoses Urinary Tract Infection (UTI), Chronic Obstructive Pulmonary Disease (COPD), Dementia, Thyrotoxicosis, Deep Venous Thrombosis (DVT), Atrial Fibrillation, Congestive Heart Failure, Hypertension, Chronic Kidney Disease, Diverticulosis. Potential for weight fluctuations, mechanically altered diet. 11/8/24 s/p hospitalization. Impaired skin. + edema to bilateral lower extremities (BLE). Weight gain 11/14/24 Weight loss; - edema BLE 12/2/24 Weight loss r/t (related to) edema Date Initiated: 10/07/2024 The goals of the care plan included: o Resident will exhibit no signs or symptoms of dehydration as evidenced by good skin turgor, moist mucous membranes, moist lips, no complaints of thirst, free from electrolyte imbalance lab values by next review. Date initiated: 10/07/24. Target date: 01/21/25. o Resident edema will subside Date Initiated: 11/08/2024 Target Date: 01/21/2025 o Resident's pressure injury/wound will improve/heal by next review date Date Initiated: 11/08/2024 Target Date: 01/21/2025 Interventions in the care plan included: o Monitor oral intake of food and fluid Date Initiated: 10/07/2024 o Monitor Skin Integrity Date Initiated: 11/08/2024 o Monitor weight monthly/weekly Date Initiated: 10/07/2024 o Provide > 8 cups fluid per day with meals/between meals Date Initiated: 10/07/2024 o Provide diet as prescribed Date Initiated: 10/07/2024 o Provide fortified foods (specify) Date Initiated: 11/08/2024 o Provide necessary assistance at mealtime and between meals Date Initiated: 11/08/2024 o Provide nourishments/snacks/fluids prn Date Initiated: 10/07/2024 o Provide oral supplements as ordered Date Initiated: 10/07/202 A Nutrition Progress note, dated 12/02/24, documented: Note Text: Wt reviewed: 11/21-117lbs; 11/29-107lbs. reweight completed. Noted with 10lbs/8.5% significant weight loss x 1 week. Regular Diet order with pureed altered texture, nectar liquids. During meal rounds, resident dependent with meals; PO intake ~75% of today's lunch. Nursing documents 50-75% of most meals. Receiving Ensure Plus as ordered with ~50% as per nursing. Resident's family informed of weight status via phone. Resident s/p edema upon readmission. As per nursing, resident with decreased edema. Wound care to sacrum noted; see Wound Evaluation 11/27 for details. Wound care including MVI/Minerals with protein supplementation to aide in healing. MD (Medical Doctor) is aware. Continue with fortified cereal at breakfast meal. Increase Magic Cup to 2x daily at lunch and dinner. Continue to follow as warranted. On 11/07/2024, the resident weighed 123 lbs. On 11/29/2024, the resident weighed 107 pounds which is a -13.01 % Loss. An admission Progress note dated 11/06/24 documented Resident #52's admission weight of 115 pounds. During an interview on 12/05/24 at 11:30 AM, with Staff C, Registered Dietitian (RD), when asked about Resident #52's weight loss, Staff C replied, She came back with edema. She was post status and was on diuretics before. Our weekly weight is due. We got a weight on Tuesday or Wednesday and she was 117 pounds and I requested a re-weigh and today her weight was 115. I requested the re-weight because I was questioning the accuracy. 107 pounds was a re-weight from last week's weights. When she first came back, she had bilateral edema. Reduced edema. I asked for a re-weight on 11/29, and she weighed 107 pounds. Her intake was fine, she was already on supplements, we increased her nourishment. When asked about recommendations for supplements, Staff C replied, When they make a recommendation its placed in order and in the MAR (Medication Administration Record). Magic Cup is in the meal tracker, so it will show in the meal ticket not in the orders. During an interview, on 12/05/24 at 11:51 AM, with Staff Q, RN, when asked about providing the supplements to the residents, Staff Q replied, The supplements come from us (nursing) we document the intake in the progress notes. A side-by-side review of progress notes with Staff Q revealed no documentation of the intake of the supplements in Resident #52's records. During a follow up interview with Staff C, on 12/05/24 at 1:15 PM, when asked about documenting the percentage of intake of meals, Staff C replied, when they do the intake, it includes just the lunch. The supplements are written in the doctors' orders and they give them to the resident and document the percentage consumed in the MAR. Review of the MAR and progress notes revealed no documentation of intake of the supplements. Durine a side-by-side review of Resident #52's electronic health records with Staff C, revealed no documentation of the resident's intake.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) Resident # 8 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (a lung condition requiring low level of oxygen administration to allow better lung perfusion), Atrial Fibrillation, and Dependence on Supplemental Oxygen. A review of Minimum Data Set (MDS) Section C revealed a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. A review of physician orders dated 11/21/24, revealed oxygen at 2 Liters by nasal cannulae to keep oxygen saturation equal or greater than 90% every shift. Another order revealed to change nebulizer mask and tubing weekly, place in plastic bag on (Friday between 7:00AM-3:00PM), place in plastic bag when not in use every AM shift, and every Friday. A review of nursing progress notes dated 04/26/24 revealed to administer and monitor the effectiveness of treatments{(see current physicians orders), (such as oxygen -incentive spirometer -nebulizer treatments)}. A review of a nursing care plan revealed Resident #8 has alteration in breathing patterns related to Chronic Obstructive Pulmonary Disease with goals: to prevent acute therapy tasks and equipment including ventilators, among residents and staff, respiratory distress, and complications; with interventions requiring resident to have oxygen through nasal cannula at bedtime, and with staff administering, and monitoring the effectiveness of treatments {(see current physicians orders) (such as oxygen, incentive spirometer, and nebulizer treatments)}. During observation on 12/02/24 at 11:30 AM, Resident #8 was wearing oxygen nasal cannula on both nares at the end of long clear oxygen tubing with a tape tag black marked 11/18. The oxygen flow meter was set at 3 Liters per minute on the portable oxygen box machine. During the following day observation on 12/03/24 at 2:00 PM, Resident #8's oxygen cannulae and tubing were observed with an attached tape tagged and black marked 11/18. Resident was sitting on his bed, and not wearing the oxygen nasal cannula on both nares. Further observation revealed some parts of the oxygen cannula and tubing were under the portable oxygen box machine on the floor. The nasal cannula portion and the tubing were not inside any plastic containment. During another observation on 12/04/24 at 9:21AM, Resident #8 was asleep on his left side in bed, wearing nasal oxygen cannula on both nares of a clear oxygen tubing attached to the portable oxygen box machine. The tubing was tape tagged and black marked 11/18. The oxygen level was at 3 Liters per minute. During an interview with Resident #8 on 12/02/24 at 11:30 AM, he stated he uses oxygen when he sleeps. When asked about the oxygen tubing, he stated the facility provides him with long tubing. When asked about the frequency of oxygen tubing changes, he stated that Sometimes, the facility staff change the oxygen tubing. Based on observations, and record review, the facility failed to ensure a resident receiving oxygen has a physician's order for 1 of 4 sampled residents reviewed for respiratory affecting Resident #111 and failed to ensure respiratory supplies are cared for in a manner to prevent infection for 4 of 4 sampled residents for respiratory affecting Residents #17, # 111, #6 and #8. The findings included: Review of the facility's policy titled, Department (Respirator Therapy) -Prevention of Infection with no date (just a printed date of 12/05/24) included in part the following: Purpose The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among residents and staff. Infection Control Considerations Related to Oxygen Administration: 7. Change the oxygen cannula and tubing every seven (&) days, or as needed. Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses. 1) Record review for Resident #111 revealed the resident was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses that included, in part, the following: Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set assessment for Resident #111 dated 11/19/24 revealed in Section C a Brief Interview of Mental Status score of 14, indicating intact cognition. Review of the Physician's Orders for Resident #111 revealed no evidence of an order for oxygen. On 12/02/24 at 12:04 PM, an observation was made of Resident #111 sitting up in bed wearing oxygen, the oxygen concentrator was set at 2 liters. 2) Record review for Resident #6 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnoses of Infection and Inflammatory Reaction Due to Other Cardiac and Vascular Devices, Implants and Grafts, and Chronic Obstructive Pulmonary Disease. Review of the Minimum Data Set for Resident #6 dated 11/18/24 revealed in section C a BIMS score of 15, indicating intact cognition. Review of the Physician's Orders for Resident #6 revealed an order dated 11/21/24 documented to change the nebulizer mask and tubing weekly; date and place in dated plastic bag (Fri 7-3). Place in dated bag when not in use every day shift every Friday On 12/02/24 at 9:30 AM, an observation was made of Resident #6's nebulizer mask on top of a personal cart (mask not in a plastic bag). On 12/02/24 at 5:50 PM, an observation was made of Resident #6's nebulizer mask, laying on the nightstand next to a plastic bag. During an interview conducted on 12/02/24 at 5:52 PM with Resident #6, who was asked if she receives breathing treatments, she said oh yes, she needs them. 3) Record review for Resident #17 revealed the resident was admitted to the facility on [DATE] with a diagnoses that included, in part, the following: Acute On Chronic Diastolic (Congestive Heart Failure), Primary Pulmonary Hypertension, Anxiety Disorder, Dementia, and Presence of Cardiac Pacemaker. Review of the MDS for Resident #17 dated 11/13/24 documented in Section C a BIMS (Brief Interview for Mental Status) score of 9, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #17 revealed an order dated 09/10/24 for oxygen 2 Liters/min per nasal cannula continuously every shift for Shortness of Breath. Review for Nursing Progress Notes for Resident #17 from 11/24/24 to 12/01/24 revealed no documentation of oxygen tubing being changed. On 12/02/24 at 10:35 AM, an observation was made of Resident #17 sitting up in bed wearing oxygen via nasal cannula. The nasal canula had a label with the date of 11/11/24. During an interview conducted on 12/03/24 at 11:31 AM with the Director of Nursing (DON). She stated she has been working at the facility for 2 months. When asked about administering oxygen, she said the resident needs an order. When asked about oxygen tubbing being changed, she said it should be changed weekly and as needed. When asked about storage of nebulizer masks, she said they should be in a plastic bag at the bedside when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to identify triggers for residents diagnosed with Post-Traumatic Stress Disorder (PTSD), for 2 of 2 residents sampled for mood and behavior, (Resident #72 and Resident #28). The finding include: 1.) Review of the facility's policy titled, Trauma Informed Care Proc with Document ID #98875710, published on 05/19/2023 revealed the following: Purpose: a. To guide Staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice: and b. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. General Guidelines: Triggers are highly individualized. Some common triggers may include: a. experiencing a lack of privacy or confinement in a crowded or small space. b. exposure to loud noises. c. certain sights such as objects; and or d. sounds, smells, and physical touch Resident Screening included the following: 1. Perform universal screening of residents, which include a brief, non-specialized identification of possible exposure to traumatic events, 2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant, and sensitive. 3. Screening may include information such as : 1. Perform universal screening of residents, which include a brief, non-specialized identification of possible exposure to traumatic events, 2. Utilize screening tools and methods that are facility-approved, competently delivered, culturally relevant, and sensitive. 3. Screening may include information such as : a. trauma history, including type, severity and duration. b. depression, trauma-related or dissociative symptoms. c. risk for safety (self or others); d. concerns with sleep or intrusive experiences. e. behavioral, interpersonal or developmental concerns. f. historical mental health diagnosis. g. substance use. h. protective factors and resources available; and i. physical health concerns, 4. Utilize initial screening to identify the need for further assessment and care. Resident Care Planning: 1. Develop individualized care plans that address past trauma in collaboration with the resident ad family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident. Review of the facility's documentation, titled, Stressful Life Experiences Evaluation submitted by the MDS Coordinator on 12/04/24 at 3:00 PM, revealed the following: A. Stressful Life Experiences: INSTUMENT: Please indicate how much you have been bothered by each problem in the past month. For these questions, the response options are Not at All, A Little Bit, Moderately, Quite a Bit, or Extremely. An individual is considered to have screened positive if the sum of these items is 14 or greater. There was no question indicating triggers for PTSD. 1) Resident #28 was admitted to the facility on [DATE], with diagnoses including, Diabetes Mellitus without Complications, Post-Traumatic Stress Disorder (PTSD), Dysphagia Following Cerebral Infarction, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. A review of the Minimum Data Set (MDS) Section C revealed a Brief Interview of Mental Status (BIMS)score of 14, indicating intact cognition. A review of progress notes dated 09/14/24 revealed a behavior code number 1 (one) labelled as depressed or withdrawn and to document number of times behavior occurred on each shift. Additional progress notes written by Social Services Staff, dated 09/24/24 revealed Resident #28 will demonstrate adjustment to nursing home placement by/through review date. A review of Physician Progress Notes dated 09/16/24 revealed a doctor tried to complete a psychology assessment, but was unable to locate Resident #28. A review of Psychiatry Referral Progress Notes dated 09/19/24 revealed the chief complaint for the consultation was for Resident #28's history of depression. There was no consultation related to PTSD. During an observation and interview with Resident #28 on 12/12/24 at 12:18 PM, he stated he is not happy. He was observed with a contracted left hand, and left elbow bandage. Resident #28 stated he wants to get out of the facility, because staff do not answer call lights when he needed them the most. In an interview with Staff N, a Certified Nursing Assistant (CNA), on 12/04/24 at 10:11 AM, when asked how he addresses residents who are exhibiting distress, he responded that he observes body shaking, and resident's state of confusion about time, place and events, and resistance to care. When asked about the common signs of resident's distress, he stated agitation, or being scared. When asked how he manages resident's distress, he stated he checks the residents regularly and familiarizes himself with resident's needs. When asked how he knows if a resident was a trauma survivor, and what does he need to do differently for that resident, he stated when a resident is unable to move any body parts, and have dressing on the head, he would know based on his visual observation. This staff added that his eyes can detect if a resident was a trauma survivor. He added that residents might be constipated, and not going to the bathroom, not responding to his questions and always lying down in bed. He added he will read resident's records, calm resident's anxiety, and try to understand them. When asked about the types of behavioral health training he has completed, he responded he had some, but does not remember the date or the name of the training. In an interview with a Social Services Staff on 12/04/24 at 12:21 PM who has been working in the facility for one year, when asked about Resident #28's care plan for PTSD , she stated, There is no care plan that has been created. She added that the reason there was no care plan for PTSD was, first upon admission the resident denied anxiety and depression, and secondly, because the resident was evaluated by the psychiatrist. When asked regarding the resident's triggers, she stated she did not identify triggers on 09/13/24 upon admission, because she wanted to do a continuing process of building rapport with the resident. She added she is quarterly monitoring the resident and maybe next time she will be able to ask for triggers. When asked when is the next time, she did not give a specific date. When asked how she proposes caring for residents with PTSD with no information about his triggers, she stated it was a continuing process, but she is planning to eventually ask about the resident's triggers. When asked why she has not created a care plan for resident #28's PTSD yet, she responded that she plans to keep asking the resident, because she wants to make sure Resident#28 is comfortable with her. She added that she plans to quarterly assess Resident #28. When asked regarding Resident #28's PTSD diagnosis, she stated it was derived from admission. When asked when she is planning to create a PTSD care plan because 3 months had passed since the resident's admission to the facility, she responded she has not made any evaluation to ask for triggers and insisted that she must make a rapport with the resident first. She added it is a continuous process. When asked about a Psychiatry Evaluation of Resident #28 related to PTSD, she stated she will provide the documentation to the Surveyor, but until the end of this survey, no Psychiatry Evaluation was presented. In an interview with the MDS Coordinator on 12/04/24 at 4:11 PM, when asked how she demonstrated her knowledge of Resident #28's current behavioral and emotional needs, she stated these are based on care evaluations from Psychiatrist, Psychologist, and Social Services assessments. When asked how often she attends Staff Behavioral in-service training, she stated once a year. When asked about the types of behavioral health training she had completed, she stated it was an annual in-service provided by facility to all Staff. When asked how she demonstrates competent interactions when addressing the resident's behavioral care needs, she responded by providing services based on resident's culture. When asked how she evaluates resident's anxiety, she responded by checking resident's appearance and verbalization. When asked how she would know if a resident was a trauma survivor, and what would she do differently for that resident, she stated she must create a care plan in the MDS. She added that a section in the MDS has specific space for creating a care plan. She added that baseline care plan for the resident should be done in 2 to 3 days, while the comprehensive care plan in 30 days. When asked regarding PTSD interventions, she stated some examples are approaching the resident in a calm manner, assuring the resident to prevent him/her from getting anxious. When asked who is responsible for completing the Stressful Life Events documentation, she stated a Social Worker, but the MDS Coordinator inputs clinical assessments, plans, goals and interventions with the Social Services Staff, then both establish a care plan meeting based on the completed admission evaluation. When asked regarding a required time frame to complete a resident's care plan meeting , she stated approximately 2 weeks after the admission evaluation. When asked who completes the Stressful Life Events, she stated the MDS Coordinator with data and update information, assessment and intervention from the Social Services Staff. She added that during a care plan meeting, staff discussed the content of the admission evaluation including the Stressful life events form. There is a time frame for completion of Stressful life events form which is approximately 2 weeks after admission. When asked the facility's process for identifying residents with possible Mental Disability (MD), Intellectual Disability (ID), or related condition prior to admission to the facility, this staff responded that she assesses resident, follows admission and nurses' interventions, supervises resident and follows doctor's orders on admission. In an interview with Staff P, a Registered Nurse (RN) on 12/05/24 at 11:30 AM, when asked how the facility identifies residents with newly evident or possible serious MD, ID or related condition after admission, she responded by speaking with the resident and watching the resident's behaviors. This staff added that changes in behaviors are important indicators of new behavioral symptoms and stressing that any complaints of pain must be assessed. 2) Record review for Resident #72 revealed the resident was admitted to the facility on [DATE]. Review of the diagnoses for Resident #72 revealed the resident had a diagnosis of Post-Traumatic Stress Disorder (PTSD) Unspecified dated 11/14/24. Review of the Minimum Data Set for Resident #72 dated 08/14/24 documented in Section C a Brief Interview of Mental Status score of 15, indicating intact cognition. Review of the Stress for Life Screening for Resident #72 dated 02/07/23 and 11/12/24 revealed no documentation of triggers (related to PTSD) being asked or discussed with the resident. Review of the Social Service Progress Notes for Resident #72 dated from 02/07/23 to 12/01/24 revealed no documentation of triggers (related to PTSD) being asked or discussed with the resident. During an interview conducted on 12/02/24 at 11:25 AM with Resident #72, who stated she has PTSD, but was not able to clearly articulate to the surveyor what her triggers were. She stated she does have triggers, and they are related to others controlling her or taking her items. The resident stated she is seen by a Psychiatrist. An interview was conducted on 12/03/24 at 1:40 PM with the Social Service Director (SSD), who stated she has worked at the facility since December last year. When asked about residents with diagnoses of PTSD the SSD stated upon admission we do a stress for life evaluation, refer to psychology and psychiatry services and do monitoring for behaviors and would create a care plan for the PTSD for the resident. When asked about Resident #72 the SSD stated the resident had a stress for life screening upon admission on [DATE] and was not positive. She had a stress for life screening every quarter with the most recent on 11/12/24 and was positive. When asked if the stress for life screening addresses or asks about triggers, she stated it does not. When asked if she asks the resident about triggers, she said they do not ask residents about their triggers, usually the resident would just tell them. The SSD acknowledged there were no triggers documented for Resident #72.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review, the facility failed to ensure the controlled substance medication reconciliations were accurate for 6 of 12 sampled residents reviewed during the controlled substance record review (Residents #10, #51, #73, #88, #345, and #346). The findings included: Review of the facility's policy titled, Controlled Substances, dated November 2022, included the following: Policy Statement: The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Dispensing and Reconciling Controlled Substances: 1.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. 2.The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and d. Destruction, waste and return to pharmacy records. 1) Record review for Resident #10 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Dementia, Osteoarthritis, Anxiety Disorder, Cognitive Communication Deficit, and Chronic Pain Syndrome. Review of the Physician's Orders showed that Resident #10 had an order dated 11/29/23 for Percocet (oxycodone-Acetaminophen) Tablet 10-325 mg, give 1 tablet by mouth four times a day for moderate to severe pain. On 12/04/24 at 5:15 PM, a review of Resident #10's Controlled Drug Disposition sheet was conducted. The disposition sheet documented Percocet 10-325 mg (24 tablets), to be given four times daily for moderate to severe pain, was received by the facility from the pharmacy on 11/26/24. There were 11 tablets left in the controlled substance box. Further review of the disposition sheet revealed the last Percocet tablet was given on 11/29/24 at 9:30 PM. Review of Resident #10's November Medication Administration Record (MAR) revealed the Percocet 10-325 mg tablet was documented as administered to Resident #10 on 11/30/24 at the scheduled times of 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. 2) Record review for Resident #51 revealed that the resident was admitted to the facility on [DATE] with a readmission on [DATE] with the following diagnoses: Fracture of Shaft of Left Fibula, Anxiety Disorder, Psoriatic Arthritis Mutilans, Dementia, and Osteoarthritis. Review of the Physician's Orders showed that Resident #51 had an order dated 09/24/24 for Oxycodone HCl Oral Capsule 5 mg, give 5 mg by mouth every 6 hours as needed for pain. Review of Resident #51's Controlled Drug Disposition sheet revealed Oxycodone HCL 5 mg (28 capsules) was received at the facility from the pharmacy on 10/01/24. Resident #51 was given the medication on 10/01/24, 10/11/24, 10/18/24, 10/22/24, and 10/25/24. Further review of the Disposition sheet revealed that there were 23 Oxycodone HCL 5 mg capsules left in the controlled substance box with the last one administered on 10/25/24 at 3:35 PM. Review of Resident #51's October MAR revealed that Resident #51 was administered Oxycodone HCL 5 mg on all the above dates and on 10/03/24 at 1:25 PM (which was not documented in Resident #51's Controlled Drug Disposition sheet). The resident's controlled substances was not reconciled. 3) Record review for Resident #73 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Sequelae of Cerebral Infarction, Hypertension, Atherosclerosis of Aorta, and Gastro-Esophageal Reflux Disease. Review of the Physician's Orders showed that Resident #73 had an order dated 10/24/24 for Temazepam Oral Capsule 15 mg, give 1 capsule by mouth at bedtime for insomnia. On 12/04/24 at 4:59 PM, a review of Resident #73's Controlled Drug Disposition sheet was conducted. The disposition sheet documented Temazepam15 mg (10 capsules), to be given at bedtime for insomnia, was received by the facility from the pharmacy on 12/01/24. There were 8 capsules left in the controlled substance box with the last capsule administered on 12/02/24 at 8:13 PM. Further review of the Disposition sheet revealed that a signature, date and time was added after the 12/02/24 entry (on 12/03/24 at 10:12 PM). However, the count on the Disposition sheet matched with the amount left in the controlled substance box (8 capsules). Review of Resident #73's December MAR documented that Resident #73 was administered Temazepam on 12/03/24, as scheduled (no exact time was recorded in the MAR). On 12/05/24 at 1:34 PM a side-by-side review of Resident #73's Controlled Drug Disposition sheet was conducted with Staff L, Licensed Practical Nurse (LPN). She acknowledged that there were 7 capsules left of the Temazepam in the controlled substance box and one capsule was administered on 12/04/24. When asked if she received any report from the night nurse regarding the documentation for 12/03/24 (which the amount given was left empty), Staff L stated she did not receive any information and was not sure what happened. However, the amount of the medication was correct in the controlled substance box, and she was not concerned. 4) Record review for Resident #88 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: non-Hodgkin lymphoma, Myelofibrosis, and Polycythemia Vera. Review of the Physician's Orders showed that Resident #88 had an order dated 08/03/24 for Morphine Sulfate Extended Release (ER) 15 mg tablet, give 1 tablet by mouth every 12 hours for pain. Review of Resident #88's Controlled Drug Disposition Sheet revealed Morphine Sulfate ER 15 mg (28 tablets) was received at the facility from the pharmacy on 11/28/24. Resident #88 was given the medication on 11/28/24 at 10:57 PM, 12/03/24 at 10:09 PM, and 12/04/24 at 9:00 AM. Further review revealed that there were 25 Morphine Sulfate ER 15 mg tablets left in the controlled substance box which matched the Disposition sheet count. Review of Resident #88's December MAR documented Resident #88 was administered Morphine Sulfate ER 15 mg from 12/01/24 to 12/03/24 at 9:00 AM and 9:00 PM. The resident's controlled substance was not reconciled. 5) Record review for Resident #345 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Stage 3B, and Urinary Calculus. Review of the Physician's Orders showed that Resident #345 had an order dated 11/07/24 for Tramadol HCl Oral Tablet 50 mg, give 1 tablet by mouth every 6 hours as needed for Pain Control for 7 Days, end date 11/14/24. Review of the Physician's Orders showed that Resident #345 had an order dated 11/22/24 for Tramadol HCl Oral Tablet 50 mg, give 1 tablet by mouth every 6 hours as needed for Back Pain for 3 Days, end date 11/25/24. Review of Resident #345's Controlled Drug Disposition sheet revealed Tramadol HCl 50 mg (24 tablets) was received at the facility from the pharmacy on 11/08/24 and revealed Resident #345 was given the medication on 11/22/24 at 9:59 PM, 11/23/24 at 7:00 PM, 11/24/24 at 8:51 PM, and 11/25/24 at 1:39 PM. Further review of the Disposition sheet revealed that 18 tablets remained, which matched the count in the controlled substance box. Review of Resident #345's November MAR revealed no nurse initialed for the administered Tramadol HCl 50 mg on 11/25/24 at 1:39 PM (which was recorded in Resident #345's Controlled Drug Disposition sheet). The resident's controlled substances were not reconciled. 6) Record review for Resident #346 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Parkinson's Disease Without Dyskinesia, Other Chronic Pain, Dementia, and Anxiety Disorder. Review of the Physician's Orders showed that Resident #346 had an order dated 12/01/24 for Oxycodone HCl Tablet 15 mg, give 1 tablet by mouth three times a day for moderate to severe pain for 3 days, end date 12/04/24. Review of the Physician's Orders showed that Resident #346 had an order dated 12/05/24 for Oxycodone HCl Tablet 15 mg, give 1 tablet by mouth three times a day for moderate to severe pain. Review of Resident #346's Controlled Drug Disposition sheet revealed Oxycodone HCL 15 mg (9 tablets) was received at the facility from the pharmacy on 12/01/24. Resident #346 was given the medication on 12/02/24 at 9:53 AM and 5:44 PM, on 12/03/24 at 11:12 AM, 2:00 PM, and 5:49 PM, and 12/04/24 at 9:00 AM and 12:30 PM. Further review revealed that there were 2 Oxycodone HCL 15 mg tablets left in the controlled substance box which matched the count on the Disposition sheet. Review of Resident #346's December MAR revealed that Resident #346 was administered Oxycodone HCL 15mg on all the above dates, in addition to 12/01/24 and 12/02/24 at 5:00 PM (which were not documented in Resident #346's Controlled Drug Disposition sheet). The resident's controlled substances were not reconciled. During an interview conducted on 12/05/24 at 1:10 PM with Staff J, Registered Nurse (RN), she stated she is one of the weekend supervisors and picks up shifts sometimes during the week. She stated if a resident is scheduled for a controlled medication, such as a pain medication, she is to follow Physician's orders which she can view on the computer (PCC). Staff J stated she would evaluate pain level, dispense and administer the medication. After the resident takes the medication, she stated that's when she signs in PCC and almost at the same time sign the Controlled Drug Disposition sheet with the time from PCC. Staff J acknowledged that reconciliation of controlled substance stored in the medication cart is done by the nurses during the change of shift. An interview was conducted on 12/05/24 at 1:34 PM with Staff L, LPN. She acknowledged after administration of a controlled medication is when she documents in PCC and the Controlled Drug Disposition sheet of the medication. In addition, Staff L stated that the entered times in both places (PCC and Disposition sheet) need to match. During an interview conducted on 12/05/24 at 1:43 PM with the Director of Nursing (DON), she stated she has been working at the facility for 2 months. She stated nurses are to do reconciliation of the controlled medications during the change of shift. In addition, two weeks ago, she and the managers started to perform audits of medication carts and controlled substance reconciliation daily. She stated the audits consisted of checking the medication blister sheets and Disposition sheets count matched and in-service education was provided for discrepancies. The first week she did the audits daily and the managers took over the following week and she was confident that it was done at least several times a week for each medication cart. The DON also stated education was provided to the nurses to report any discrepancies at any time to her. The 6 residents' Disposition sheets (Residents #10, #51, #73, #88, #345, and #346) were reviewed with the DON and she acknowledged the plan in place is not working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure medication error rate was below 5 percent; a total of 32 opportunities were observed with 4 medication errors identified which yield a medication error rate of 12.50 percent, affecting 2 of 5 sampled residents reviewed for medication administration, Resident #63 and Resident #32. The findings included: Review of the facility's policy titled, Administering Medications, dated April 2019, included the following: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: 4.Medications are administered in accordance with prescriber orders, including any required time frame. 1) Record review for Resident #63 revealed the resident was admitted to the facility on [DATE] with the following diagnoses: Acute Leukemia of Unspecified Cell Type in Remission, Drug Induced Subacute Dyskinesia, Anxiety Disorder, and Major Depressive Disorder. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) of 15, which indicated that she was cognitively intact. Review of Section N revealed Resident #63 was on antipsychotic, antianxiety, antidepressant and Antipsychotics were received on a routine basis. During a medication administration (med pass) on the [NAME] unit conducted on 09/24/24 at 9:28 AM, with Staff B, Registered Nurse (RN), she was observed preparing the following medications to administer to Resident #63: Buspirone HCl 5 mg tablet, give 1 tablet by mouth two times a day for Anxiety. Lactulose Solution 20 GM/30ml, give 30 ml by mouth two times a day for Constipation. Metoprolol Tartrate 25 mg tablet, give 1 tablet by mouth two times a day for Hypertension. Omeprazole 20 mg capsule delayed release, give 1 capsule by mouth two times a day for Gastroesophageal Reflux Disease (GERD). Sennosides-Docusate Sodium Tablet 8.6-50 mg, give 2 tablets by mouth two times a day for Constipation. Vitamin C (Ascorbic Acid) 500 mg tablet, give 500 mg by mouth two times a day for nutrition supplement. Lorazepam (Zanax) 0.5mg tablet, give 1 tablet by mouth one time a day for Anxiety. Reconciliation of Resident #63's physician's orders and Medication Administration Record (MAR) revealed Resident #63 was scheduled to receive the above medications at 9:00 AM, plus 3 other medications which were not observed as administered during the med pass: Ingrezza (Valbenazine Tosylate) 60 mg capsule, give 1 capsule by mouth one time a day for Tardive Dyskinesia. Polyethylene Glycol 3350 Powder, to give 17 grams by mouth two times a day for Stool Softening. Ferrous Sulfate 325 mg (65 Fe) tablet, give 1 tablet by mouth one time a day for Anemia. Further review of Resident #63's December MAR revealed Staff B initialed as administering all the medications scheduled for 9:00 AM. On 12/03/24 at 9:35 AM (after the med pass observation), Resident #63 was observed in her wheelchair, in the hallway between [NAME] and Windsor units wheeling herself towards the Windsor unit for an activity event. During an interview conducted on 12/03/24 at 10:23 AM with Staff B, she stated she has been working at the facility for 1 month. When asked about the 3 medications that were not observed during med pass observation, she stated she administered the Ingrezza 60 mg and the Polyethylene Glycol 3350 Powder to Resident #63 after med pass observation was done. Staff B stated Resident #63 sometimes complains that she is getting too many medications therefore she administered the medications afterwards. However, Staff B realized the Ferrous Sulfate 325 mg (65 Fe) needed to be ordered and currently the facility has not received it. When asked why she documented the Ferrous Sulfate 325 mg as administered, she stated she forgot that the medication had to be ordered. Review of the Medication Administration Audit Report (time stamp) revealed Staff B documented Resident #63 received the 9:00 AM scheduled medications between 9:32 and 9:40 AM including the Ingrezza 60 mg (9:32 AM), Polyethylene Glycol 3350 Powder (9:34 AM) and Ferrous Sulfate 325 mg (9:33 AM). The last medication observed during the med pass was Lorazepam 0.5 mg, which according to the time stamp, the documentation time was 9:40 AM. An interview was conducted on 12/03/24 at 1:50 PM with the Director of Nursing (DON) and review the time stamp report for Resident #63. She acknowledged that the medications (Ingrezza 60 mg, Polyethylene Glycol 3350 Powder, and Ferrous Sulfate 325 mg) were omitted from the med pass and Staff B documented them as being administered while the med pass was observed. 2) Review of the manufacturer's prescribing information for Fiasp FlexTouch insulin injector pen at https://www.novo-pi.com/fiasp.pdf included in part the following: Priming your FIASP® FlexTouch® Pen: Step 7: oTurn the dose selector to select 2 units Step 8: oHold the Pen with the needle pointing up. Tap the top of the Pen gently a few times to let any air bubbles rise to the top. Step 9: oHold the Pen with the needle pointing up. Press and hold in the dose button until the dose counter shows 0. The 0 must line up with the dose pointer. oA drop of insulin should be seen at the needle tip (See Figure J). o If you do not see a drop of insulin, repeat steps 7 to 9, no more than 6 times. o If you still do not see a drop of insulin, change the needle and repeat steps 7 to 9. Record review for Resident #32 revealed the resident was originally admitted to the facility on [DATE] most recent readmission on [DATE] with diagnoses that included, in part, the following: Hemiplegia and Hemiparesis Following Unspecified Cerebrovascular Disease Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus, Parkinson's Disease, and Dementia. Review of the Minimum Data Set for Resident #32 dated 11/01/24 documented in Section C, a Brief Interview of Mental Status score of 12, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #32 revealed an order dated 04/21/24 for Fiasp FlexTouch 100 UNIT/ML Solution pen-injector, Inject subcutaneously before meals for Diabetes. Inject as per sliding scale: if 60 - 150 = 0; 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units; 301 - 350 = 12 units; 351 - 400. On 12/03/24 at 8:30 AM, an observation of a med pass was conducted with Staff B, Registered Nurse (RN) for Resident #32. Staff B, RN prepared the Fiasp FlexTouch 100unit/ml insulin pen to give 6 units subcutaneously to the resident. Staff B, RN primed the insulin pen by holding the pen upside down (needled pointing to the floor). An interview was conducted on 12/03/24 at 8:33 AM with Staff B, RN who stated she has worked at the facility for 1 month. When asked about priming the insulin pen, she said she did, she turned the dial and saw the liquid insulin come out of the tip of the needle. When asked why the needle was facing down instead of up, she said that is how she was shown by another nurse to do so. An interview was conducted on 12/03/24 at 2:15 PM with Consultant Pharmacist who was asked if Fiasp FlexTouch 100 UNIT/ML Solution pen-injector dosage would be accurate if the insulin pen was not properly primed. She stated she could not say the dose would be accurate or not accurate if the insulin pen was not primed according to manufacturer's instructions. She acknowledged the Fiasp FlexTouch 100 UNIT/ML Solution pen-injector should be primed with the needle pointing up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) Record review for Resident #115 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Parkinsonism, Hypertension, Anxiety Disorder, Malignant Neoplasm of Central Portion of Female Breast, Dysphagia, and Insomnia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #115 had a Brief Interview for Mental Status (BIMS) of 12, which indicated that she was moderately cognitively impaired. Review of Section N revealed that Resident #115 was on antipsychotic, antianxiety, and received antipsychotics on a routine basis. During an initial observational tour conducted on 12/02/24 10:22 AM, Resident #115 was noted to have a few over the counter (OTC) medications on top of her nightstand table, visible and easily accessible to other residents, employees and visitors. Further observation revealed the OTC medications were two used bottles of Nasal sprays (one with an expiration date of 06/2022), a Neosporin ointment tube, Preparation H ointment tube and a large bottle of Probiotic chewable supplement. Review of the Physician's Orders showed that Resident #115 had no orders for self-administer medications, and no orders for any of the above OTC medications. An interview conducted on 12/02/24 at 10:24 AM with Resident #115, she revealed that she had been looking for the OTC medications and felt someone moved them to her nightstand. She stated she has used the nasal spray because sometimes she feels congested. During a second initial observational tour conducted on 12/03/24 10:13 AM, Resident #115 was still noted to have the OTC medications on top of her nightstand table, visible and easily accessible to other residents, employees and visitors. During an interview conducted on 12/03/24 at 12:35 PM with the Director of Nursing (DON), she stated she has been working at the facility for 2 months. She stated she has been inspecting all the residents' rooms and educating the nursing staff to make sure no medications are in the residents' rooms. She acknowledged that it has been difficult since residents' families bring in medications for the residents. She stated she was surprised that there were OTC medications in Resident #115's room. The management team had just inspected the units. A follow-up interview was conducted on 12/05/24 at 2:02 PM with the DON. She stated that the OTC medications at the bedside of Resident #115 were brought in by the resident's [family member]. She stated she had a plan in place for medications at the bedside. The first week the plan went in place she audits the second floor and was done with residents' permission. The DON acknowledged that there are still concerns with OTC medication in the residents' rooms. 6) During a medication administration (med pass) observation conducted on 12/03/24 at 9:28 AM in the [NAME] unit with Staff B, Registered Nurse (RN), a Senna Plus bottle was observed not closed and spilled into the drawer and the hallway floor. Staff B picked up the tablets in the drawer with a tissue, while the wound care nurse (WCRN) helped to pick up the tablets that went onto the floor. Staff B was about to discard the tablets in the sharp container (attached to the medication cart), and was stopped by the WCRN which the WCRN noted would discard them in the drug buster located at the medication room. After the med pass, the surveyor pointed out another Senna Plus tablet on the floor which was missed. Staff B picked up the tablet with a glove and discarded it into the sharp container. When Staff B was asked if that is the proper practice to discard medications, she stated if it was a controlled substance, she would need another nurse to sign the waste and the manager would discard the medication in the drug buster. However, for medications like this one, they can be discarded in the sharp container. An interview was conducted on 12/04/24 at 1:50 PM with the DON. She stated as per policy, nurses are to dispose of medications using the drug buster that is in the medication room. She acknowledged discarding the medications in the sharp container is a bad habit by the nurses. Based on observations, interviews and record review, the facility failed to secure medications at bedside for 3 out of 34 sampled residents; (Residents #49, # 72, 115 ) and failed to secure 1 of 7 med carts; failed to secure medication left on top of 1 of 7 med carts; and failed to properly dispose of medication(s) during 2 out of 5 medication observations. The findings included: Review of the facility's policy titled, Medication Labeling and Storage with a published date of 05/19/23 included in part the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Review of the facility's policy titled, Self-Administration of Medications with a Published date of 05/19/23 included in part the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. 8. Self-administering medications are stored in a safe and secure place, which is not accessible by other residents. Review of the facility's policy titled, Discarding and Destroying Medications with a revised date of November 2022 included in part the following: Medications that cannot e returned to the dispensing pharmacy (e.g., non-unit-dose medications, medications refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 6. e)The collector is responsible for managing the collection receptacles, including picking up and properly disposing of medications collected in the receptacles and training facility staff on the procedures associated with collection and storage of controlled substances awaiting disposal. 7.For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: b) Mix medication, either liquid or solid with an undesirable substance. 1) On 12/03/24 at 8:26 AM, during an observation with Staff B, Registered Nurse (RN), left a Fiasp FlexTouch 100unit/ml insulin pen on top of the unlocked and unattended med cart ([NAME] unit) to obtain insulin pen needles. An interview on 12/03/24 at 8:26 AM , Staff B, RN, revealed she has worked at the facility for 1 month. When asked about leaving the insulin on the unlocked and unattended med cart she said she did not know why she did that, but meds and the med cart should always be locked up. 2) Record review for Resident #49 revealed the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, in part, the following: Atrial Fibrillation, and Essential (Primary) Hypertension. Review of the Minimum Data Set (MDS) for Resident #49 dated 11/09/24 documented in Section C a Brief Interview of Mental Status (BIMS) score of 7 indicating severe cognitive impairment. Review of the Physician's Orders for Resident #49 revealed no order for Tums (calcium carbonate). Record review for Resident #49 revealed no evaluation for self-administration of medication. On 12/02/24 at 10:18 AM, an observation was made of Resident #49 in bed with a bottle of Tums on her nightstand. 3) Record review for Resident #72 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Post Traumatic Stress Disorder. Review of the Minimum Data Set for Resident #72 dated 08/14/24 revealed in Section C a Brief Interview of Mental Status score of 15, indicating intact cognition. Record review for Resident #72 revealed no evaluation for self-administration of medication. Review of the Physician's Orders for Resident #72 revealed an order dated 11/20/23 for Artificial Tears Ophthalmic Solution 0.2-0.2-1 % (Glycerin-Hypromellose-Polyethylene Glycol 400) Instill 2 drop in both eyes every 2 hours as needed for eye drop. Review of the Medication Administration Record for Resident #72 from 11/01/24 to 12/01/24 revealed no documentation of Artificial Tears being administered. On 12/02/24 at 11:25 AM, an observation was made of Resident #72 sitting up in bed with 2 bottles of artificial tears on her overbed table. On 12/03/24 at 9:30 AM, a second observation was made of Resident #72 sitting up in bed with 2 bottles of artificial tears on her overbed table. During an interview conducted on 12/02/24 at 11:25 AM with Resident #72, who was asked about the eye drops at her bedside, she stated one is a backup, and she has dry eye syndrome, so she uses the drops several times a day. She stated her doctor gave orders for her to have them at the bedside and give them to herself. 4) On 12/03/24 at 7:59 AM, a med pass observation was conducted with Staff A, Licensed Practical Nurse (LPN), who was working on Windsor med cart #2 and passing medications to Resident #84. After resident tool all medications orally, Staff A, LPN noticed a small pink pill on the floor next to the resident's bed. Staff A, LPN picked up the pill and disposed of it in the sharp container in the resident's bathroom. An interview was conducted on 12/03/24 at 8:02 AM with Staff A, LPN who stated she has worked at the facility for 10-11 years. When asked about medication disposal, she said she should have disposed of the pill in the drug buster solution, not put it into the sharp's container in the resident's bathroom. An interview was conducted on 12/03/24 at 11:31 AM with the Director of Nursing (DON) who stated she has been at the facility for 2 months. When asked if residents can have medications at the bedside, the DON stated normally not unless the resident specifically has a of plan of care for self-administration. When asked what is needed for the resident to self-administer medication, the DON stated they would need to be evaluated for self-administration and have a care plan for that as well. When asked about med carts, treatment carts and emergency carts being locked, she said they all should be locked at all times unless the nurse is using them. When asked about medication disposal, she stated they should be disposed of per their policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide food that meets residents' preferences, allergies and intolerances for 6 of 6 sampled residents observed during dining observation (Resident's #122, #54, #39, #69, #44, and #46). The findings include: 1) Record review revealed that Resident #122 was admitted to the facility on [DATE] with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side and Non-traumatic Intracranial Hemorrhage. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score of 11, which indicates slight cognitive impairment. In an interview conducted on 12/02/2024 at 10:45 AM Resident #122 stated that breakfast was okay, but it would be great if only she could really get what is on her meal ticket. For example, this morning she didn't get the grits that were on the meal ticket. In a second interview conducted on 12/02/2024 at 1:30 PM Resident #122 stated that she asked staff for a turkey sandwich instead of what was on the menu today. The staff answered that there were no more turkey sandwiches. Resident #122 did not touch her plate because this food tastes like dog food. 2) Record review revealed that Resident #54 was admitted ot the facility on 10/07/2024 with diagnosis of Hemiplegia and Hemiparesis following other Cerebrovascular Disease affecting the left non-dominant side. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score is 11. In an observation conducted on 12/02/2024 at 1:10 PM Resident #54's meal ticket consisted of a No Added Salt diet with the following: Beef & Vegetable Stir Fry 6oz, Steamed [NAME] 4ounces (oz), Mandarin Orange 1/2 Cup, Ginger Ale 1Can, Apple Juice 8oz. And the tray consisted of Beef & Vegetable Stir Fry, Steamed Rice, 2 Cups of Mandarin Orange, and 2 Cans of Cola and was missing the Apple Juice and the Can of Ginger Ale as noted on the meal ticket. 3) Record review revealed that Resident #39 was admitted to the facility on [DATE] with diagnosis of Parkinson's Disease without Dyskinesia, without mention of fluctuations and multi-system Degeneration of the Autonomic Nervous System. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score of 13, which indicates intact cognition. In an observation conducted on 12/02/2024 at 1:15 PM, Resident #39's meal ticket consisted of a Regular Diet with the following: Egg Salad Sandwich 3oz, Lettuce/tomato Slice 1 serving (Srv), Tossed [NAME] Salad ½ Cup, Dressing 2 Packets (Pkt), Diet Ginger Ale 8oz, Fruit Cup ½ Cup. And the tray consisted of Egg Salad Sandwich, Lettuce/tomato Slice, Tossed [NAME] Salad, dressing 1 Pkt, 1 Can of Cola and was missing the Fruit Cup and the Diet Ginger Ale. 4) Record review revealed that Resident #69 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus without complications and unspecified Dementia, unspecified severity without behavioral. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the Brief Interview of Mental Status (BIMS) score of 8, which indicates Moderate Cognitive Impairment. In an observation conducted on 12/02/2024 at 1:21 PM, Resident #69's meal ticket consisted of a Regular Diet with the following: Beef & Vegetable Stir Fry 6oz, Fortified Mashed Potatoes 4oz, Ice Cream of Any flavor 4oz, Sugar Free Lemonade 8oz. And the tray consisted of Beef & Vegetable Stir Fry 6oz, Fortified Mashed Potatoes 4oz, Mandarin Orange and was missing the Sugar Free Lemonade and the Ice Cream. In a brief interview conducted on 12/02/2024 at 1:22 PM, Resident #69's Private Aid stated that the meal tickets almost never match the tray and when she asks the staff for missing items on the tray, or about the meal tickets not matching the tray the answers she usually gets are: the meal ticket was printed wrong, or they get it confused. 5) Record review revealed that Resident #44 was admitted to the facility on [DATE] with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting left the non-dominant side. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that the Brief Interview of Mental Status (BIMS) score of 10, which indicates Moderate Cognitive Impairment. In an observation conducted on 12/02/2024 at 1:30 PM, in the second-floor dining room, Resident #44's meal ticket consisted of a No Added Salt Diet with the following Chef Salad 1 Each (Ea.), Crackers 1 Package (Pkg), Mandarin Oranges ½ Cup, Diet Ginger Ale 8oz. And the tray consisted of Chef Salad, 1 Can of Cola and was missing the Crackers, Mandarin Oranges and the Diet Ginger Ale. In an interview conducted on 12/04/2024 at 5:00 PM with the facility Food Service Assistant, she stated that she gets the residents' preferences by interviewing them, and she also gives them ideas of what they carry on the facility's menu and asks them what they usually eat at home. She also stated that some residents go with facility's food choices that are on the menu and other ones pick different things. As soon as the food preferences are obtained, she adds them on the meal tracker. If the residents have ingredients/food that they dislike, she adds them in the categorical refusal as part of the electronic system and the program automatically substitutes and gives them their picked preferences. The Food Service Assistant also explained the process of quality control of the tray line and the accuracy of the meal tickets is regulated by a staff member (starter) and another staff member(checker) to monitor the accuracy of the food items on the trays to ensure that the correct food items are placed on the trays. For residents who do not like the food choices on their tray, they will offer sandwiches and then said, there is no such thing as being out of sandwiches. 6) Review revealed that Resident #46 was admitted to the facility on [DATE] with diagnoses of Paraplegia and Chronic Obstructive Pulmonary Disease. The Minimum Data Set assessment dated [DATE] showed a Brief Interview Status (BIMS) score of 14, which is cognitively intact. A review of the list of food items posted outside the main dining room for the Tuesday breakfast meal dated 12/3/24 listed the following: pancakes, turkey sausage, oatmeal, and banana. A review of Resident #46's meal ticket for Tuesday 12/3/24, revealed the following: pancakes, cereal, orange juice, coffee, creamer, whole milk and Splenda. The breakfast meal tray did not have banana on the tray. An interview was conducted on 12/03/24 at 9:36 AM with the Food Service Assistant (FSA), who stated she has been working at the facility for about 3.5 weeks. When asked about food preferences, she said food preferences and likes/dislikes are addressed at the time of admission and are documented in the meal tracker system. When asked about the posted breakfast for 12/03/24 that included a banana, she said they had substituted grapes. When asked about Resident #46, the FSA acknowledged there were no preferences, likes, or dislikes for fruit for the resident in the meal tracker system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide special eating equipment (adaptive devices) who need them when consuming meals and snacks for 1 of 1 sampled resident reviewed for adaptive equipment, affecting Resident #46. The findings included: Review of the facility's policy titled, Adaptive Equipment Policy and Procedure with no dated (just the printed date of 12/05/24 included in part the following: Adaptive equipment refers to any device or tool that assists residents in performing activities of daily living (ADLs), mobility, or other functional tasks. This policy aims to ensure that residents receive appropriate adaptive equipment and that staff members are trained in its proper use. 3. Equipment Acquisition and Inspection a. The facility should maintain a designated inventor of commonly used adaptive equipment. b. Upon receipt of newly ordered equipment, it should be inspected for any damage, defects, or missing parts. c. Any concerns or issues with the equipment should be reported to the appropriate personnel for resolution. 5. Poper Fit and Adjustment a. Adaptive equipment should be properly fitted and adjusted to ensure the resident's safety, comfort and optimal function. 6> Maintenance and Cleaning a. Regular maintenance and cleaning schedules should be established for all adaptive equipment b. Equipment should be inspected for wear and tear, damage, or malfunctioning parts on a routine basis. Record review for Resident #46 revealed the resident was originally admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses included, in part, the following: Paraplegia, and Neuromuscular Dysfunction of Bladder. Review of the Minimum Data Set assessment for Resident #46 dated 10/13/24 documented in Section C a Brief Interview of Mental Status score of 14, indicating intact cognition. Review of the Physician's Orders for Resident #46 revealed an order dated 03/05/24 for plate guard, spill-proof cup and lid with two handles, and weighted utensils with all meals Review of the Care Plan for Resident #46 dated 04/14/23 with a focus on the resident is at nutrition risk related to PMH (past medical history) Paraplegia, Metabolic Encephalopathy, Anemia, CKD (Chronic Kidney Disease) 4, intermittent confusion hx (history) of poor/fair appetite and dietary supplements refusals, also hx of ordering meals from outside facility The goals were for the resident to consume >75% of meals and show no signs/symptoms of dehydration and the resident will maintain weight of +/- 10% of CBW through next review date. The interventions included in part the following: Adaptive Device: Plate Guard, Spill-proof cup and lid with handle, and weighted utensils will all meals On 12/02/24 at 10:52 AM, an observation was made of Resident #46 sitting up in bed with the call bell on the floor, a full Styrofoam cup of water and 2 empty two handled sippy cups on the nightstand, all were out of her reach to the resident. She said they moved the water when her breakfast came and never put it (the water or cups) back on her tray (over bed table). On 12/03/24 at 8:40 AM, an observation was made of Resident #46 sitting up in bed with a breakfast tray in front of her, with one handled cup with no spill lid containing coffee, a two handled cup with a lid that was not secured containing orange juice (Photographic Evidence Obtained). An interview was conducted on 12/03/24 at 8:50 AM with Staff G, Certified Nursing Assistant (CNA), who stated she has worked at the facility for a couple of months. When asked about the adaptive equipment for the resident, she said she gets two handled no spill cups, built up utensils and plate guard. When asked about the one handled coffee cup with no spill lid and orange juice in a two handled cup with loose fitting lid, she said she will put them in the two-handled cups with sippy lids that the resident has at the bedside. When asked do the 2 handled cups and lids go to the kitchen to be washed, she said no, whoever assists the resident with meal, will wash the cup. An interview conducted on 12/03/24 at 9:36 AM, with Food Service Assistant (FSA), who stated she has been working at the facility for about 3.5 weeks. When asked about adaptive equipment for a resident, she said the therapy department will give an order and the kitchen will ensure the adaptive equipment ordered gets on each meal tray for the resident. When asked about Resident #46, the FSA stated she gets built up utensils, a plate guard and two handled spill proof cup for beverages. When the FSA was shown the photo of Resident #46's breakfast tray form 12/03/24, she acknowledged the resident did not receive the appropriate adaptive equipment (two handled spill proof cups). An interview was conducted on 12/03/24 at 1:56 PM, with the Director of Rehab, who stated she has worked at the facility for 12 plus years. She stated adaptive equipment should all come from the kitchen including cups, plates and utensils. When asked what is ordered for Resident #46, she stated built up utensils, two handled spill proof cups and plate guard. When asked why the resident needs the adaptive equipment, she stated the resident has tremors and depends on needs of stability to pick up the cup and need spill top to keep from spilling liquids on her, to maintain dignity and safety.

Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F755, Pharmacy services, procedures, pharmacist, records; and F810, assistive devices, eating equipment, utensils. These repeated deficient practices have the potential to affect all 146 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed the facility was cited F755 and F810 during the Recertification survey with an exit date of 08/24/23. During an interview with the facility's Administrator on 12/5/24 at 3:30 PM, the Administrator was apprised that these 2 deficiencies will be cited again on this current survey. The Administrator stated she will be working to remedy this issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to follow Standard Infection Control procedures while performing perineal care for 1 of 1 sampled resident (Resident # 28); failed to safely dispose of contaminated lancets used for glucose monitoring; and failed to maintain personal drink on a medication cart, in a manner to prevent contamination. The findings included: 1) A review of facility's policy (with no date) titled,Handwashing/Hand Hygiene, revealed the facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Page one of the policy, with letter c for Indications for Hand Hygiene, explained that hand hygiene is indicated after contact with blood, body fluids, or contaminated surfaces; and letter g, explaining hand hygiene is indicated immediately after glove removal. Review of the facility's policy titled, Perineal Care : Level II, revealed the purposes of perineal care procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Record review revealed Resident # 28 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Dysphagia following Cerebral Infarction, Benign Prostatic Hyperplasia without lower urinary tract symptoms, and Post-Traumatic Stress Disorder. A review of Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS ( Brief Interview of Mental Status) score of 14, indicating intact cognition. During a perineal care observation on 12/04/24 at 9:54 AM, Staff N, a Certified Nursing Assistant (CNA), was starting to perform care to Resident # 28. Staff N was wearing a blue protective gown, a white N 95 mask covering his mouth and nose areas, and a set of blue gloves on both hands. This Staff touched Resident #28's privacy curtain on the foot part of the bed, then touched the resident's left leg. Staff then removed the set of gloves from both hands and put on a new set of gloves. He did not perform hand hygiene. Staff N started touching Resident #28's other leg and made a comment about the long reddish marks noted. Staff N informed Resident #28 that he will perform a bed bath. This staff washed and rinsed the front chest, neck, stomach and the front perineal area (including penis, and scrotum). This staff then towel dried these areas, and with the same set of gloves touched the resident's hands, put on the resident's shirt, and finally washed and dried the resident's feet. He did not change his gloves after these tasks. Staff N turned Resident #28 to the left side, touched and pressed the bed control and manipulated the bed using the same gloves he used on the front perineal area of Resident #28, This Staff told Resident #28 he will clean the bottom perineal area. Staff N wiped the fecal matter on the bottom perineal area after dipping the cloth wipes inside the water basin, then with another cloth wipe cleaned the resident's inner thighs. This staff dried the areas with a towel after getting 2 wet wipes from the basin with water using the same set of gloves. Staff N touched the bed linen on the foot part of the bed, touched the resident's shirt, and turned the resident on the right side with the same set of gloves. Staff N removed both gloves from both hands after removing the resident's brief that was full of fecal matter. This staff did not perform hand sanitizing. He grabbed a box of gloves from the wall next to the bathroom, and put it on top of Resident #28's [NAME] drawer. He put on a new set of gloves, touched the bed control, and told the resident he will wash his upper back. This Staff used the same water he used to wash and rinse the back anal region with fecal matter, to wash the upper portion of Resident #28's back. Staff N grabbed a cloth wipe, soaked inside the water basin and washed, rinsed, and towel dried the resident's upper back area. 2) On 12/03/24 at 8:24 AM, a blood glucose monitoring observation was conducted of Staff B, Registered Nurse (RN). After the RN checked the blood glucose for the resident, she disposed of the used lancet by encapsulating the lancet in the used glove she had been wearing and placed it in the open trash container next to the resident's bed. An interview was conducted on 12/03/24 at 8:30 AM with Staff B, who stated she has worked at the facility for 1 month. When asked about used lancets that have come into contact with the resident's blood being disposed of in the resident's open trash container, she stated it is okay because there is no needle sticking out, it retracts. 3) On 12/03/24 08:24 AM, an observation was made of med cart on [NAME] unit with a Starbucks cup sitting on the side of the med cart in the section with the spoons, straws, cups and medication cups used for the residents. An interview was conducted on 12/03/24 at 8:26 AM with Staff B, who was asked about the Starbucks cup, on the med cart in with the spoons, straws, cups and medication cups used for the residents, she acknowledged that it was hers and said she needed her coffee, it probably should not be here.

Based on observations, interviews, and record review, the facility failed to follow the Menu Planning, in accordance with established national standards, for one week out of three menu cycles. This had the potential to affect all residents that consume their meals prepared by the facility. The findings included: A review of the facility's policy titled, Menu Planning dated 07/17/24, documented the following: The nutritional needs of individuals will be provided in accordance with the established national standards adjusted for age, gender, activity level, and disability. Through nourishing, well-balanced diets unless contraindicated by medical needs. All current menus will be written to provide an adequate amount for each meal to satisfy recommended daily allowances and written using an acceptable standard meal planning guide. Further review revealed that the menus at the facility were used based on a 2000-calorie/day diet with the following: Dairy/Milk: 2 to 3 cups equivalents per day. Fruits: 2 to 2.5 cups equivalents per day. Vegetables: 2.5 cups equivalents per day. A review of the facility's Spring Summer Menu 2024, Week 1, showed the following fruit exchanges each day: Sunday, 12/1/24, showed no fruit serving for breakfast, no fruit serving for lunch, and ½ cups of fruit serving for dinner. This provided only ½ of the fruit serving a day, not the needed 2 cups as per the facility's menu guidelines. Monday, 12/2/24, showed was no fruit for breakfast, ½ cup of fruit for lunch, and ½ cup of fruit for dinner. This provided only 1 cup of fruit a day, not the needed 2 cups as per the facility's menu guidelines. Tuesday, 12/3/24, showed no fruit for breakfast, ½ cup fruit serving for lunch, and ½ cup fruit serving for dinner. This provided only 1 cup of fruit serving a day and not the needed 2 cups of fruit serving as per the facility's menu guidelines. Wednesday, 12/4/24, showed no fruit serving for breakfast, ½ cup of fruit serving for lunch, and no fruit serving for dinner. This provided only ½ of the fruit serving a day, not the needed 2 cups as per the facility's menu guidelines. Thursday, 12/5/24, showed no fruit serving for breakfast, no fruit serving for lunch, and ½ cups of fruit serving for dinner. This provided only ½ of the fruit serving a day, not the needed 2 cups as per the facility's menu guidelines. Friday 12/6/24 showed no fruit serving for breakfast, no fruit serving for lunch, and ½ cup of fruit serving for dinner. This provided only ½ of fruit serving a day, and not the needed 2 cups of fruit serving as per facility's menu guidelines. Saturday 12/7/24 showed no fruit serving for breakfast, no fruit serving for lunch, and ½ cup of fruit serving for dinner. This provided only ½ of fruit serving a day, and not the needed 2 cups of fruit serving as per facility's menu guidelines. In an interview, conducted on 12/3/24 at 1:36 PM with Staff C, the Registered Dietitian, it was stated that the facility's menus were created and reviewed by the Corporate Dietitian. In another interview conducted on 12/4/24 at 9:32 AM, Staff C stated that the facility's menus were created to provide a 2000 calories-based diet with the following: 2 to 3 cups per day of dairy, 2 to 2.5 cups of fruit, and 2 to 2.5 cups of vegetables. She further acknowledged that the facility's Spring Summer Menu 2024 did not meet the needed serving of fruits daily as per established national standards. Staff C reported that fruit servings are also provided upon request from residents and that it may show on their meal tickets as a preference.

Based on observations and interviews, the facility failed to prepare foods in a manner consistent with standards for food safety. The findings included: 1). During the initial kitchen tour, on 12/02/24 at 9:28 AM, accompanied by the Certified Dietary Manager (CDM), it was noted that there was a leak at the filter from the steamer. The CDM stated that she was aware of the leak and Maintenance would be making repairs. 2). Upon approaching the entrance to the kitchen, on 12/03/24 at 9:35 AM, Staff R, Dietary Aide, answered and opened the door with gloved hand and then proceeded to rinse off her gloved left hand in a food preparation sink before handling ready to eat lettuce. Staff R was instructed to remove the gloves and perform hand hygiene. 3). During the follow up tour, on 12/05/24 at 6:34 AM, accompanied by the CDM, the following were noted: a. Staff R was observed stacking bowls on the food service line with her bare hands and fingers directly in the food contact surface of the bowls. Staff R was instructed to place the bowls in the dishwashing area to be washed and sanitized, perform hand hygiene and don single use and disposable gloves. b. The internal temperatures of pork roasts that were to be used for pulled pork as the dinner meal was 76 degrees Fahrenheit (F) and 66 degrees (F). It was noted that the roasts were in 6-inch deep full sized hotel pans, with a layer of parchment paper and covered with 2 layers of aluminum foil. At the time of the observation, the CDM confirmed that the roasts were cooked the previous day and acknowledged that they were not cooled properly. c. Staff R, Dietary Aide, was observed at the dedicated hand sink rinsing her gloved hands. When asked the purpose of washing the gloves, Staff R stated that she was washing the gloves because there was stuff on it. The CDM instructed Staff R to remove the gloves and perform hand hygiene and to don a pair of new disposable gloves. At the conclusion of the tour, the CDM acknowledged the findings from the tour of the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide a safe environment to the residents as evidenced by allowing a visitor to enter the facility at 6:14 AM, without properly identifying the visitor. The findings included: Review of the facility's policy titled, Visitation revised on 08/2022 provided by the Administrator documented .the facility provides 24-hour access to individuals visiting .some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents such as: keeping the facility locked or secured at night with a system in place . On 06/25/24 at 6:14 AM, the surveyor arrived at the facility's main entrance, rang the doorbell and the automatic door opened. The surveyor walked up to the reception desk and completed the registration/sign-in using the facility's Advanced Registration machine at the reception desk. Observation revealed no staff member at the reception desk and no staff member came to the main entrance to greet or identify the surveyor. The surveyor proceeded to enter the elevator and with no elevator code required, the surveyor arrived at the facility's second floor, the long-term care units. On 06/25/24 at 6:18 AM, the surveyor arrived at the facility's Windsor Unit on the second floor. An interview was conducted with Staff A, Registered Nurse (RN) who stated he has been working in the facility for two months on the 11:00 PM-7:00 AM shift. Staff A was asked if he opened the main entrance door for the surveyor and replied he did not. Staff A further stated the resident's family members can visit the resident at any time of the day. On 06/25/24 at 6:22 AM, an interview was conducted with Staff B, RN in the Windsor unit. Staff B was asked who was in charge and stated that they did not have a supervisor during the night shift and that all nurses were in charge. Staff B was asked if she opened the main entrance door for the surveyor and replied she did not. Staff B was asked to contact the manager on duty. On 06/25/24 at 6:32 AM, an interview was conducted with Staff C, RN in the [NAME] Unit on the first floor, who stated she has been working in the facility since 02/2024 on the 11:00 PM- 7:00 AM shift. Staff C was asked if she opened the main entrance door for the surveyor and replied she did not hear a doorbell for her to open the door. On 06/25/24 at 7:05 AM, an interview was conducted with Staff D, in the [NAME] Unit, who stated she has been working in the facility for two and half years. Staff D was asked regarding the facility's protocol to follow once someone is at the main entrance door and rings the doorbell for entry. Staff D stated that once she hears the doorbell, she checks the I-pad camera and pointed to the I-Pad located at the nurse's station. Staff D continued to state that if she cannot view the person, she goes to the main entrance door. Staff D added if she does not know who the person is, she would not let the person in. Staff D stated she then will ask their name and what they are there for, check the resident record to make sure the person is listed, then she lets them come in. Staff D stated she did not open the entrance main door this morning for the surveyor's entry. On 06/25/24 at 7:12 AM, an interview was conducted with Staff E, RN in the [NAME] Unit- first floor who stated she has been working in the facility for nine months on the 11:00 PM-7:00 AM shift. Staff E was asked regarding visitors during her shift and stated that usually they don't let people in at night unless the resident is on hospice. The hospice staff calls the family, and they may come at night. Staff E pointed to an I-Pad located at the nurse's station and stated that it works 95% of the time, added sometimes she could open the main entrance door for the Pharmacy person, and the X-ray Technician or the Phlebotomist. Staff E stated she did not open the entrance main door this morning for the surveyor's entry and added probably someone in the [NAME] Unit may have. On 06/25/24 at 7:47 AM, an entrance conference was conducted with the facility's Administrator. During an interview, the Administrator was apprised that someone opened the automatic main entrance door remotely for the surveyor to enter the facility at 6:14 AM. The Administrator was informed that no staff member came to the door to identify the surveyor, and no one asked questions before allowing entry. The Administrator stated the staff should have come and opened the door for the surveyor. He added there was a camera at the first-floor unit and there was an intercom, and the staff was able to speak to the surveyor via intercom. The Administrator was asked to submit a copy of the facility's Protocol related to letting visitors in during the 11:00 PM-7:00 AM shift. The Administrator provided the facility's Visitation policy. On 06/25/24 at 12:50 PM, during an interview, the Administrator stated they were able to identify the staff member who opened the door to the surveyor and added the staff will be educated regarding the process of letting a visitor in the facility after hours. On 06/26/24 at 4:10 PM, during an interview, the Administrator stated that the facility had a front desk person from around 7:30 AM to around 9:00 PM; if a visitor comes after 9:00 PM and before someone is at the desk, the [NAME] unit staff was the only unit able to let someone in. The Administrator stated the staff will come to the front desk, instruct the person to complete a questionnaire on the Advanced entry machine and direct them to the room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure that a resident received wound care consistent with professional standards of practice for 1 of 1 sampled resident for wound care (Resident #3). The findings included: Review of the facility's policy titled, Wound Care revised on 10/2010 documented .use disposable cloth (paper towel is adequate) to establish a clean field on resident's overbed table, place all items to be used during the procedure on the clean field .put on exam glove, loosen tape and remove dressing, pull glove over dressing and discard into appropriate receptacle, wash and dry hands thoroughly, put on gloves .use no-touch technique .pour liquid solutions directly on gauze sponges .apply treatment as indicated .dress wound .be certain all clean items are on clean field .use clean field saturated with alcohol to wipe overbed table . take only the disposable supplies that are necessary for the treatment in the room . Review of Resident #3's clinical record documented an admission on [DATE] and a readmission on [DATE]. The resident's diagnoses included Quadriplegia, Anoxia Brain Damage, Diabetes Mellitus Type 1, Contractures, and Neuromuscular Dysfunction of Bladder. Review of Resident #3's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0, indicating that the resident had severe cognition impairment. The assessment documented under Functional Abilities and Goals showed that the resident was dependent on the staff to complete the activities of daily living. Review of Resident #3's Wound Care Specialist note dated 06/19/24 documented a Stage 3 Right buttock pressure wound with measurements as 3.4 centimeters (cm) length by 3.3 cm width by 0.4 cm depth. The pressure wound was acquired while in the facility. Review of Resident #3's physician order dated 06/19/24 documented, Cleanse right buttock with normal saline, apply Leptospermum Honey and calcium alginate topically, cover with foam dressing, change daily and as needed for wound care. On 06/26/24 at 9:36 AM, wound care observation for Resident #3 performed by the facility's dedicated wound care nurse (WCN) started. Observation revealed the WCN placed on a foam tray, one vial of normal saline solution, an opened tube of Medihoney, one Calcium Alginate with antibacterial Silver 2 x 2 dressing, a few gauze sponges, one bordered dressing, and a pair of scissors from the treatment cart's drawer. The WCN was assisted by Staff F, Certified Nursing Assistant (CNA). On 06/26/24 at 9:40 AM, observation revealed the WCN entered the resident's room and placed the foam tray with the wound care supplies on top of the resident's overbed table without establishing a clean field. The WCN went to the bathroom away from the wound care supplies, to perform hand hygiene, donned gloves and returned to the resident's bedside. Observation revealed the WCN removed the soiled dressing, tightened up the dressing, looked around and placed the dressing on top of the pad underneath the resident. Further observation revealed the WCN did not remove her pair of gloves after the removal of a soiled/dirty dressing. The WCN, with the same pair of gloves, reached the vial of normal saline solution, squeezed the solution into the residents' open wound, reached and opened a sponge gauze packaging, removed the gauze and cleaned the wound. The WCN then reached the Calcium Alginate packaging, removed the alginate gauze and cut up a piece with a pair of scissors. The WCN disinfected the scissors in front of the surveyor prior to use it. Observation revealed the WCN touched and held the calcium alginate gauze with her soiled gloves, applied Medihoney to the alginate gauze and then placed it on the open wound, opened the bordered dressing packaging and applied on top of the calcium alginate gauze. Further observation revealed the WCN, with her soiled pair of gloves, reached to her uniform pocket, pulled a sharpie marker to write on the bordered dressing. Furthermore, observation revealed the WCN retrieved the soiled dressing she placed on the bed pad underneath the resident, with her gloved hand and stated she will throw it away. The WCN discarded the foam tray and soiled dressing into a trash container bag in the bathroom, placed the scissors and the Medihoney tube on top of the sink, removed her gown, performed hand hygiene then carried the scissors and the Medihoney tube and placed both on top of the treatment cart. The WCN disinfected the pair of scissors, placed the pair of scissors and the Medihoney tube in the first drawer of the treatment cart. Resident #3's wound care was completed at 9:53 AM. On 06/26/24 at 9:54 AM, an interview was conducted the WCN who was asked when she would change gloves during the procedure and stated she will change gloves if the wound was bloody. The WCN was asked again to state the wound care procedure and stated she will remove the soiled/previous dressing and will put on a new pair of gloves because she will do a new dressing and does not want to introduce bacteria to the wound. The WCN stated she should not put the Medihoney tube back in the cart because of the risk of infection, and it should be left in the resident's room. On 06/26/24 at 1:34 PM, during an interview, the Assistant Director of Nursing (ADON) was apprised of the wound care observations findings. The ADON stated the WCN had to change gloves after the removal of the soiled/previous dressing and that the Medihoney should not be put back in the treatment cart once it was in the resident's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide toileting/incontinence care to 3 of 3 sampled residents (Residents #1, #2 and #3), reviewed for toileting / incontinent care and failed to follow the physician orders regarding blood glucose results for 2 of 3 sampled residents (Resident #1 and #2). The findings included: 1) Review of Resident #1's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Cerebral Atherosclerosis, Diabetes Mellitus Type 2, Chronic Kidney Disease, Hypothyroidism, Dementia, Peripheral Vascular Disease and Anxiety. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3, indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was totally dependent on the staff for the activities of the daily living including toileting and bathing. The assessment documented under Bladder and Bowel that the resident was always incontinent of bladder and bowel. Review of the resident's care plan titled Resident #1 is at risk for complications associated with bladder incontinence. Risk of UTI (Urinary Tract Infection); Risk for skin breakdown initiated on 01/22/2018 and revised on 08/28/23 documented an intervention that read Check frequently for incontinent episodes. On 10/09/23 at 10:33 AM, an interview was conducted with Staff A, Certified Nursing Assistant (CNA) who stated that she has 10 residents assigned to her. Staff A stated that it was an ongoing job and there was always something to be done. Staff A stated that 8 out of 10 of her assigned residents were totally dependent on her for toileting/incontinence care. Staff A was asked how many of the eight (8) residents had she checked their brief or done incontinence care this morning. Staff A replied she had not touched any of the eight (8) residents that were dependent on her for incontinence care. Staff A stated that it takes a lot of time to provide a residents morning care. Staff A was asked if she had done Resident #1's incontinence care/morning care and stated she had not since she started her shift. Staff A stated that justly her total dependent residents were wet because they had not been changed since night shift. Staff A stated the residents are supposed to have their brief changed or checked every two (2) hours. Staff A stated it is not just passing meal trays, she has to make sure the residents are awake, give them water, reposition and change them, there is a lot to do. On 10/09/23 at 10:54 AM, a side by side review of Resident #1's adult brief was conducted with Staff A, CNA. Staff A stated apart from checking the resident for safety this morning when she started her shift, Staff A reiterated she had not touched the resident this morning. Observation revealed the resident was wearing two adult briefs. Staff A stated the brief was wet, the resident needed to be washed and changed. Staff A stated that the resident was not supposed to have two briefs, only one. Staff A was asked why she had not done Resident #1's brief change and stated she started with the resident down the hall who had a morning appointment. 2) Review of Resident #2's clinical record documented an admission date to the facility on [DATE] with no readmissions. The resident's diagnoses included Cerebral Infraction, Diabetes Mellitus Type 2, Hypothyroidism, Neurologic Disorder in Lime Disease and Anxiety. Review of Resident #2's MDS quarterly assessment dated [DATE] documented a BIMS score of 9, indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff for the activities of the daily living including toileting and was totally dependent from the staff for bathing. The assessment documented under Bladder and Bowel that the resident was always incontinent of bladder and frequently incontinent of bowel. Review of Resident #2's Wound Care Specialist note dated 10/04/23 documented that the resident had a stage 4 left buttock wound. On 10/09/23 at 11:09 AM, a side by side review of Resident #2's adult brief was conducted with Staff A, CNA. Staff A stated that she had not touched, checked or changed the resident's brief at the time of the review. Observation revealed the resident's adult brief was soaking wet and had a soiled dressing on her back that was partially covering an open wound. Staff A stated that the resident gets dressing changes to the sacrum by the nurse. Staff A stated the resident was her priority to get washed. 3) Review of Resident #3's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Atherosclerotic Heart Disease, Asthma, Depressive Disorders, Hypertension, Generalized Osteoarthritis and Hypothyroidism. Review of Resident #3's MDS significant change assessment dated [DATE] documented a BIMS score of 10, indicating that the resident had moderate cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the staff to complete the activities of daily living including toileting. The assessment documented under Bladder and Bowel that the resident had an indwelling catheter and was always incontinent of bowel. Review of Resident #3's 2023 October Treatment Administration Record (TAR) documented cleanse blanchable redness to buttocks with soap and water, apply barrier cream every shift. On 10/09/23 at 11:23 AM, an interview was conducted with Resident #3 who stated her adult brief was changed last night. The resident was asked how she felt about having on a soiled brief since last night and replied, I don't like it, but what can I do. On 10/09/23 at 11:24 AM, a side by side review of Resident #3's adult brief was conducted with Staff A, CNA. The review revealed the resident had a stool soiled brief. The resident stated, I always have a bowel movement when they check the diaper. On 10/09/23 at 2:14 PM, an interview was conducted with Staff B, CNA who state 8 out of her 10 assigned residents assigned were total care. Staff B stated that sometimes she was not able to get to the residents every two (2), like they are supposed to. On 10/09/23 at 5:05 PM, during an interview, the Director of Nursing (DON) was asked to state the facility's policy related to toileting/incontinence care/brief change and replied she did not know the policy from the top of her head. The DON stated that the residents should be turned, have their brief checked every 2 to 3 hour and as needed or twice a shift. The DON was apprised of the findings. 4) Review of Resident #1's clinical record documented an admission to the facility on [DATE], and a readmission on [DATE]. The resident diagnoses included Diabetes Mellitus Type 2, Chronic Kidney Disease, and Dementia. Review of Resident #1's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3, indicating that the resident had severe cognition impairment. Review of Resident #1's active physician orders for October 2023 documented a physician's order dated 12/18/23 for Humalog G KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (millimeters) (Insulin Lispro) Inject 18 unit subcutaneously before meals for DIABETES, HOLD FOR BLOOD SUGAR LESS THAN 180. The physician's order was changed on 08/17/23. Review of Resident #1's August 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 08/11/23 at 8:00 AM, the resident's documented blood sugar was 87 and a nurse's initial with a check mark, indicating that 18 units of insulin was administered. The insulin for 8:00 AM was to be held, as per physician's order. Review of Resident #1's active physician's orders for October 2023 documented a physician's order dated 08/19/23 for Humalog G KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (millimeters) (Insulin Lispro) Inject 12 unit subcutaneously before meals for DIABETES, HOLD FOR BLOOD SUGAR LESS THAN 180. The physician's order was changed on 08/23/23. Review of Resident #1's August 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 08/19/23 at 8:00 AM and at 12:00 PM, the resident's documented blood sugar was 120 and a nurse's initial with a check mark, indicating that 15 units of insulin was administered. The insulin for 8:00 AM and 12:00 PM was to be held, as per physician's order. Review of Resident #1's August 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 08/20/23 at 12:00 PM, the resident's documented blood sugar was 126 and a nurse's initial with a check mark, indicating that 12 units of insulin was administered. The insulin for 12:00 PM was to be held, as per physician's order. Review of Resident #1's active physician's orders for October 2023 documented an order dated 08/23/23 for Humalog G KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (millimeters) (Insulin Lispro) Inject 10 units subcutaneously before meals for DIABETES, HOLD FOR BLOOD SUGAR LESS THAN 180. Review of Resident #1's August 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 08/25/23 at 8:00 AM, the resident's documented blood sugar was 130 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 8:00 AM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/02/23 at 4:00 PM, the resident's documented blood sugar was 102 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/03/23 at 8:00 AM and 12:00 PM, the resident's documented blood sugar was 114 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 8:00 AM and 12:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/05/23 at 4:00 PM, the resident's documented blood sugar was 172 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/16/23 at 8:00 AM, the resident's documented blood sugar was 142 and a nurse initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 8:00 AM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/19/23 and 09/20/23 at 4:00 PM, the resident's documented blood sugar was 136 and 169 respectively and a nurse's initial with a check mark indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/27/23 at 4:00 PM, the resident's documented blood sugar was 176 and a nurse's initial with a check mark indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/29/23 at 12:00 PM, the resident's documented blood sugar was 122 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 12:00 PM was to be held, as per physician's order. Review of Resident #1's September 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 09/30/23 at 8:00 AM, the resident's documented blood sugar was 174 and a nurse's initial with a check mark, indicating that 10 units of insulin was administered. The insulin for 8:00 AM was to be held, as per physician's order. Review of Resident #1's October 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 10/01/23 at 8:00 AM and 12:00 PM the resident's documented blood sugar was 122 and 140 respectively with a nurse's initial and a check mark, indicating that 10 units of insulin was administered both times. The insulin for 8:00 AM and 12:00 PM was to be held, as per physician's order. Review of Resident #1's October 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 10/03/23 at 4:00 PM, the resident's documented blood sugar was 128 and a nurse's initial with a check mark indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's October 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 10/07/23 at 4:00 PM, the resident's documented blood sugar was 151 and a nurse's initial with a check mark indicating that 10 units of insulin was administered. The insulin for 4:00 PM was to be held, as per physician's order. Review of Resident #1's October 2023's Medication Administration Record (MAR) was conducted. The review revealed that on 10/08/23 at 8:00 AM and 12:00 PM the resident's documented blood sugar was 122 and 178 respectively with a nurse's initial and a check mark, indicating that 10 units of insulin was administered both times. The insulin for 8:00 AM and 12:00 PM was to be held, as per physician's order. On 10/09/23 at 4:38 PM, a side by side review of Resident #1's August, September and October 2023's MAR was conducted with the Director of Nursing. The DON confirmed the findings and stated that the check marks indicated that the insulin was administered. 5) Review of Resident #2's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included Cerebral Infraction, Diabetes Mellitus Type 2, Hypothyroidism, Neurologic Disorder in Lime Disease and Anxiety. Review of Resident #2's MDS quarterly assessment dated [DATE] documented a BIMS score of 9, indicating that the resident had moderate cognition impairment. Review of Resident #2's active physician's order documented an order dated 04/13/23 for Obtain and record accu-check blood sugar twice daily without coverage. Notify the MD (medical doctor) if blood sugar is less than 70 or greater than 300 two times a day for Diabetic monitoring before breakfast and dinner. Review of Resident #2's August and September 2023 MAR documented on 08/29/23 and on 09/20/23, the resident's blood sugar test result was 334 and 302, respectively. Further review revealed the lack of documentation of calling the physician related to a blood sugar greater than 300, as per physician's order. On 10/09/23 at 4:39 PM, a side by side review of Resident #2's August and September 2023's MAR was conducted with the Director of Nursing. The DON confirmed the findings and stated that there was no documentation related to calling the physician about the resident's blood sugar greater than 300.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review; the facility failed to administer a psychotropic medication ordered upon admission for 1of 2 sampled residents reviewed for admission orders (Resident #299). The findings included: The facility's policy titled, Physician Services published 10/20/2022 revealed the The medical care of each resident is supervised by a licensed physician. Supervising the medical care of residents includes prescribing medications and therapy. Resident #299 was admitted to the facility on [DATE] at 4:00 PM, per admission evaluation. He had a Brief Interview of Mental Status score of 12, per a social service evaluation dated 08/20/23. This indicated the resident is mildly impaired in his cognition. Medical diagnoses included Anemia, Dysphagia due to Throat Cancer, Anxiety, and Pneumonitis. On 08/21/23 at 11:55 AM, Resident #299 was interviewed and stated he was upset and anxious because he did not get his Xanax the past couple of nights. A review of the physician orders revealed the physician ordered Alprazolam Oral Tablet 0.25 mg (milligrams) *Controlled Drug* Give 0.25 mg via PEG-Tube at bedtime for anxiety, ordered 08/18/23 at 22:48 to be started on 08/19/23. (Alprazolam is the generic name of Xanax, an anti-anxiety drug). On 08/19/23 a nursing progress note revealed the Alprazolam was not administered. Alprazolam 0.25 mg was not administered /held on 08/19/23, 08/20/23, 08/21/23, and 08/22/23 without an order to hold the medication. A nursing progress note dated 08/22/23 documented the Alprazolam 0.25 mg was waiting for delivery. A review of the medications in the Omnicell (emergency medications) revealed 10 tabs of Alprazolam 0.25 mg in the inventory. A review of Resident #299's social service care plan revealed Resident is at risk for mood indicators secondary to diagnosis of depression and anxiety that both have pharmaceutical intervention as well as changing health with an intervention of Administer psychotropic meds as ordered. An interview was conducted with the Director of Nurses (DON) on 08/23/23 at 4:00 PM. It was discussed regarding the resident having an order for Alprazolam, it was not given and there was no physician order to hold it. The resident also had an order for Lorazepam (an anti-anxiety drug) which was given. The DON was not able to tell this surveyor why Alprazolam was held and why the resident had 2 orders for anti-anxiety medications, and why the Alprazolam was not administered on 08/19/23 - 8/22/23, when it was in the Onicell inventory. Further record review revealed Resident #299 was discharged to hospice on 08/23/23.

Based on observation, records review, and interviews, the facility failed to follow the order and facility protocol for enteral feeding for 1 of 1 sampled residents reviewed for tube feeding (Resident #50). The findings included: Review of the facility for enteral feeding documented in part, the following: 1) Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and or use of a feeding tube, such as: e) Esophageal swelling, strictures, fistulas; and f) clogging of the tube. On 08/21/23 at 12:15 PM, it was observed that Resident #50 was lying in bed. The tube feeding meal for Resident #50 was attached to the pole, but the pump was off. According to the writing on the bag, the feeding started on 08/20/23, no time indicated. There were 600 ml out of 1000 ml left to be infused. Photographic Evidence Obtained. On 08/21/23 at approximately 1:41 PM, meals were observed on Resident #50's bedside table, placed before the resident while she sat on the bed. Resident #50 was not feeding herself. Soon after the surveyor left the resident's room, the second-floor Unit Nurse Manager entered the resident's room and was observed feeding the resident. On 08/21/23 at 1:45 PM, the surveyor interviewed the Nurse Manager (NM) to inquire about Resident #50's ability to feed herself. The NM reported that Resident #50 feeds herself, at times, but they must monitor her to ensure she continues to perform the task independently; if she does not, they assist to feed her. On 08/22/23 at 12:27 PM, the tube feeding meal, Jevity 1.5 Cal. 1500 cal/1000 ml was observed hanging on the pole, and running at 80 ml/hr. The date and time written on the bag were 08/22/23 at 6:00 AM. There as 800 ml/1000 left to be infused. Photographic Evidence Obtained. Review of the physician's orders documented: a) 06/12/23: Pleasure Feeds diet, Mechanically Altered Ground texture, Thin Liquids consistency may have chopped texture sandwiches and desserts. b) 07/21/23: Enteral Feed every shift Jevity 1.5/960ml continuous feed @80ml/hr x12hr or until total volume is infused; with 720ml water flush at 60ml/hr x12hr via PEG tube. START FEEDING AND FLUSHES AT 8 PM until completely infused. Provided daily: ~1440kcal, ~1450ml fluid, ~61g pro Enteral Feed. Based on the physicians' orders, if the tube feeding started at 8:00 PM on 08/20/23, on 08/21/23 during the first observation, there should have remained zero content in the bag by 8:00 AM, there were 600 ml remaining in the bag. During the second observation, there should have been 520 ml remaining and not 800 ml. The order was to run the feeding from 8:00 PM and to 6:00 AM. Review of the Nurses progress notes dated 8/22/23 documented no reasons why the continuous feeding for Resident #50 was discontinued or interrupted. There was no justification why the order was not followed. Review of Resident #50's weight record for the last six months revealed the following: 08/03/23 92.0 Lbs Mechanical Lift 07/13/23 92.0 Lbs Mechanical Lift 07/05/23 91.0 Lbs Mechanical Lift 06/05/23 90.0 Lbs Mechanical Lift 05/23/23 90.0 Lbs 05/16/23 89.0 Lbs 05/12/23 89.0 Lbs 05/06/23 90.0 Lbs 04/18/23 94.0 Lbs 04/13/23 95.0 Lbs 04/04/23 97.0 Lbs 03/21/23 95.0 Lbs 03/08/23 95.0 Lbs 03/03/23 98.0 Lbs The care plan dated 05/30/23 documented the following: ADL (activities of daily living) Self-Care Deficit R/T (related to) Asp. PNA (Aspiration Pneumonia), Dementia, Generalized Weakness/ decrease ability to perform self-care. The Goals included: o ADL needs will be met daily as evidenced by well groomed, neat/clean, comfortable o Assist to turn and reposition, shifting weight to enhance circulation o Encourage to perform self-care and provide only assistance that is needed to complete task. o Explain all procedures and purpose prior to performing task and encourage self-performance o Invite, encourage, to actively participate during one to one sessions to stimulate memory with Christian songs, touching manipulatives, for enjoyment and to diverting the resident from pulling her tube out and unsafely standing up. The dietary plan of care dated 05/30/23 documented the following: [Resident #50] required tube feeding for nutritional support r/t Dementia and Dysphagia dx (diagnosis), Average Meal Intake < (less then) 25% pleasure trays, Significant Weight Loss, mechanically altered diet, severe cognitive impairment, diarrhea at times. The Goals included: o Resident will exhibit no signs or symptoms of aspiration by next review date. o Resident will maintain weight with no further loss by next review date. o Resident will be free from abnormal bowel movement by next review date. o Resident will tolerate tube feeding without complications such as: aspiration, infection, abdominal pain/distention, dehydration, diarrhea, constipation/fecal impaction, vomiting by next review. Staff will: o Maintain the head of resident's bed (HOB)at 30 - 45 degrees 30 - 60 minutes after bolus feeding. o Monitor and report signs/symptoms of aspiration o Monitor and report signs/symptoms of dehydration o Monitor labs when available - report abnormal data to physician/provider promptly o Monitor tolerance of tube feeding o Monitor weight monthly/weekly o Provide mouth care as needed o Provide tube feeding as ordered o Provide water flush as ordered o Provide water flush with medications per nursing policy An interview was conducted with Staff F, Registered Nurse, on 08/22/23 at 2:14 PM. Staff F stated the discontinued tube feeding observed on 08/21/23, (dated 8/20/23), was placed by the night shift who worked on 08/20/23. Staff F said the feeding machine had stopped from time to time, and she had to restart it. She said that she restarted the machine three times today, (on 08/22/23). After she flushed it the last time, it did not stop again. Staff F explained that she did not recall the exact time the machine stopped, but it was early morning. When asked if that was the protocol to follow for a defective feeding machine, Staff F answered, they would change the machine if the situation persisted. She stated the machine worked fine after the third time. She stated the machine was supposed to run until the full 960 ml was infused. An interview was conducted with the Director of Nursing (DON) on 08/23/23 at 11:52 AM. The DON revealed that Resident #50 was not at the time participating in therapy (which would be a reason to stop the machine). She said that Resident # 50 had a habit of pulling out her tube feeding which was documented and verified in the Care Plan, but the resident had not done so lately. The DON stated the resident moves a lot in bed and that could have caused the infusion flow of the tube feeding to stop. She said that staff are supposed to continuously check on the resident during enteral feeding to make sure that the feeding is not interrupted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide medications to meet the needs for 1 of 13 sampled residents reviewed during medication reconciliation of controlled substances (Resident #349); and failed to provide medications to meet the needs for 1 of 7 sampled residents observed for medication administration (Resident #297). The findings included: Record review for Resident #349 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 03/15/23 with diagnoses that included: Type 2 Diabetes Mellitus with Other Skin Complications, Recurrent Depressive Disorders, and Anxiety Disorder. Review of the Minimum Data Set assessment for Resident #349 dated 08/18/23 revealed in Section C a Brief Interview of Mental Status score of 11, indicating moderate cognitive impairment. Review of the Physician's Orders for Resident #349 revealed an order dated 03/31/23 for Alprazolam 0.25 mg given 1 tab by mouth two times a day for anxiety. Review of the Physician's Orders for Resident #349 reveled an order dated 03/31/23 for Pregabalin 25 mg given 1 by mouth one time a day for pain. Review of the Medication Administration Note for Resident #349 dated 08/23/23 at 5:25 PM included: Pregabalin Oral Capsule 25 mg give 25 mg by mouth one time a day for pain. Resident did not receive medication error. ARNP (Advanced Registered Nurse Practitioner) made aware. Review of the Medication Administration Note for Resident #349 dated 08/23/23 at 5:23 PM included: Alprazolam Oral Tablet 0.25 MG Give 0.25 mg by mouth two times a day for anxiety. Resident did not receive made error. ARNP made aware. Review of the Care Plan for Resident #349 dated 03/22/22 with a focus on potential for side effects related to the use of anti-anxiety required for diagnoses of anxiety/agitation. The goals were to have no behavior symptoms through the next review date. The interventions included: Medicate as ordered. Review of the Care Plan for Resident #349 dated 03/22/22 with a focus on the resident has a potential for alteration in comfort related to decreased mobility and neuropathy. The goals were to verbalize effective pain management as evidenced by decrease in pain score to 1-2 by next review date. The interventions included: Medicate as ordered and notify physician if pain is not relieved. During a medication cart review conducted on 08/23/23 at 3:05 PM with Staff F, Registered Nurse (RN) she stated that she has worked at the facility for 1 year. Resident #349's medication reconciliation sheet was reviewed for the medication Alprazolam 0.25 mg which listed the amount remaining was 15, however, there were actually 16 remaining. Resident #349's medication reconciliation sheet was reviewed for the medication Pregabalin 25 mg which listed the amount remaining was 10 however, there were actually 11 remaining. During an interview conducted on 08/23/23 at 3:15 PM with Staff F who was asked if she had performed a medication reconciliation count of the controlled substances in the cart at the beginning of her shift, she said yes. When asked if she administered the medication Alprazolam 0.25 mg for Resident #349, she said yes. When asked if she had signed off on the Electronic Medication Record for Resident #349 as giving the same medication, she said yes. When asked if she was sure she gave the medication in question, she looked at the next medication reconciliation sheet for the same resident for the medication Pregabalin 25 mg and stated maybe I forgot to pop the medications and give them. When she was shown the medication reconciliation sheets for the medications in question for Resident #349, she said she really thinks she did not give the medications and immediately informed the Unit Manager. During an interview conducted on 08/23/23 at 3:30 PM with Resident #349 who was asked if she received her medications Alprazolam and Pregabalin earlier today, she said I honestly do not know, I would assume so when I got all of my other medications. The resident was anxious and stated she would be very upset if she did not get the medications that she needs. 2) Resident #297 was admitted to the facility on [DATE] at 5:33 PM from an acute care hospital. Admitting diagnoses included, Aftercare following joint replacement surgery, Hypothyroidism and Type 2 Diabetes Mellitus. Her Brief Interview for Mental Status score was 15, per the Medicare 5 day Minimum Data Set with an assessment reference date of 08/22/23. This indicated the resident was cognitively intact. On 08/22/23 at 9:30 AM during preparation for medication administration with Staff G, Registered Nurse, only 2 medications could be located in the medication cart. Alogliptin Benzoate Oral Tablet 25 milligrams (mg) 1 tablet one time a day was not given 08/21/23 and 08/22/23. Losartan Potassium 100mg tablet was not given on 08/21/23. Zonisamide Oral Capsule 100mg which is an anticonvulsant was not given on 08/20/23, 08/21/23, and 08/22/23. Nateglinide tablet 120mg to be given three times a day for diabetes was not given on 08/20/23, 08/21/23 at 9:00 AM and 1:00 PM and 08/22/23 at 9:00 AM. An interview was conducted with Staff G on 08/22/23 at 9:45 AM as to where these medication were. Staff G stated she usually works nights and was not familiar with these medications for Resident #297. On 08/22/23 the Nurse Practitioner who was in the facility was notified that Resident #297 was not going to be given Alogliptin Benzoate Oral Tablet 25 mg, Losartan Potassium, Zonisamide Oral Capsule, and Nateglinide tablet 120mg at 9:00 AM. A review of the nursing progress notes revealed neither the Physician or Nurse Practitioner was notified of the non administration of the medication on 08/20/23 or 08/21/23. This was discussed with the Director of Nurses on 08/22/23 at 11:30 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide special drinking equipment while consuming meals for 3 (Resident #30, #92, and #94) of 3 sampled residents. The findings included: 1) During the observation of the lunch meal on 08/21/23 at 12:15 PM, it was noted that the meal tray card of Resident #30 documented to provide 2 Handled Cup With Lid for tray beverages. Observation of the lunch meal tray noted that only 1 adaptive drinking cup was sent for the 3 beverages (Cranberry Juice (2) and Water) on the meal tray. The surveyor brought the issues to the attention of the Charge Nurse who stated the adaptive cups lessen spillage during independent drinking and called the dietary department for additional adaptive cups. Observation of the breakfast meal on 08/22/23 at 9:30 AM noted that the meal tray included a carton of milk, however an adaptive 2-handled cup with lid was not included on the meal tray. It was noted that Resident #30 was required to drink directly from the milk carton resulting in spillage during drinking. Interview conducted with Resident #30 at the time of the observation noted to state that she requires all beverages to be in adaptive 2-handled mug with lid to prevent spillage during drinking of beverages. Resident #30 further stated she has 3 -4 beverages per meal and only receives 1 adaptive mug on the meal trays . During the review of the clinical record of Resident #30 on 08/21/23, the following were noted: Date Of admission: re-admission [DATE] Diagnoses: Paraplegia, Depressive Disorder, Protein-Calorie malnutrition, Bipolar II Disorder Current Physician orders: 02/01/23 - Divided plate and 2-handle mug with lid all meals 04/12/23: No Added salt Diet MDS (Minimum Data Set) assessment: 06/13/23 (Annual) Sec B: Understood 7 Understands Sec C : BIMS = 14 Sec G ; Eat - Independent Sec K : No Swallow Disorder Current Care Plan: 06/20/23 < Problem - Nutritional Problem * Intervention - Provide Adaptive Eating Equipment # Compartment Plate and 2-Handled Mug with Lid for all meals Review of Occupational Discharge summary dated [DATE] documented that Resident #30 stated that tremors are getting worse and had spillage during meal times, and requires 2-handled cup with lid and plate guard with all meal. 2) During the observation of the lunch meal on 08/21/23, it was noted that the meal tray was served to the room of Resident #92. Further observation noted the resident's meal tray card documented: Divided Plate, and Spill Proof Cup with Lid and Handle. Observation noted that only one adaptive drinking cup had been provided for 3 beverages (coffee, milk, and juice). Resident noted to have confusion and spillage while drinking from a regular cup, Observation of the breakfast meal on 08/22/23 at 8:30 AM noted the ,meal tray served to the room of Resident #92. Further observation noted again that only 1 adaptive drinking cup had been provided for 3 beverages (juice, coffee, and milk). The surveyor informed the Chargé Nurse who stated she was unaware that only 1 adaptive cup was being provided for multiple beverages included on the meal tray . Review of clinical record of Resident #92 noted the following: Date Of admission: [DATE] Diagnoses: Dementia, Cognitive Deficit, and Dysphagia. Current MD (Medical Doctor) Orders include: 07/26/23 - Divided plate with all meals 07/26/23 - Spill proof cup/lid and handle with all meals 07/07/23 - Only spoon with all meals - unable to differentiate functions of fork and knife 06/08/23 - Mechanically Altered Chopped Texture diet MDS assessment: 7/22/23 Quarterly Sec B: Sometimes understood/Rarely Understands Sec C: BIMS =3 (Cognitively Impaired) Sec G: Eat = Supervision with Set Up Sec K ; No swallow Disorder, 59/95#- Mechanically Altered Diet Nutrition Progress Notes: 7/8/23 - Underweight, advanced dementia, Intake 75-100%, 06/08/23 - Requires adaptive equipment during meals, 01/10/23 - Adaptive equipment to facilitate eating . Current Care Plan - 08/01/23: < Nutritional Problem - * Intervention - Provide Spill proof cup/lid and handle with all meals . Weight History: 08/04/23 - 98 # 04/03/23 = 96 # 09/08/22 = 100 # 07/06/22 = 106# Ht = 59 BMI=19.8 (Underweight) Review of Occupational Therapy discharge documentation dated 03/22/23 noted that Resident #92 requires spill proof cup with lid and handles with all meal. 3) During the observation of the lunch meal on 08/22/23 at 12:30 PM, it was noted that the meal tray was delivered to the room of Resident #94. Further observation noted the meal tray card to document Spill Proof Cup with Lid and Handle. Observation of the meal tray noted that only one adaptive cup had been provided for 3 beverages (juice, milk, and water). Resident #94 noted to be assisted by staff for feeding and was spilling beverages from regular cup. During the observation of the breakfast meal on 08/22/23 at 8:45 AM, it was again noted that only 1 Spill proof Cup with Handle and Lid had been provided for 3 tray beverages ( juice, coffee, and milk). Review of clinical record of Resident #94 noted the following: Date Of admission: [DATE] Diagnoses: Arthritis, ASHD, Current Physician Orders include: 07/26/23 - Spill Proof cup/lid and handle with all meals 07/28/23 - Divided plate with all meals 02/16/22 - Regular Diet 06/16/21 = Liquid Protein 30 ml BID (twice daily) 06/01/22 - Ensure Plus 240 ml BID Weight History: Weight Loss: 08/04/23 = 115# 07/20/23 = 113# 05/06/23 = 120 02/06/23= 127 Height = 63 BMI = 20.4 MDS assessment: 05/19/23 Sec B ; Understood & Understands Sec C: BIMS = 12 (moderately impaired cognition) Sec G: Eat = Independent - One person assist Sec K : NO Swallow Disorder , 63/120#, Care Plan: 05/30/23 < Potential For Nutritional Problem - * Intervention - Provide Adaptive Equipment with All Meals Current Nutrition Note: 07/07/23 - Requires adaptive equipment -independent and assist with meals, triggers for significant wt (weight) loss 5.8% in 30 days Review of Occupation Therapy Discharge note dated 06/23/23 notated that Resident #94 required use of divided plate, built-up utensils, and spill proof cup with lid and handle. Review of Occupation Therapy Note dated 08/23/23 documented that Resident's #94's divided plate and built-up utensils have been discontinued, but noted to require Spill Proof Cup with Lid and Handle. Interview conducted with the Director of Skilled Therapy on 08/23/23 noted that she was unaware that the dietary department was providing only 1 adaptive drinking cups with resident meals. It was confirmed with the Director that an adaptive drinking cup is to be provided for each beverage included on the meal trays. Interview with the Food service Director (FSD) on 08/23/23 noted that the dietary department was only providing 1 adaptive drinking cup with meal trays. FSD stated he was unaware that an adaptive drinking cup should be provided for each beverage included on the meal trays .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide ceiling suspended curtains, to provide total visual privacy for 2 of 145 residents. The findings included: 1) Record review for Resident #7 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE] with diagnoses included: End Stage Renal Disease and Dependence on Renal Dialysis. Review of the Minimum Data Set for Resident #7 dated 07/01/23 revealed in Section C a Brief Interview of Mental Stats score of 13 indicating a cognitive response. During an observation conducted on 08/21/23 at 11:10 AM Resident #7 was not in her semi-private room and there was no privacy curtain for Resident #7. During an observation conducted on 08/22/23 at 10:15 AM of Resident #7 was lying in her bed in her semi-private room with no privacy curtain for the resident. During an observation conducted on 08/23/23 at 9:40 AM of Resident #7's semi-private room and there continued to be no privacy curtain for the resident. During an interview conducted on 08/22/23 at 10:15 AM with Resident #7 who was asked about the missing privacy curtain, she said she was not sure when the privacy curtain went missing. 2) Record review for Resident #21 revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission on [DATE], with diagnoses that included Type 1 Diabetes Mellitus with Diabetic Neuropathy, Morbid (Severe) Obesity Due to Excess Calories, Bipolar Disorder, and Major Depressive Disorder. Review of the Minimum Data Set for Resident #21 dated 07/13/23 revealed in Section C a Brief Interview of Mental Status score of 11 indicating moderate cognitive impairment. During an observation on 08/21/23 at 11:17 AM there was no privacy curtain for Resident #21 who is in a semi-private room. During an observation on 08/22/23 at 10:00 AM of no privacy curtain for Resident #21 who is in a semi-private room. During an observation on 08/23/23 at 9:30 AM of no privacy curtain for Resident #21 who is in a semi-private room. During an interview conducted on 08/21/23 at 11:15 AM with Resident #21, she complained that she has no privacy curtain, and it bothers her. When asked how long the privacy curtain has been missing, she said a long time. She told someone when it first happened, but the curtain was never replaced. During an interview conducted on 08/23/23 at 9:30 AM with Resident #21 who was asked how it makes her feel that she does not have a privacy curtain, she said It really bothers me. During an interview conducted on 08/24/23 at 11:15 AM with the Director of Housekeeping, she stated the process for cleaning the privacy curtains is usually performed by the AM (morning) floor tech and they are usually back up the next day, sometimes he is not able to get the privacy curtains back up right away. When asked when the privacy curtains will be replaced with a clean one when the old one is removed, she said no, we do not have any spare privacy curtains, but we do now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe and clean environment in resident rooms and common areas, as well as failed to maintain laundry equipment in a repair. The findings included: 1) On 08/21/23 at 9:30 AM, an observation was conducted inside the first-floor soiled utility room where the laundry shoot is located, it was noted that the ceiling vent was covered with dust, debris, and moldlike substance, there were stains on the ceiling, corner of wall had plaster and paint missing, the covering behind the wire shelf was pulling away from the wall, the wall behind the covered garbage container was dirty, and the sink was dirty, the laundry shoot was rusted and dirty (Photographic Evidence Obtained). 2) On 08/21/23 at 9:40 AM, an observation was conducted of the drainage behind the washing machines which had a buildup of debris on the sides that was approximately 2 inches thick (Photographic Evidence Obtained). 3) On 08/21/23 at 9:44 AM, an observation was conducted in the laundry area of 1 of 3 working dryers which had a torn lint trap liner. There was lint like debris around the inside of the window of 1 of the 3 working dryers. All 3 working dryers had melted debris on the inside drums (Photographic Evidence Obtained). 4) On 08/21/23 at 9:55 AM, an observation was conducted in the laundry area of the window ledge located next to one of the personal washing machines was crumbling with large chucks of the ledge missing (Photographic Evidence Obtained). 5) On 08/21/23 at 10:00 AM, an observation was conducted in the laundry area of 2 out of the 4 ceiling lights that had either missing or burnt-out light bulbs, and 1 of ceiling light cover was broken with plastic missing (Photographic Evidence Obtained). 6) Next to the washing machines, the raised platform for the laundry chemicals was covered with a white substance and the floor next to the raised platform was dirty (Photographic Evidence Obtained). During an interview conducted with the Director of Maintenance who stated he has been working at the facility for about 32 years. When asked about the drainage behind the washing machines, he said they clean that area once a month or more often as needed. An interview conducted with the Staff C, a Laundry Aide who stated she has worked for the facility for about 6 years. When asked about the crumbling window sill next to the personal washer, she said it may have been like that for about a month. When asked if she ever reported it to maintenance, she said they must know because they come in here. 7) During resident screenings conducted by surveyors on 08/21/23 and 08/22/23 and the Environment Tour conducted on 08/23/23 at 11:30 AM with the Administrator, Director of Maintenance and Director of Housekeeping, the following were noted: (a) The public/staff bathroom located on the second floor located between the Windsor and [NAME] Units it was noted: < Offensive urine room odor. < Areas of dried brown matter on room floor. < Room floor heavily soiled and large dark stains around toilet bowl. < Room walls soiled and stained. Peeling wallpaper. < Room hand wash sink was soiled and the floor area around the sink was noted to have large black stains. < Room ceiling tiles soiled and not secured to ceiling. (b) Resident #212 - Resident stated the wheels of the wheelchair are heavily soiled and has asked staff repeatedly to have her wheelchair cleaned, however the facility has not responded to her request. Observation of the resident's wheelchair noted the front (2) and back wheels (2) where heavily soiled and had a thick build-up of dust, dirt, and hair. Photographic Evidence Obtained (c) Resident #102 - Resident stated the wheels of the wheelchair are heavily soiled and has asked staff repeatedly to have her wheelchair cleaned, however the facility has not responded to her request. Observation of the resident's wheelchair noted the front (2) and back wheels (2) where heavily soiled and had a thick build-up of dust, dirt, and hair. Photographic Evidence Obtained (d) room [ROOM NUMBER] - Observation and interview noted the resident fell with injury on 08/22/23 at 4 AM. Observation on 08/22/23 at 11 AM noted that the resident was lying in bed with the bed linens covered in dried blood. The privacy curtain was also noted to have areas of dried blood. Photographic Evidence Obtained (e) room [ROOM NUMBER] - The bathroom floor tiles noted to have numerous large cracks. One of two-bathroom lights were not working. (f) room [ROOM NUMBER] - The bathroom floor was noted to have large area of dried brown matter around the toilet area. (g) The clean linen storage room located on the second floor located between the Windsor and [NAME] Units noted the floor littered with trash, dust, dirt, and debris. The floor was also noted to have large areas of black stains. Photographic Evidence Obtained (h) room [ROOM NUMBER] - The doors of the room closet had fallen off of their track, privacy curtain stained, and large area of room peeling wallpaper. (i) [NAME] Community Shower Room - ceiling vent heavily soiled and and surrounding wall area mold type matter. (j) [NAME] Corridor - Windows located at the end of hall noted to be laden with green algae type matter. (k) [NAME] Nurse Bathroom - bathrooms lights located over hand washing sink were not working. * All environment findings were reviewed and acknowledged with the Administrator on 08/23/22.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for potentially 141 of the 145 facility residents that included; elimination of potential use of dented cans of food, maintenance of refrigeration units, maintenance of exhaust hoods, proper cleaning and maintenance of food preparation equipment, proper labeling and dating of opened food packages, and maintaining regulatory chemical levels in the 3-compartment sink. The findings included: During the initial observation tour of the main kitchen on 08/21/23 at 8:45 AM, and accompanied with the Food Service Director (FSD) and Administrator, the following were noted: (a) The door gaskets of Reach-in refrigerator #1 (Traulsen) were noted to have a build-up of a black mold substance and the front of the unit was full of condensation. It was discussed with the FSD that the gaskets were old and door was not shutting tightly resulting the condensation issues. Photographic Evidence Obtained. (b) The exhaust hood which is located over the major food preparation equipment was noted to be soiled and had large areas of peeling paint. It was discussed with the Administrator that the hood unit was not being properly maintained for cleanliness and paint exterior. Photographic Evidence Obtained. (c) The bench mounted commercial can opener was noted to be soiled and rust laden. The blade was old, and the exterior was in disrepair. It was discussed with the FSD that the opener is not being cleaned and sanitized on a daily basis and the opener blade is in need of replacement. The surveyor requested that the unit be properly cleaned and blade replacement prior to continued use. Photographic Evidence Obtained. (d) The interior of Convection Oven #1 was noted to have a thick layer of black carbon within the cavity and on the doors (2). The FSD stated that the oven had not been cleaned on a regular basis Photographic Evidence Obtained. (e) Observation of the dry/can storage room noted that there was a #109 can of Cut Sweet Potatoes that had 2 large dented areas. The can was noted to be bulging from the bottom indicating a potential contamination . The surveyor requested that the can be removed from the rack immediately. The FSD stated that the can should have been located to the dented can rack. Photographic Evidence Obtained. 2) During a follow-up observation tour of the main kitchen on 08/22/23 at 11:30 AM, the following were noted: (f) it was noted that a #10 can of Fruit Cocktail was on the food preparation table and was intended for the dinner meal dessert of 08/22/23. Observation of the can noted a visible large dent on the top corner of the can. Interview with the FSD revealed that staff were unaware that dented cans should not be utilized for resident meals. Staff stated that the can was located on the storage shelf rack that are intended for resident use. Photographic Evidence Obtained. (g) Observation of the food preparation table noted that commercial foods were not documented with an opening date. The commercial foods included: Potato Pearls (57 ounces package) and Lemon & Pepper Seasoning Salt (28-ounce package). Photographic Evidence Obtained. (h) Observation of food preparation cutting boards noted that 1 (yellow board) of 5 boards exterior was heavily worn with cutting grooves and areas of black mold type substance. Photographic Evidence Obtained. (i) Observation noted that the 3-compartment was being utilized for the washing of food preparation equipment. At the surveyors request a est was conducted to ensure regulatory level of chemical in the sanitizing sink. The test performed by the FSD noted inadequate level of Quaternary sanitizing chemical. Photographic Evidence Obtained.

Based on observations and interviews the facility failed to assure that staff handle, store, process, and transport laundry to prevent the spread of infection and failed to implement a surveillance plan to accurately identify, track, and report a Covid outbreak infection. The findings included: Review of the facility's policy titled, Laundry and Bedding, Soiled with a published date of 05/18/23 included: Soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Under Transport 6. Clean linen is protected from dust and soiling during transport and storage to ensure cleanliness. Under Section Laundry Processing 3. When using fans in laundry processing areas, the ventilation does not flow from soiled processing areas to clean laundry areas. 8. If laundry chutes are used, they are designed and maintained so as to minimize dispersion of aerosols from contaminated laundry (e.g., no loose items in the chute and bags are closed before tossing into the chute). Review of the facility's policy titled, FL Covid-19 Resident and Staff Testing: with a revised date of 11/2022 included under Section I Reporting Test Results 2. Facilities must continue to report Covid-19 information to CDC's National Healthcare Safety Network. 1) On 08/21/23 at 9:30 AM, an observation was made In the first-floor soiled laundry room where the laundry shoot is located had a bin under the laundry shoot with a dirty mop head pad, an empty mesh personal clothing bag a used glove and debris (Photographic Evidence Obtained). 2) On 08/21/23 at 9:35 AM, an observation was made in the first-floor soiled laundry room where the laundry shoot is located had a bin for soiled housekeeping supplies. In this bin was an unbagged dirty mop head, a bag of dirty mop heads, several pieces of used personal protective equipment (gloves), and debris (Photographic Evidence Obtained). 3) On 08/21/23 at 9:40 AM, an observation was made inside the laundry washer/dryer area of a large pedestal fan covered with dust-like debris blowing over the uncovered clean laundry being transferred from the washers to the dryers (Photographic Evidence Obtained). 4) On 08/21/23 at 9:45 AM, an observation was made inside the laundry washer/dryer area of the lids for the 2 washers used for personal laundry were rusty and dirty (Photographic Evidence Obtained). 5) On 08/21/23 at 9:50 AM, an observation was made inside the laundry washer/dryer area of 2 of the wire laundry transport carts were rusted where the laundry is placed (Photographic Evidence Obtained). During an interview conducted on 08/21/23 at 9:35 AM with the Director of Housekeeping (DOH) who stated the staff are not supposed to place any housekeeping cleaning materials, unbagged materials or personal laundry down the laundry shoot. The DOH stated sometimes when the bags come down the laundry shoot the bags get ripped. During an interview conducted on 08/21/23 at 9:43 AM with Staff C, Laundry Aide, who stated she has been working at the facility for 6 years. When asked how often the pedestal fan is cleaned, she stated it is cleaned 3 times a day and the lint traps for the dryers are cleaned every 2 hours. 6) Review of the line listing provided to surveyor (copies of Covid-19 Outbreak Surveillance Line List Form) it was unclear when or with whom the outbreak started. These forms did not clearly indicate what the symptoms were, if any for residents/staff and test results were not attached. For Resident #147 his electronic medical record revealed the resident had tested positive for Covid on 07/25/23. Resident #147 was not included on the line list report to DOH (Department of Health) for 07/25/23 nor was it reported late on 07/26/23. There is no record of when staff test positive, what symptoms they have, or when they start to isolate themselves or when they return to work. During an interview conducted on 08/22/23 at 2:00 PM with the Assistant Director of Nursing/Infection Preventionist (ADON/IP) who stated their last covid outbreak started on 08/04/23 with a resident, another resident tested positive on 08/09/23. Both of the residents were placed in isolation for 10 days. During an interview conducted on 08/23/23 at 12:30 PM with the Director of Nursing who was covering in the absence of the Infection Preventionist who stated she has worked at the facility for 14 months. who stated she was unable to determine when the Covid outbreak started prior to 08/04/23. When asked about when the outbreak started that included 07/25/23, she does not have the date. The DON stated the IP would have reported an outbreak to the DOH. The DON stated even though she does not recall the date, she did recall that it started with a resident who had got it from his wife was a visitor. The DON stated the IP would have done contact tracing for the initial outbreak (date unknown) and they would have immediately tested the roommate if the resident had one regardless if symptomatic or not and any close contact staff member regardless if symptomatic or not. Then they would continue in outbreak mode They would have tested symptomatic resident and symptomatic staff. The DON confirmed that Resident #147 tested positive for covid on 07/25/23 while in the facility and it was not reported to DOH.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide privacy for telephone communications for 1 of 1 sampled residents reviewed for privacy (Resident #12). The findings included: Review of the facility's policy titled, Confidentiality of Information and Personal Privacy, dated 04/11/22, documented the following: The facility will strive to protect the resident's privacy regarding his or her written and telephone communications. Review of the facility's policy titled, Telephones, Resident Use Of, dated 04/11/22, documented the following: Designated telephones are available to residents to make and receive private telephone calls. The telephones at the nursing stations should ordinarily be reserved for staff use, unless no other alternative is available. Residents should use telephones at the nursing stations for as brief a period as possible. Telephones will be in areas that offer privacy and accommodate the hearing impaired and wheelchair bound residents. Review of the record showed that Resident #12 was re-admitted to the facility on [DATE] with diagnoses which included: Cerebral Infarction, Legal Blindness, and Recurrent Depressive Disorders. Review of Section C of the Minimum Data Set, dated [DATE] documented that Resident #12 had a Brief Interview for Mental Status of 09, which indicated that she was moderately cognitively impaired. During an observation conducted on 04/18/22 from approximately 12:30 - 1:00 PM, Resident #12 asked staff to make a phone call and was brought to the nursing station in the [NAME] Unit where she discussed private matters (family dynamics and specific family issues) on the facility's telephone. When asked, Staff G, Certified Nursing Assistant, stated that Resident #12 had a phone in her room. She further stated that Resident #12 required assistance with the phone and that it was easier to provide her with assistance at the nursing station rather than in her room. In an interview conducted on 04/21/22 at 7:38 AM, the Administrator stated that residents had telephones in their rooms that could be used to make private phone calls. Two surveyors informed the Administrator of the findings, and she acknowledged the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide necessary care and services to ensure that 1 (Resident #192) of 12 sampled residents ability to eat did not diminish. The findings included: During the observation of the lunch meal on 04/18/22 at 12:30 PM, the [NAME] Unit, it was noted that the lunch meal was placed on the over-bed tray table in front of Resident #192, however the resident was not eating. Interview with Resident #192 at the time of the observation noted the resident to be very alert and orientated and stated that she is blind and requires extensive to total assist with meals. The resident further stated that she tells aides when delivering the meal that she needs help eating, but they never return. The surveyor inquired if she complained to Administration and stated I have been here 3 weeks without assistance and I am used to eating the foods cold. Resident #192 stated that she has total blindness in the left eye and blurred vision in the right eye. She further stated that she wants to receive therapy to be able to use eating skills for independent eating. An additional observation of Resident #192, conducted of the breakfast meal on 04/19/22 noted that the food transportation cart on the [NAME] Unit at 7:50 AM. Further observation noted that the breakfast food tray that was served on a disposable Styrofoam plate until 55 minutes latter at 8:50 AM. The resident requested the aide to set her up in a chair to assist eating independently. She was transferred and able to eat the meal which consisted of only cereal, and toast. It was also observed that the the son of Resident #192 was in the room during the 04/19/22 observation and confirmed that the resident is not receiving the assistance with meals that is required. A review of the clinical record of Resident #192 noted a date of admission to the facility on 4/4/22. The resident's diagnoses included, Acute Cholecystitis, ASHD (Arteriosclerotic Heart Disease), Laparoscopic Surgery, and CHF (Congestive Heart Failure). Review of Physician Orders included: No Added Salt Diet (4/4/22) Liquid Protein 30 ml BID (Twice per day) (4/10/22) Weekly Weights (4/4/22) The resident's weight history documented: 04/14/22 = 150 pounds 04/4/22 = 159.5 pounds (9.5 pound weight loss in 10 days) The Minimum Data Set (MDS) dated [DATE], documented the following: Section B: Vision- Severely Impaired Section C: BIMS (Brief Interview of Mental Status) score = 13, indicating intact cognition Section G: Supervision With Eating Review of Physician's Progress Notes revealed the following: 04/18/22 - Resident is legally blind 04/14/22 - Resident is Legally Blind 04/12/22 - Extensive Assist with eating and drinking 04/11/22 - Resident is Legally Blind 04/10/22 - Resident requires total assist for eating and drinking 04/08/22 - Resident requires total assist for eating and drinking 04/07/22 - Resident is Legally Blind 04/07/22 - Resident requires extensive assist with eating and drinking A Nutrition assessment dated [DATE], documented that the resident has a fair meal intake of 50% and requires supervision with meals. Further review revealed there was no documentation indicating that the resident is Legally Blind and requires extensive to total assist with meals. Care Plan review noted that the the resident has a nutrition problem relating to Cholecystitis, however there are no interventions that includes the resident is legally blind and requires extensive to total assist with meals and fluids. The issues were discussed by the surveyor and confirmed with the Director of Nursing and Administrator on 04/20/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a midline intravenous (IV) catheter was assessed for 1 of 1 sampled residents reviewed for IV catheters, Resident #104, as evidenced by no documentation Resident #104's midline IV catheter was being assessed or checked for patency since the insertion date. The findings included: Review of the facility policy titled Midline Dressing Changes states in part, 'Purpose: The purpose of this procedure is to prevent catheter-related infections associated with contaminated, loosened or soiled catheter site dressings. General Guidelines: Change midline dressing 24 hours after catheter insertion, every 5-7 days, or if it is wet, dirty, not intact, or compromised in any way.' Review of the facility policy titled Central Venous and Midline Catheter Flushing states in part, 'Purpose: The purpose of this procedure are to maintain patency of midline and central venous catheters. Flushing Protocol: Flush catheters at regular intervals to maintain patency.' On 04/18/22 at 10:00 AM, an initial observation was conducted of Resident #104 in her room in bed. Observed to her right upper arm was a midline IV catheter with the insertion site covered with a transparent dressing. Resident #104 was unable to verbalize the reason for having the IV access site. Review of the clinical record revealed Resident #104 was admitted to the facility on [DATE] with diagnoses to include, Cerebral Vascular Accident with Left Sided Paralysis, Diabetes and Congestive Heart Failure. Further review of the clinical record revealed a Nursing Progress Note dated 04/11/22 at 11:24 PM, documenting, 'Midline inserted to right upper arm, no complication noted to site, Normal Saline IV at 55 milliliters/hour initiated for dehydration.' Review of Physician Orders revealed an order dated 04/15/22 at 11:10 PM documenting, 'IV site check every shift.' Under Order Type is documented 'Other Treatment - (Treatment Administration Record (TAR).' Further review of the Physician Orders dated 04/15/22 documented 'IV Midline Catheter (Right Upper Extremity) Change catheter site dressing every week Thursday and PRN (as needed) with transparent dressing every night shift.' Review of the April 2022 TAR revealed no documentation of an order for the IV site checks every shift or IV catheter dressing changes to be done every week. Further review of the TAR revealed no evidence of documentation Resident #104's IV midline site was being assessed or flushed to ensure continued patency and no evidence of any dressing changes since the insertion date of 04/11/22. Review of the Nursing Progress Notes from 04/11/22 through 04/21/22, revealed no documentation of any assessment or flushing of the IV midline or any documentation of any dressing changes conducted. On 04/21/22 at 11:35 AM, Resident #104's right upper arm IV midline site was observed. Upon closer observation of the transparent dressing it was noted there was no date on the dressing of when the IV catheter was inserted or if the dressing had been changed since insertion on 04/11/22. Review of Resident #104's Care Plans revealed no Care Plan addressing the resident was experiencing dehydration which required the insertion of an IV midline catheter and the administration of IV fluids. Further, there was no Care Plan addressing the need to assess the IV midline catheter for any signs of infection; the need to flush the IV midline to ensure continued patency; or change the IV midline catheter dressing weekly as ordered by the Physician. On 04/21/22 at 12:20 PM, an interview was conducted with Licensed Practical Nurse (LPN) Staff F, caring for Resident #104, and an inquiry was made how often they assess an IV midline to which she stated every day then stated every shift. An inquiry was made how often they change the dressing to which she stated weekly. An inquiry was made where they document their assessments and dressing changes to which she stated on the TAR. A request was made to look at Resident #104's TARs and show where she documented her assessment and dressing changes of the IV midline site. LPN Staff F checked the TAR and could not locate a place to document an assessment every shift or weekly dressing change since the insertion on 04/11/22. LPN Staff F then checked the Physician Orders revealing an order dated 04/15/22 to check the IV midline site every shift with dressing changes every week on Thursdays. LPN Staff F then went back to the TARs revealing the orders were not there to which she stated 'I guess it did not make it to the TAR.' A further inquiry was made if she has assessed the IV midline site or changed the dressing to which she had no comment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure splint devices were applied for 1 of 1 sampled residents reviewed for Position/Mobility, Resident #104, as evidenced by failing to apply a left hand splint, left elbow splint and bilateral lower extremity boots for Resident #104 to prevent further contractures. The findings included: Review of the facility policy for Restorative Nursing Services states in part, 'Residents will receive restorative nursing care as needed to help promote optimal safety and independence Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. physical, occupational or speech therapist). Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care.' On 04/18/22 at 10:00 AM, 12:20 PM and 2:40 PM, Resident #104 was observed in her room in bed in a hospital gown. Resident #104's left hand was observed to be very contracted in a clenched position. There was no splint in place. On 04/19/22 at 9:20 AM, 12:30 PM and 2:30 PM, Resident #104 was observed in her room in bed in a hospital gown. Resident #104's left hand was observed to be very contracted in a clenched position. There was no splint in place. On 04/20/22 at 10:12 AM, Resident #104 was observed in her room in bed in a hospital gown. Resident #104's left hand was observed to be very contracted in a clenched position. There was no splint in place. On 04/20/22 at 12:55 PM, Resident #104 was observed in her room in bed in a pink night gown. Certified Nursing Assistant (CNA) Staff L was at the resident's bedside assisting with feeding the resident her lunch meal. Resident #104 was observed with no splints on her left hand. Review of the clinical record revealed Resident #104 was admitted to the facility on [DATE] with diagnoses to include Cerebral Vascular Accident with Left Sided Paralysis, Diabetes and Congestive Heart Failure. Further review of the clinical record revealed Resident #104 had a hospital admission on [DATE] and was readmitted to the facility on [DATE]. Review of a Care Plan date initiated 04/01/22 documented, ' Potential for alteration in comfort related to decreased mobility, spasticity, contractures - Desired outcome- Left Upper Extremity will be positioned with appropriate orthotic devices for hemiplegic/contracture management. Interventions - Left elbow orthosis splint as tolerated. Left wrist/hand splint as tolerated. Restorative Nursing Program for BUE PROM (bilateral upper extremity passive range of motion) in all planes and BUE orthotic contracture management as tolerated.' Review of the April 2022 Physician Orders revealed an order dated 04/15/22 for a left elbow orthosis splint as tolerated; left wrist/hand splint as tolerated; and bilateral lower extremity padded calf board foot rest support board when up in wheelchair at all times as tolerated. All orders documented to monitor for redness or skin breakdown. The Physician Orders did not provide a frequency or schedule for the number of hours the splints were to be worn daily. On 04/20/21 at 1:30 PM, an interview was conducted with Occupational Therapist (OT) Staff M who stated Resident #104 was picked up on their case load on 03/22/22 and discharged from their case load on 04/18/22 but the final discharge note had not been written yet. He stated the OT was for contracture management. He further stated the left hand splints should be on for 3-4 hours daily, off for 1 hour then put back on. At this time the Director of Rehabilitation arrived joining the conversation. She stated the resident will be transitioned to Restorative Nursing, but they have not done the paper work yet for the discharge. An inquiry was made what hand splints 'as tolerated' meant, and she then stated they have to take the splints off to make sure the skin is alright. An inquiry was made what the purpose of Resident #104's splints were and she stated for contracture management and prevention. The Director of Rehabilitation was advised the resident's splints had not been observed on the resident for the past 3 days and they had not been observed in the resident's room. The Director of Rehabilitation stated they must be in the room. A request was made for her to go up to room and show where the splints are located. On 04/20/22 at 1:45 PM, Resident #104's room was observed with the Director of Rehabilitation who found the 3 splints on the resident's wheelchair pushed up against the wall. A request was made for her to put the left wrist splint on. She obtained the wrist splint and began attempting to unclench the resident's fingers which were very stiff. The resident complained of pain when the Director of Rehabilitation was trying to pry open her fingers. Resident #104 then stated to the Director of Rehabilitation to try putting on the elbow splint first as it might be easier to get the wrist splint on. The Director of Rehabilitation applied the left elbow splint. She then attempted again to put on the left wrist splint, still unable to pry open the resident's fingers. At this time the resident told her to put lotion on her fingers to make them unclench. The Director of Rehabilitation did this and she was then able to get the left wrist splint on. An inquiry was made to Resident #104 who puts her splints on for her to which she stated 'Nobody'. The resident then asked the Director of Rehabilitation to apply her boot splints. The Director of Rehabilitation pulled up the covers from the resident's legs to reveal both feet had foot drop. The Director of Rehabilitation applied the boots. During the application of the 3 splints the resident was compliant and did not refuse to have them applied. An inquiry was made to the Director of Rehabilitation for the reason for the boot splints to which she stated to prevent sores, prevent internal rotation and to prevent ankle contractures. An inquiry was made to Resident #104 if she was uncomfortable with the splints on to which she stated she was good. The resident looked very content. On 04/20/22 at 3:00 PM, Resident #104 was observed in her room in bed. All 3 splints remained in place. In an interview conducted with Resident #104, she expressed she did not mind wearing the splints. On 04/21/22 at 11:35 AM, Resident #104 was observed in her room in bed. The left wrist and elbow splints were in place and she was wearing the bilateral boots. Resident #104 stated she was pleased the splints were on and further stated I have the boots on too. She stated the therapist put the splints on and the aide put the boots on. On 04/21/22 at 1138 AM, an interview was conducted with CNA Staff L who had Resident #104 on her daily assignment. An inquiry was made who is responsible for applying the resident's splints to which she stated it is restorative nursing that puts on the splints, then quickly recanted stating it is all our jobs to put on splints. On 04/21/22 at 12:30 PM, an interview was conducted with Restorative CNA Staff G and an inquiry was made about Resident #104 and if she was on her restorative nursing list. CNA Staff G stated Resident #104 is on restorative for the lower extremities as she is on case load with OT for the upper body. CNA Staff G confirmed prior to the resident's hospitalization in March, the 2 left arm splints were applied daily for 2-3 hours and the boots were applied. CNA Staff G stated she did the boots today and the OT did the splints. CNA Staff G confirmed the resident had been using the splints regularly prior to her hospitalization but could not state if the left hand splints have been applied since her return from the hospital. Review of an Interdisciplinary Team Referral to Therapy dated 04/20/22 for Occupational Therapy documented - Patient is currently on OT skilled services which is assessing LUE elbow and wrist hand splint as well as determining wearing tolerance in order to establish appropriate schedule and caregivers training. This additional OT referral was initiated after the discussion and observations conducted with the Director of Rehabilitation on 04/20/22 at 1:45 PM. On 04/21/22 at 12:35 PM, an interview was conducted with the Director of Rehabilitation who stated they put Resident #104 back on the OT case load to determine a schedule for the splints as a schedule had not been determined. The Director of Rehabilitation confirmed prior to the resident's hospital stay in March, she was wearing the splints for 3-4 hours a day. The Director of Rehabilitation also confirmed post the hospital stay, the splints have not been applied regularly, possibly due to a lack of a specified schedule so they will work with the resident now to determine the length of time the resident can tolerate wearing the splints.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to address significant weight loss in a timely manner for 3 of 12 sampled residents reviewed for nutrition (Resident #12, Resident #25 and Resident #125). The findings included: Review of the facility's policy titled, Weight Assessment and Intervention, dated 04/11/22, documented the following: Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If they weight is verified, nursing will immediately notify the dietitian in writing. The dietitian will respond within 24 hours of receipt of written notification. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month - 5% weight loss is significant, greater than 5% is severe; 3 months - 7.5% weight loss is significant, greater than 7.5% is severe; 6 months - 10% weight loss is significant, greater than 10% is severe. 1) Review of the record documented that Resident #12 was re-admitted to the facility on [DATE] with diagnoses which included: Cerebral Infarction, Type 2 Diabetes Mellitus, Mild Protein-Calorie Malnutrition, Atherosclerotic Heart Disease, and Hyperlipidemia. Review of Section C of the Minimum Data Set (MDS) dated [DATE] documented that Resident #12 had a Brief Interview for Mental Status (BIMS) score of 09, which indicated that she was moderately cognitively impaired. Review of the Care Plan dated 02/26/22 documented that Resident #12 had nutritional problems with significant weight loss. Interventions were to assess weights and food intake as needed/indicated and for the Registered Dietitian (RD) to evaluate and make diet change recommendations as needed. Review of the weights documented that Resident #12 weighed 115 pounds on 03/22/22 and 109 pounds on 04/02/22. This showed that Resident #12 experienced a 5.2% significant weight loss within a 2 week timeframe. Review of all Dietary Progress Notes in PointClickCare (electronic charting system) showed that there were no progress notes addressing the 5.2% weight loss. Review of all Nutrition Assessments in PointClickCare showed that there were no assessments addressing the 5.2% weight loss. In an interview conducted on 04/20/22 at 8:06 AM, Staff B, Dietetic Technician, she stated that she was responsible for conducting initial assessments, quarterly assessments, annual assessments, and significant change progress notes for residents that were not at high nutritional risk. She further stated that the RD was responsible for conducting assessments for residents at high nutritional risk. According to her, residents at high nutritional risk were those with renal conditions, tube feeding, wounds, and significant changes in weight. Staff B stated that all assessments and notes were documented in PointClickCare. She further stated that residents were weighed upon admission, weekly for 4 weeks, and then monthly thereafter. When asked about re-weighs, she stated that if a resident experienced a weight loss greater than 3-5 pounds, she would ask for a re-weigh. She further stated that she would expect to obtain the re-weigh within 24 hours. According to her, weights were documented in PointClickCare. Staff B stated that a significant weight change would be 5% within 30 days or 10% in 90 days. She further stated that if a resident experienced a significant change in weight, she would follow up with them immediately. When asked about Resident #12, Staff B acknowledged that there were no assessments/progress notes addressing the 5.2% significant weight loss. When asked if an assessment addressing the weight loss should have been conducted, Staff B stated, Yes, there should have been. Staff B acknowledged that Resident #12's significant weight loss had been overlooked. 2) Review of the record documented that Resident #25 was admitted to the facility on [DATE] with diagnoses which included: Protein-Calorie Malnutrition, Cerebral Infarction, and Dementia. Review of Section C of the MDS dated [DATE] documented that Resident #25 had a BIMS score of 03, which indicated that she was severely cognitively impaired. Review of the Care Plan dated 02/18/22 documented that Resident #25 had potential nutritional problems with weight loss. Interventions were for the RD to evaluate and make diet change recommendations as needed. Review of the weights documented that Resident #25 weighed 117 pounds on 09/01/21 and 108 pounds on 10/15/21. This showed that Resident #25 experienced a 7.6% severe weight loss within a 1 month timeframe. Review of the Dietary Progress Note dated 11/02/21 documented that Resident #25 had a current weight of 108 pounds, which was a 7.5% change in weight. This showed that Resident #25's severe weight loss was not assessed until 18 days after it was identified. In an interview conducted on 04/20/22 at 8:06 AM, Staff B confirmed that Resident #25 experienced a 7.6% severe weight loss between 09/01/21 - 10/15/21. Staff B further confirmed that the severe weight loss was not assessed until 11/02/21, which was 18 days after the weight loss was identified. Staff B acknowledged that the severe weight loss was not assessed in a timely manner and that an assessment should have been completed sooner. 3) On 04/19/22 at 11:19 AM, an interview was conducted with Resident # 125. Resident #125 was in bed with her breakfast tray on her overbed table with the breakfast dishes on it. Observation of the breakfast tray revealed she ate 90% of her breakfast. This surveyor asked the resident how breakfast was and she replied that she has been having a bad taste in her mouth which makes food taste metallic so she doesn't usually eat breakfast. She stated that she thinks she lost weight because of this. She was asked if she had seen a dietician and she replied that she had not seen a dietician recently. Resident #125 was initially admitted to the facility on [DATE] with medical diagnoses of cerebral palsy, cerebral infarction, and type 2 diabetes. A Medicare 5 day Minimum Data Set (MDS) assessment was done with an assessment reference date of 03/23/22 which indicated in Section C that the resident has a Brief Interview of Mental Status (BIMS) of 14 indicating she is cognitively intact. A review of the resident's diet order revealed her diet as low concentrated sweets (LCS) and no added salt (NAS), regular texture, thin consistency. There were no supplements ordered. A review of the Resident #125's weights for 2022 revealed on 01/07/22 she weighed 189.5 pounds, on 02/04/22 she weighed 185 pounds, on 03/04/22 she weighed 176 pounds and on 04/12/22 she weighed 152.4 pounds. This was a 14% weight loss in 1 month and a 20% weight loss in 3 months. On 04/19/22 at 1:06 PM, an interview was conducted with Staff B, a Diet Tech. Staff B stated that at this time there is no Dietician in the facility and they have a remote Dietician. The previous Dietician abruptly left a few days ago. Staff B continued to state that she is doing assessments and any high risk assessments will be done by the Dietician. Staff B was asked who notifies her of a resident's weight loss or gain? She stated the Dietician will tell her. She was asked if a resident were weighed on 04/12/22 would you be aware of her weight yet. She stated that the weight list is given to the Director of Nurses (DON) who gives it to the restorative aide and the DON puts the weights in the computer. They run a weight report which was done by the remote Dietician. This surveyor asked for the weight report at 1:15 PM. At 3:05 PM she returned without a weight report for April and stated that she was not aware of the resident's weight loss in April. An interview was then conducted with the acting DON on 04/19/22 at 3:14 PM, who stated the nurses put the weights in the computer and should notify the Dietician if they see the weight is less than the previous month. The dietician will determine who to weigh monthly and weekly. The DON stated that she should have seen the weight loss by now for Resident #125. The surveyor asked for Resident #125 to be weighed the following morning. On 04/20/22 at 9:44 AM the resident was weighed by Staff C, a Certified Nurses Aide. The re-weigh was 154.8 pounds, a 2.4 pound gain since 04/12/22. Staff C stated she is given a list of residents to be weighed and gives the weights to the nurse because there is no Dietician now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the medication error rate was 7 percent. 2 medication errors were identified while observing a total of 26 opportunities, affecting Resident #26. The findings included: Review of the facility's policy titled Administering Medications published 04/11/2022 documented Medications are administered in a safe and timely manner and as prescribed. Review of Resident #26's clinical record documented an initial admission to the facility on [DATE] with diagnoses including Dementia without behavioral disturbances, Type 2 Diabetes Mellitus, and Polyosteoarthritis. A quarterly Minimum Data Set (MDS) assessment was done with an assessment reference date of 02/07/22. Section C of the assessment included a Brief Interview for Mental Status of 9, which indicated the resident has moderate cognitive impairment. Review of Resident #26's physician orders for April 2022 documented Artificial Tears Solution 5-6 milligram (mg)/milliliter Instill 1 drop in both eyes three times a day for dry eyes. Additionally, Resident #26's physician orders for April 2022 documented Famotidine Tablet 20 mg give 1 tablet by mouth one time a day for acid indigestion. On 04/20/22 at 9:31 AM, observation of medication administration for Resident #26 was performed of Staff A, a Licensed Practical Nurse. Staff A pulled out a bottle of Famotidine 10 mg from the medication cart and proceeded to administer 1 tablet to Resident #26. Staff A also administered Artificial tears 2 drops to each eye of the resident during the same medication observation. An interview was conducted with Staff A after the medication observation. Staff A stated that he did not realize that he gave Famotidine 10 mg instead of 20 mg to Resident #26 and he will give her an additional 10 mg now. On 04/21/22 at 9:30 AM, an interview was conducted with the Director of Nurses regarding the medication observation on 04/20/22 for Resident #26. She acknowledged that the resident should have been given Artificial Tears 1 drop to each eye and Famotidine 20 mg per physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to secure and obtain an order for self-administration of prescription oral rinse for 1 of 1 sampled residents reviewed for self-administration of medications (Resident #84) and failed to secure medications in 2 of 2 nursing stations on the second floor. The findings included: Review of the facility's policy titled, Self-Administration of Medications, dated 04/11/22, documented the following: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. 1) Review of the record documented that Resident #84 was re-admitted to the facility on [DATE] with diagnoses which included: Anxiety Disorder, Bipolar Disorder, and Dysphagia. Review of Section C of the Minimum Data Set, dated [DATE] documented that Resident #84 had a Brief Interview for Mental Status score of 15, which indicated that she was cognitively intact. During an observation conducted on 04/18/22 at 12:56 PM, an opened prescription bottle of Chlorhexidine Gluconate 0.12% (oral rinse) was on top of Resident #84's bedside dresser. When asked about the prescription oral rinse, Resident #84 stated, This is a mouthwash for allergies. I do this by myself. A review of the Physician's Orders for Resident #84 was conducted on 04/19/22 at 1:43 PM, which showed that Resident #84 did not have a physician's order for Chlorhexidine Gluconate 0.12%. Review of the Care Plan dated 04/07/22 showed that there was no documentation to show that Resident #84 was able to self-administer medications. In an interview conducted on 04/19/22 at 2:28 PM, Staff H, Licensed Practical Nurse, stated, If a resident wanted to self-administer medications, the doctor would have to approve it and there would be an order for the resident to self-administer medications. When asked about Resident #84, Staff H stated that she did not know if Resident #84 had orders to self-administer medications. Staff H then looked through the electronic chart and stated that she needed to speak with her supervisor because she did not see any orders for Resident #84 to self-administer medications. Staff H returned from speaking with her supervisor and confirmed that Resident #84 did not have any orders to self-administer medications. Staff H then accompanied the surveyor to Resident #84's room where Resident #84 provided Staff H with the opened prescription bottle of Chlorhexidine Gluconate 0.12%. Resident #84 stated that she brought the prescription bottle with her upon her admission to the facility. Staff H stated that the prescription bottle should have been documented upon admission. 2) During a tour of the [NAME] Unit and Windsor Unit on 04/20/22 at 9:30 AM, it was noted that prescription medications and biological were being stored unsecured in utility drawers at the nurses station as per the following: (a) [NAME] Unit: Restasis (15 vials) with pharmacy label documented filled on 08/31/21. The resident currently residents at the facility, however no current physician order for administration of Retasis. (b) Windsor Unit: 8 vials = 0.9% Sodium Chloride Injection - 1 vial cap opened . Photographic Evidence Obtained

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and policy review; the facility failed to provide a resident with snacks to consume at dialysis for 1 of 1 sampled residents (Resident #20) reviewed for dialysis. The findings included: The facility's policy titled Dialysis created on 2/2019 states Dietician will be made aware to provide meals/snacks as needed. Resident #20 was admitted to the facility on [DATE] with recent readmission post hospitalization on 04/01/22. Medical diagnoses include end stage renal disease, anemia, type 2 diabetes and dependence on renal dialysis. He is on a Renal diet, regular texture, thin liquids consistency. The Medicare 5 day Minimum Data Set assessment with an assessment reference date 04/04/22 reveals a Brief Interview of Mental Status (BIMS) score of 7, indicative the resident has severe cognitive impairment. The chart review revealed the resident goes to the Dialysis Center for dialysis on Tuesday, Thursday, and Saturday approximately 5:00 AM with a chair time of 5:40 AM and he returns to the facility between 10:30-10:45 AM. An interview was conducted on 04/20/22 at 10:55 AM with Staff F, a Licensed Practical Nurse, who works with the resident on the day shift. She stated he has breakfast when he returns from dialysis. The facility sends food with him to dialysis. He takes medication before he goes to dialysis. An interview was then conducted with Resident #20 on 04/20/22 at 11:00 AM who stated that he eats great but gets hungry at dialysis because he does not have any food to eat at dialysis. An interview was then conducted with Staff B, a Diet Tech. Staff B stated she was not sure what the facility was giving to Resident #20 to eat at dialysis so we should find out from the kitchen. Staff B and this surveyor went to the kitchen and interviewed Staff E, a cook, on 04/20/22 at 11:14 AM who stated the dialysis residents get a breakfast tray sent to them in the morning and if they don't want to eat it then they can eat it when they come back because it will be in nursing. It was further stated that Dialysis residents get a sandwich, apple sauce, graham crackers and a ginger ale to take with them. The person who accepts the bag from the kitchen will sign for it. On 04/20/22 at 11:31 AM, an interview was conducted with Staff D, a Corporate Food Service Director. Staff D stated they don't provide the food bag for dialysis residents anymore. They provide a breakfast tray before they go and provide food when they return. He added that since COVID, the facility stopped providing food because the Dialysis Center would not allow it, but he will check with the Administrator regarding what they are allowing now. Staff D never provided additional information to this surveyor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 2 sampled residents receiving a Puree Diet, Resident #64, did not have access to food items not recommended for residents on a Puree Diet. The findings included: Review of the facility policy for Therapeutic Diets states in part, 'Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences A therapeutic diet is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.' Review of the facility definition of Puree Diet states 'The puree diet is for residents who have difficulty chewing and/or swallowing. Foods allowed on this plan must be pureed, pudding like food that is in the form of an easy to swallow bolus with moist, pudding-like consistency without particles. Foods to Avoid include under the category Solid Fats and Added Sugars - any food that is stringy, chunky and cannot be completely pureed.' On 04/18/22 at 10:10 AM, an initial observation and interview was conducted with Resident #64 in her room. Observed next to her bed was a feeding pump and an inquiry made if she received tube feedings to which she stated she gets the tube feedings at night. A further inquiry was made if she is allowed to eat anything by mouth to which she stated she can have a puree diet but she does not like the puree texture. Observed on her overbed table was a container of thickened lemon water and cranberry juice. Review of the clinical record revealed Resident #64 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction, right sided paralysis, dysphagia (difficulty swallowing) and diabetes. Further review of the clinical record revealed a Physician Order dated 03/23/22 for a low concentrated sweets, no added salt, puree texture, nectar thickened liquids consistency. Further, Resident #64 had feeding tube feeds to be infused via a feeding pump from 7:00 PM to 7:00 AM for a total of 12 hours daily. Review of a Care Plan last reviewed 03/16/22 documented 'Resident has swallowing problem related to dysphagia. On enteral feedings as the primary route of nutrition and hydration. She is on oral diet with pureed consistency and thickened liquids. Intervention to include: All staff to be informed of resident's special dietary and safety needs. Diet to be followed as prescribed.' On 04/18/22 at 12:55 PM, Resident #64 was observed with her lunch meal consisting of puree chicken and potatoes, chicken gumbo soup, ice cream, yogurt, thickened water and juice. Resident #64 reiterated she does not like the consistency of the puree diet. On 04/20/22 at 10:12 AM, Resident #64 was observed in her room, in bed with numerous red jelly beans sitting loose on her overbed table in front of her, in addition to 4 wrapped hard candies. An inquiry was made to her if she is allowed to have these candies while being on a puree diet to which she stated she did not know. Also observed on the overbed table were 2 juices left over from her breakfast meal. On 04/20/22 at 12:45 PM, Resident #64 was observed in her room in bed with the jelly beans and hard candies still on the overbed table. An inquiry was made to the resident where she obtained these candies to which she stated a family member from out of state sent them to her. Resident #64 was observed eating her puree soup for lunch, with the bowl sitting right next to the jelly beans indicating her lunch meal was delivered to her with the jelly beans on the table, with no staff member identifying jelly beans are not an appropriate food for a resident on a puree diet. On 04/20/22 at 12:50 PM, an interview was conducted with Licensed Practical Nurse (LPN), Staff F and an inquiry was made about Resident #64's diet. Not knowing off the top her her head she referred to the electronic record and stated LCS (low concentrated sweets) NAS (no added salt) puree solids, nectar thick diet. Staff F was advised Resident #64 has jelly beans and hard candy on her overbed table. An inquiry was made if that was an appropriate food for a resident on a puree diet, to which she stated no, she will take them away. Staff F proceeded to go to Resident #64's room to deal with the issue. On 04/20/22 at 1:00 PM, an interview was conducted with Speech Therapist (ST) Staff K and an inquiry made about Resident #64's swallowing ability, to which she stated the resident has had many swallow studies and from the results it has been determined there is no potential for improvement; she has structural deficits and vocal paralysis and is not able to maintain a patent airway. Staff K further stated the resident is a high risk for aspiration, as her airway is compromised. An inquiry was made about the resident's ability to chew and swallow a jelly bean to which Staff K stated a jelly bean is hard outside and soft inside, it could stick to the roof of the mouth and the resident may not be able to remove it depending on her tongue action. Staff K confirmed eating jelly beans would not be a safe practice for Resident #64 and could lead to aspirating or choking on the jelly bean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide drinking cups with cartons of milk for the breakfast meal on 04/19/22, for 32 residents on the [NAME] Unit. The findings included: Review of the approved breakfast menu for 04/19/22 documented that 8 ounces of milk was to be served. Review of the Production Count for the breakfast meal dated 04/19/22 documented that 98 residents received whole milk, 24 residents received skim milk, 4 residents received 2% milk, and 3 residents received lactaid milk. During an observation of the breakfast meal on 04/19/22 at 8:56 AM, it was noted that 32 residents on the [NAME] Unit who received a carton of milk with their meal did not receive a drinking cup. In an interview conducted on 04/20/22 at 7:43 AM, the Dietary Supervisor stated that most residents receive milk cartons with their breakfast meals. When asked why the milk cartons were not served with drinking cups, the Dietary Supervisor stated that most of the drinking cups were used to serve juice and that there were not enough drinking cups to serve with the milk cartons. He then acknowledged that the milk cartons should have been served with a drinking cup to promote residents' dignity. In an interview conducted on 04/20/22 at 8:04 AM, the Administrator stated that the kitchen did have drinking cups and that they were not provided with the milk cartons for the breakfast meal served to the residents on 04/19/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior that included the Central Supply Rooms (2), [NAME] Unit, [NAME] Unit , and Windsor Unit. The findings included: 1) During observation conducted on 04/18/22 at 2 PM of the central Supply Rooms (2) , accompanied by the Central Supply Supervisor, the following concerns were noted: room [ROOM NUMBER]: (a) The air-conditioning vent located on the ceiling in the middle of the room was noted to have the entire exterior and surrounding area covered in a black mold type substance. It was discussed with the supervisor that the vent was blowing the suspected mold onto nursing supplies located in the room. The supervisor stated she was aware of the condition of the vent but had not reported it to maintenance. (b) The entire floor area of the supply room was covered with dirt, dust, trash, and areas of black mold type matter. The supervisor stated that she has been in charge for 3 months and the floor area has never be cleaned. (c) The middle of the room contained a large wood pallet (8 X 3) that was covered with a rug. Further observation noted that the surface of the rug was heavily soiled with dirt, dust, and debris. Cases of supplies stored directly on the soiled rug included; Bathing Scrubs (4), Blue Masks (1), Incontinent Briefs (4), and Biotene (3). The supervisor stated that the rug has been in the room since her starting date and has never been cleaned. (d) Observation noted that 13 cases of supplies were stored directly on the soiled floor. The cases of supplies included: Glucose testing Strips (5), TB Syringes (2) , Nebulizer machines (2) , and Covid Immunization Syringes (4). The supervisor stated that many of the cases of supplies were stored directly on the soiled floor. (e) Numerous ceiling tiles (4) located in numerous areas of the room were noted to be soiled, stained, and molded. The supervisor stated that she never reported the tiles for replacement. Photographic Evidence Obtained. room [ROOM NUMBER]: (f) The room was noted to house nutritional supplements and gastric tube feedings. Observation noted that there were 6 soiled oxygen concentrators stored in the room and 4 soiled gastric feeding pumps. (g) The door to the bathroom located within the storage room was noted to open and a urine smell was noted. (h) The supply room also had an office area with the door open. The office contained numerous bags of open foods and drinks. The floor area was heavily soiled and the office was unkept. 2) First Floor - [NAME] Unit room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair, sharp edges to bottom of bathroom entry door. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. peeling ceiling paint in main room. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Bathroom door damaged and in disrepair. room [ROOM NUMBER] - Numerous stains to hallway carpet in front of room entry door. room [ROOM NUMBER] - Numerous stains to hallway carpet in front of room entry door. 3) Second Floor - [NAME] Unit: Hallway #1 (Rooms 201-214): All room entry doors and doorframes noted to have numerous and large areas of wood damage and peeling paint. The walls, handrails and baseboards of the main hallway were also noted to have areas of severe wood damage and areas of peeling paint. room [ROOM NUMBER] - Missing areas of room baseboards, large hole in wall (W-bed), room wall damage, areas of peeling room wall paper, and the arm rest of the over the toilet seat was broken and a large area of the arm was missing. room [ROOM NUMBER] - Missing areas of room base boards, and large hole in room wall. room [ROOM NUMBER] - Bathroom sink noted to have cracks throughout the entire base surface. room [ROOM NUMBER] - Poor TV reception. Resident requesting for repair. room [ROOM NUMBER] - Large scuff marks to walls located under room window, and missing areas of base boards to room. 4) Hallway #2 (Rooms 215-228): All room entry doors and doorframes noted to have numerous and large areas of wood damage and peeling paint. The walls, handrails and baseboards of the main hallway were also noted to have areas of severe wood damage and areas of peeling paint. room [ROOM NUMBER] - Exterior of overbed table was peeling (W-bed), and peeling wood exterior to foot board of bed (A-bed). room [ROOM NUMBER] - Room walls noted to large scuff marks, and foot board bed exteriors were in disrepair, and overbed tables exteriors were worn (D & W Beds). room [ROOM NUMBER] - Chipped exterior to overbed tables. room [ROOM NUMBER] - Peeling room wallpaper near window, and missing over bed light pull cord (W-bed). room [ROOM NUMBER] - Chipped exterior of bed. 5) Second Floor - Windsor Unit: Hallway #1 (Rooms #229-2241): All room entry doors and doorframes noted to have numerous and large areas of wood damage and peeling paint. The walls, handrails and baseboards of the main hallway were also noted to have areas of severe wood damage and areas of peeling paint. Hallway #2: (Rooms #243-249): All room entry doors and doorframes noted to have numerous and large areas of wood damage and peeling paint. The walls, handrails and baseboards of the main hallway were also noted to have areas of severe wood damage and areas of peeling paint. Following the environment tours all findings were again confirmed with the facility Directors. The Directors also reviewed the findings with the Administrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility's environment on the [NAME] Unit (first floor) which houses 40 residents, was not free of accident hazards. The findings included: During there environment tour of the [NAME] Unit located on the first floor on 04/20/22 at 2 PM, conducted with the Director of Maintenance and Director of Housekeeping, the following were noted: 1) Noted large areas (5) of cut up rolled up floor carpeting around North side of nurses station. Further observation noted the rolled carpeting to be protruded out and was a tripping hazard to resident and staff. The Director agreed with the surveyor's observation. 2) Observation of Community Shower #1 noted new floor tiles installed. Further observation noted that 4 floor tiles around the floor drain were raised and protruding sharp edges. It was discussed with the Mangers that the tiles were a hazard to residents feet and staff when utilizing the shower stall. The Managers agreed with the surveyors observation. 3) Observation of Community shower #1 noted that a new emergency call cord had been installed into the shower stall, however the emergency pull cord was still wrapped in tape and placed on a flat surface approximately 4 feet off the floor surface. It was discussed with the Directors that if the was an emergency in the shower stall the call bell could not be reached to activate the emergency call system. 4) Observation of the North Hallway noted a large hole (4 X 4 ) to the wall outside of room [ROOM NUMBER]. Further observation noted that electrical wiring could be seen in the hole. Interview with the Director's at the time of the observation revealed that the electrical wiring was love and could easily result in hazard to residents. Following the observations it was revealed that the [NAME] Unit was be remodeled by outside contractors, however the contractors had not been in the facility at least 10 days. It was further discussed that the contractor staff did not properly secure the unit from potential accident/hazards prior to leaving. A review of the facility census for 04/20/22 noted that there were 40 residents residing on the [NAME] Unit. Photographic Evidence Obtained of Example #1, #2, #3, and #4.

Based on observation, interview, and record review, it was determined that the approved menu was not followed for 6 residents (including Resident #26) receiving physician ordered pureed diets and 8 residents (including Resident #141) receiving physician ordered Mechanically Altered Ground Diet. The findings included: During follow-up visits to the kitchen to observe the food tray line on 04/19/22, 04/20/22, and review of the approved facility menu, the following were noted: (a) Observation of the breakfast tray line on 04/19/22 at 7:30 AM noted that 2 Turkey Sausage Links were being served as a standard sized portion for Regular, No Added Salt, and Low Concentrated Sweets Diets. At the request of the surveyor, the standard portion of the Sausage Links were weighed utilizing the facility's portion scale. It was noted that 2 Sausage Links were weighed at 1 ounce. A review of the approved breakfast menu for 04/19/22 documented that 2 ounces of Sausage Links to be served, as a standard portion size. Interview conducted with the Kitchen Supervisor at the time of the observation noted to state that he was not aware that the sausage link portion being served was not following the approved menu. (b) Observation of the breakfast tray line on 04/20/22 at 7 AM noted that a #16 scoop (2 ounces) was being utilized as a standard portion of Pureed Eggs. A review of the approved breakfast menu for 04/20/22 documented that the standard for pureed eggs was a 3 ounce portion. Interview with the Kitchen Supervisor revealed the he was unaware of the menu portion size and unaware that an incorrect scoop was being utilized. (c) Observation of lunch tray line on 04/20/22 at 11:30 AM noted that a standard serving of a Hot Dog was 1 each. At the request of the surveyor a standard portion of a Hot Dog (1) was weighed utilizing the facility's portion scale and the portion was recorded at 2 ounces. A review of of the approved breakfast menu for the 04/20/22 documented that a 3 ounce standard portion to be served to Regular, No Added Salt, and Low Concentrated Sweet Diets. Interview conducted with the Kitchen Supervisor at the time of the observation noted that he was unaware of the portion issues. It was revealed during the interview that a 4 ounce Hot Dog should have been purchased to ensure that a 3 ounce cooked portion was served. The supervisor stated that a 3 ounce Hot Dog portion was being purchased. (d) Observation of the lunch tray on 04/20/22 at 11:30 AM noted that a 4 ounce portion of Regular Baked Beans was being served to Mechanically Altered Diets. A review of the approved menu for the lunch meal of 04/20/22 documented that a Mechanically Altered Ground Baked Beans be served to Mechanical Altered Ground Diets. Interview with the Kitchen Supervisor conducted at the time of the observation revealed that he was not aware that the Mechanically Altered Menu documented a Mechanically Altered portion of Baked beans and further stated that they were not prepared as per the menu. The facility's Diet Census Report for 04/19/22 documented that there were 6 residents with physician ordered pureed diet Including Resident #26) and 8 residents with physician ordered Mechanically Altered Ground Diet (including Resident #141).

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety that include, proper storage of foods to prevent contamination, maintenance of ceiling air-conditioning vents to prevent contamination, maintain floor cleanliness, proper cleaning of ice machine filters to prevent contamination, and ensure sanitation buckets contain required levels of chemical sanitizing agents. The findings include: 1) During the initial kitchen observation conducted on 04/18/22 at 9 AM, accompanied with the Kitchen Supervisor, the following were noted: (a) Observation of the walk-in kitchen noted that there was a large pan of raw chicken (30 pounds) in a large commercial mixing bowl ,that was located on the second shelf on a food storage rack. Further observation noted that there was a pan of individual juice portions (20) and individual yogurt portions (20). It was discussed with the supervisor that there was a potential that spillage from the raw chicken could contaminate the portions of juice and yogurts resulting in food borne illness. The surveyor requested that the juices and yogurt be discarded and all raw meats, etc be placed on the lower storage shelves at all times. (b) Observation of the walk-in refrigerator noted that the refrigeration fan covers were heavily soiled with dust and black mold like substance. Further observation noted that the ceiling area around the fan covers also had a layer of dust and mold like sustance. It was discussed with the supervisor that there was a potential for the dust and mold to reach and cover foods being stored within the unit. (c) Observation of the kitchen floor noted that the area in font of the two walk-in refrigerators had large areas of peeling paint. It was discussed with the supervisor that the pieces of peeling paints could be transferred around the kitchen area and possible become a source of food contamination. (d) Observation of the commercial ice machine noted that the 4 filters located on the front of the machine were dust/dirt laden. (e) A test of the chemical solution concentration of the 3 cleaning cloth buckets was requested by the surveyor and performed by the kitchen supervisor. The test revealed that 2 of the 3 buckets failed to have the minimum required level of Quaternary chemical, as per regulation. (f) Observation of food preparation equipment noted that 2 of 2 commercial skillets were covered with carbon and the inside Teflon coating was being rub off during repeated uses. 2) During a second tour of the kitchen conducted on 04/19/22 at 7 AM, accompanied with the Dietary Manager, it was noted that there was a commercial air-conditioning vent located directly over the steam table and clean dish storage area. Further observation noted that the entire area surface of the vent was full of condensation and mold like matter. It was noted that the condensation was dripping directly down onto the right side of the steam table, onto clean dishes, and staff working directly under the vent. The surveyor requested the facility's Administrator and Director of Maintenance to come to the kitchen and view the vent issues. It was discussed with the Administrator that there was potential for foods, clean dishes, and staff to become contaminated and possible result in food borne illness .