**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide eating assistance in a dignified manner for 2 of 2 sampled residents (Resident #103 and #276) observed for in-room dining, and failed to treat residents with dignity for 4 of 4 sampled residents observed by failing to provide a privacy pouch for an urinary bag (Resident #103); calling resident as a Feeder (Residents #82) failing to provide privacy during wound care (Resident #175); and failing to provide privacy to body parts and exposure resident (Resident #475). The findings included: Review of the facility policy provided by the Director of Nursing, untitled and undated documented, Dignity policy and procedure to ensure residents are treated with respect and individuality, promoting their self-esteem and well-being .respectful communication: address residents by their preferred name (not honey or sweetie .) .Maintaining privacy and confidentiality: ensure privacy during personal care activities .by using curtains or screens and minimizing unnecessary exposure . 1) Review of Resident #82's clinical record documented an admission to the facility on [DATE] with no readmissions. Resident #82's diagnoses included Vascular Dementia, Mild, Agitation and Anxiety Disorder. The resident's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) assessment was not conducted due to the resident is rarely/never understood. The assessment documented that the resident was dependent on the staff to eating. On 03/17/25 at 12:44 PM, during in-room dining observation at the Masada Unit, Staff R, Certified Nursing Assistant (CNA) and Staff M, Unit Manager, were asked for Resident # 82's lunch intake. Staff M stated she would ask the aide. Staff M and Staff R both stated the resident is a feeder. On 03/20/25 at 11:25 AM, an interview was conducted with Staff R, CNA who was apprised of calling Resident #82 a feeder on (03/17/25) Monday. Staff R stated No, I said they need assistance. On 03/20/25 at 11:35 AM, an interview was conducted with Staff M, Unit Manager (UM), who was apprised of calling Resident #82 a feeder. 2) Review of Resident #103's clinical record documented an initial admission to the facility on [DATE]. Resident 103's diagnoses included Ventricular Premature Depolarization, Gallbladder Calculus and Hypertension. Review of Resident #103's MDS Quarterly assessment dated 01/18/ documented a Brief Interview of Mental Status (BIMS) assessment was not conducted due to the resident is rarely/never understood. The assessment documented that the resident needed supervision/touching assistance during eating. On 03/18/25 at 8:42 AM, observation revealed Resident #103 in bed and Staff P, CNA repositioning and setting up the resident for breakfast. An interview was conducted with Staff P who stated the resident feeds himself. The surveyor attempted to interview the resident, who kept his eyes open and fixed looking at the surveyor and did not answer any questions asked. At 8:43 AM, observation revealed Staff P left the resident's room. On 03/18/25 at 9:06 AM, observation revealed Resident #103 sitting up in bed, asleep, eyes closed and his food tray across from him. Further observation revealed the food tray items were untouched. Furthermore, observation revealed Resident #103 did not have a staff cuing him to eat or assisting him to eat from 8:42 AM until 9:07 AM. On 03/18/25 at 9:07 AM, observation revealed Staff M, UM entered Resident #103's room, and asked if he finished eating. Staff M repositioned a chair and started feeding the resident who was observed eating his breakfast as he was fed by Staff M. On 03/19/25 at 9:22 AM, an interview was conducted with Staff M, UM, who stated that Resident #103 usually goes to the dining room and feeds himself and added that the aide probably did not know the resident. She further stated the aide should have come to the nurse and tell her that he was not eating. Staff M was apprised of the surveyor's concerns that the resident waited approximately 25 minutes to be fed. Staff M stated it is concerning. 3) Review of Resident #103's clinical record documented an initial admission to the facility on [DATE]. Resident's diagnoses included Ventricular Premature Depolarization, Cystostomy Status, Gallbladder Calculus and Hypertension. Review of Resident #103's MDS Quarterly assessment dated 01/18/ documented a Brief Interview of Mental Status (BIMS) assessment was not conducted due to the resident is rarely/never understood. The assessment documented that the resident had an indwelling catheter (foley). Review of Resident #103's care plan titled [resident's name] has a risk for injury/infection r/t (related to) presence of indwelling catheter secondary to a dx (diagnosis) of neurogenic bladder initiated on 10/11/24 with interventions to include Privacy bag/cover in place, initiated on 10/11/24. On 03/18/25 at 8:42 AM, observation revealed Resident #103 in bed and Staff P, CNA repositioning and setting up the resident for breakfast. Observation revealed a urinary drainage bag with no privacy pouch. An interview was conducted with Staff P who stated the resident had a foley catheter. The surveyor attempted to interview the resident who kept his eyes open and fixed looking at the surveyor and did not answer any questions asked. At 8:43 AM, observation revealed Staff P left the resident's room and did not place a privacy pouch on the resident's urinary bag to provide privacy. On 03/18/25 at 8:46 AM, observation revealed the Infection Preventionist and Staff M, UM, placing a cart with Personal Protective Equipment outside of Resident #103's room. An interview was conducted with Staff M and the Infection Preventionist who both stated the resident had a foley. On 03/19/25 at 9:22 AM, an interview was conducted with Staff M, UM who was apprised that Resident #103 did not have a privacy pouch to cover the urinary drainage bag that was observed on 03/18/25. 4) Review of Resident #175's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included End Stage Renal Disease and Anxiety Disorder. Review of Resident #175's MDS admission assessment in progress dated 03/13/25 documented a BIMS score of 13, indicating that the resident had no cognition impairment. Review of Resident #175's care plan titled [resident's name] has a pressure ulcer to sacrum initiated on 03/06/25 documented intervention to include .Administer medications and treatments as ordered by the MD (Medical Doctor). On 03/17/25 at 12:17 PM, observation revealed Resident #175's room door wide open, a treatment cart parked in front of the door, and the resident's privacy curtain halfway open (Photographic evidence). The surveyor knocked at the door and was allowed to enter the room. Staff I stated Staff J was doing the resident's wound care. The observation revealed Staff I, CNA and Staff J, Wound Care Nurse (WCN) next to the resident's bedside. The resident had his cover down and was exposing a foley tubing and his legs. Staff J stated she was finishing the resident's wound care. Observation then revealed Staff J and Staff I pull the cover sheet and blanket up. On 03/20/25 at 2:36 PM, during an interview, the Director of Nursing was apprised of the findings. 5) A chart review revealed that Resident #275 was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s and unspecific protein-calorie malnutrition. The admission MDS assessment dated [DATE] revealed Resident #275 has a Brief Interview of Mental Status score (BIMS) of 05, which is severely cognitively impaired. Section GG for eating showed Resident #275 needed partial to moderate assistance. In an observation conducted on 03/17/25 at 12:34 PM, Resident #275 ' s roommate received his lunch tray. At 12:46 PM, Resident #275 still awaited his lunch tray. At 12:53 PM, which was 19 minutes later, Staff F, a Certified Nursing Assistant, came with the lunch tray for Resident #275. Closer observation showed that Resident #275 ' s roommate was done with his lunch meal. In an interview conducted on 03/20/25 at 8:50 AM with Staff F, who stated all residents must be treated with dignity. The curtain and the door need to be closed when providing patient care and ensuring residents are not exposed. It is important not to call residents names or use the word feeders. Staff F further said during dining, you need to pass the meal trays one room at a time so that you do not have one resident eating while the other resident is not. 6) Record review for Resident #475 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with Hypoxia and Gastrostomy Status. The resident did not have a completed Minimum Data Set at time of review. On 03/17/25 at 11:10 AM an observation was made of Resident #475 lying on his side in bed with the bed covers off, his shorts unbuttoned and half off with a disposable brief partially exposed and a peg tube coming out from under his shirt and draped over the resident's side. On 03/17/25 at 12:45 PM and 3:05 PM to 3:40 PM, the observation revealed Resident #475 with the door to the room open and full view from the hallway. The resident was lying in bed with no bed linens covering him while wearing only an adult brief and a shirt with his back to the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to document notification of the resident or resident representative for change in condition for 2 of 2 sampled residents reviewed for a change in condition (Resident #488 and Resident #53). The findings included: 1) Record review for Resident #53 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Dementia and Major Depressive Disorder. He was discharged to the hospital on 2/27/25. Review of the Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15, indicating intact cognition. Review of the Nurses Notes for Resident #53 dated 02/27/25 documented: At approximately 9:10 AM a call was received from the doctor's office, due to the resident's vitals being unstable. Per physician, the resident was transferred to the hospital emergency room for further evaluation. Further review of the medical record for Resident #53 revealed no evidence of a Change in Condition Evaluation was completed, no documentation of notification of resident representative or emergency contact being notified, and no documentation of the resident leaving for a physician's visit and/or with whom. 2) Record review for Resident #488 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Ischemic Cardiomyopathy. Review of the Minimum Data Set assessment dated [DATE] documented in Section C a Brief Interview of Mental Status score of 15, indicating an intact cognition. Review of the Nurses Notes for Resident #488 dated 3/11/25 included in part, the following: Observed the resident in bed awake and alert, however a little sluggish. Life-Vest in place. Head of bed elevated. Vitals signs taken. Oxygen saturation fluctuates from 89-94%. ARNP made aware, order for non-rebreather at 15 L/min and to transfer out to [name of hospital] Via 911. Call placed to 911. Review of the Nurses Notes for Resident #488 dated 3/11/25 documented: At approximately 2:30 PM The resident was transferred to ER (Emergency Room) via 911. Review of the Change in Condition Evaluation for Resident #488 dated 03/11/25 documented in Section 3, Review and Notify Section C Name of family/resident representative notified: was left blank. Review of all documentation for Resident #488 on 03/11/25 revealed no evidence of any family present or notification. During an interview conducted on 03/19/25 at 4:20 PM with Staff G Licensed Practical Nurse Unit/ Manager who was asked about a change in condition, she stated when a resident has change in condition, they will notify the family or the representative at the time of the change of condition. When asked if she documents who was notified, she said yes the family or representative or emergency contact, whomever they speak to or leave a message for. When asked if a resident was out of the facility attending a medical appointment and the physician was sending the resident to hospital directly, would they notify the family or emergency contact, she stated they would notify the family, representative or emergency contact. When asked about Resident #488 she said the daughter was in the facility at the time the resident was having the change in condition. She acknowledged she did not document that the daughter was present and was aware of the change in condition. When asked about Resident #53, she stated the wife was with the resident and since it happened at the doctor's office and they were sending the resident to the hospital, she did not contact the wife and thought she would be aware of the situation. She also acknowledged she did not document the change in condition evaluation for Resident #53.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe, clean, comfortable and homelike environment for 9 of 64 rooms. The findings included: 1). On 03/17/25 at 11:01 AM, an observation of room [ROOM NUMBER] revealed the flooring and wall behind the resident's bed were stained and the baseboard was in disrepair. 2). On 03/17/25 at 11:15 AM, an interview was conducted with Resident #16 who stated her privacy curtains needed to be washed. Observation revealed the residents' privacy curtain was stained. Further observation revealed the flooring was stained and the baseboard behind the bed was in disrepair. 3). On 03/17/25 at 11:20 AM, an observation revealed the bathroom light of room [ROOM NUMBER] was dim and blinking. The baseboard behind the resident's bed was in disrepair. 4). On 03/18/25 at 8:35 AM, an observation and interview with Resident #27 revealed her privacy curtain did not cover the window area. The resident further added that the curtain had been like that since she was moved to the room (Photographic evidence obtained). 5). On 03/17/25 at 12:12 PM, observation revealed room [ROOM NUMBER]'s wall outside the room door was in disrepair. Further observation inside of the room revealed the resident's dresser drawer with a broken piece of wood and a TV connected to a power strip. 6). On 03/17/25 at 11:40 AM, observation revealed room [ROOM NUMBER]'s baseboard behind the resident's bed and nightstand was in disrepair and the flooring was stained. On 03/19/25 at 4:15 PM, an environmental tour was conducted with the Environmental Services Representative and the Housekeeping Director. The tour revealed the following: 7). room [ROOM NUMBER] revealed a strong urine-like odor in the bathroom. The room baseboards were blackened in various sections. The bathroom wall near the door was soft and the plaster was not smooth. 8). room [ROOM NUMBER] and 112 revealed a strong urine-like odor. The Environmental Services Representative stated all of the room baseboards were previously painted over and added that the baseboard material is plastic and when they clean and buff the floor, the paint comes off. The Environmental Services Representative stated they have a plan to change all room baseboards and flooring and are awaiting on a tile delivery. Upon interview on 03/19/25 at 4:35 PM, during the tour, the Environmental Services Representative acknowledged the environmental concerns that were identified on 03/17/25 and 03/19/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to initiate an activities care plan for 1 of 1 sampled resident reviewed for activities (Resident #12) and failed to initiate a wound care plan for 1 of 2 sampled residents reviewed for pressure ulcers (Resident #39). The findings included: Review of the facility's policy untitled, undated, provided by the Director of Nursing, documented Resident Activities policy and procedure ensures resident's rights to participate in activities to promote well-being and engagement .Individualized care planning .develop a comprehensive activity plan that includes a variety of activities, schedules and staff responsibilities . 1) Review of Resident #12's clinical record documented an initial admission to the facility on [DATE] and readmission [DATE]. The resident's diagnoses included Contracture, Left Hand, Contracture, Left Ankle, Age-Related Nuclear Cataract, Bilateral, Spastic Hemiplegia Affecting Left Nondominant Side, Epilepsy, Neuropathy, and Chronic Pain. Review of Resident #12's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15, indicating that the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident needed extensive assistance/total assistance from the staff to complete the activities of daily living, does have upper extremities impairment and uses a wheelchair. Review of Resident #12's MDS Annual assessment dated [DATE] documented a BIMS of 15, indicating that the resident have no cognitive impairment. The Activities section of the assessment documented the following: *How important is it to you to have books, newspapers and magazines to read? Somewhat important. *How important is it to you to listen to music you like? Not very important. *How important is it to you to do things with groups of people? Not important at all. *How important is it to you to do your favorites activities? Somewhat important. *How important is it to you to go outside to get fresh air when the weather is good? Very important. *How important is it to you to participate in religious services or practices? Very important. Resident #12's clinical record lacked written evidence of an activities care plan developed. On 03/17/25 at 1:03 PM, an interview was conducted with Resident #12 who stated she felt lonely in her room, could not remember short or long-term things. The resident stated she used to have a workbook, but it was lost when she was moved from another room and the facility staff couldn't find it. Resident #12 was asked if someone from activities comes to her room to do any type of activity and stated, 'No. The resident was asked if she would like to do some in-room activities and stated, Yes. On 03/19/25 at 11:42 AM, an interview was conducted with the Activities Director (AD) who stated she has been working at the facility since 12/24. The AD was asked about Resident #12's Activities care plan and stated she did a care plan on 02/11/25. A side-by-side review with the AD of Resident # 12's IDT (Interdisciplinary Team) Care Conference Summary dated 02/11/25. The AD stated that it was the activities care plan. On 03/19/25 at 12:20 PM, a side-by-side review of Resident # 12's active/current care plans was conducted with Staff N, MDS Coordinator and MDS Lead. They were asked for Resident #12's activities care plan, Staff N stated he did not see one. The MDS Lead stated the activities department was supposed to create an activities care plan. Staff N stated the Activities Department staff should have completed the care plan. The MDS Lead stated when they meet for care plan conferences, the IDT goes over the care plan and updates or creates a care plan. On 03/20/25 at 3:45 PM, during an interview, the Director of Nursing and the Administrator were apprised of Resident #12's lack of a written care plan and the lack of documentation of activities provided. The Administrator acknowledged that if it is not documented it was not done. 2) Record review for Resident #39 revealed the resident was originally admitted to the facility on [DATE] and a most recent readmission on [DATE], with diagnoses that included in part, Heart Failure and Kidney Transplant Status. The Minimum Data Set assessment dated [DATE] 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 #39 revealed an order dated 03/13/25 as cleanse Right Heel wound with normal saline, pat dry, apply Betadine, cover with gauze, and wrap with Kerlix every day shift for wound. Review of the Physician's Orders for Resident #39 revealed an order dated 03/13/25 for cleanse wound to Right Leg with normal saline, pat dry, apply Betadine, cover with dry protective dressing every day shift for wound. Review of the Physician's Orders for Resident #39 revealed an order dated 03/18/24 for Enhanced Barrier Precautions for wound care. Review of the Care Plans for Resident #39 revealed no care plan for the right heel or right leg wound, and no care plan for Enhanced Barrier Precautions. On 03/18/25 at 8:55 AM, an observation was made of an already in-progress wound care, being provided for Resident #39, performed by Staff J, a Wound Care Licensed Practical Nurse, who was assisted by Staff I, a Certified Nursing Assistant (CNA). There were no Enhanced Barrier Precautions sign on the resident's door, and no isolation cart near the resident's door. An interview was conducted on 03/20/25 at 12:50 PM with Staff N, MDS Coordinator, who stated he has been in his position for just under one year. When asked if he is responsible for creating care plans for the residents, he said yes, if they are nursing care plans. When asked when he would enter the care plan for a resident with a wound, he stated it would be the same day or the next day. When asked about Resident #39 he acknowledged there was no care plan for the right leg and right heel wound that was identified on 03/13/25. Additionally, he acknowledged there was no care plan for Enhanced Barrier Precautions for Resident #39. An interview was conducted on 03/20/25 at 1:15 PM with Staff J Wound Care Licensed Practical Nurse who stated she has been with the facility for almost 1 year. When asked if she creates a care plan or enters orders for Enhanced Barrier Precautions when she enters an order for a new wound, she said no. She stated the MDS department will review her notes and create a care plan and the Infection Preventionist will review her notes and enter an order for Enhanced Barrier Precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide assistance during dining for 2 of 2 sampled residents reviewed for Activities of Daily Living (ADL) (Resident #1 and Resident #276). The findings included: A review of the facility policy titled Activities of Daily Living Policy (undated), documented the following: Identify the specific needs and goals of each Resident, considering their individual preferences and abilities. Provide assistance with feeding as needed and ensure proper nutrition and hydration. 1) A chart review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Rheumatoid Arthritis and Falls. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 is severely impaired cognitively. Under section GG for eating, Resident #1 was coded as partial to moderate assistance during dining. This means the helper does less than half the effort. The helper lifts, holds, or supports trunks or limbs but provides less than half the effort. In an observation conducted on 03/17/25 at 12:48 PM, the lunch tray came into Resident #1's room. The tray was noted with corn beef, parslied potatoes, buttered cabbage, Jello cubes, and a dinner roll. Continued observation at 12:55 PM revealed the tray was still untouched. At 1:02 PM, the tray was barely touched, with only a few bites from the buttered cabbage and no staff in the room. At 1:03 PM, Staff K, a Certified Nursing Assistant (CNA), took the lunch tray out of the room. In an observation conducted on 03/17/25 at 5:32 PM, Resident #1 received her dinner tray, and no staff were noted in the room to assist the Resident with her dinner. At 5:45 PM, no staff were noted in the room to assist. Continued observation at 5:53 PM revealed Resident #1 ate about 10% of her dinner meal, with no staff in the room to assist. The dinner tray was noted with the following: Baked macaroni and cheese, stewed tomatoes, a brownie, a slice of bread, and a carton of milk. The carton of milk was noted unopened, and the brownie and slice of bread were still wrapped. In an observation conducted on 03/19/25 at 8:32 AM, Resident #1 was eating her breakfast with no staff in the room to assist her. The tray was noted with the following: pancakes, scrambled eggs, hot cereal, juice and a carton of milk that was not poured into a cup. Closer observation showed that Resident #1 ate 20% of her breakfast meal. In an interview conducted on 03/19/25 at 4:30 PM with Staff C, a Certified Nursing Assistant (CNA), stated that Resident #1 needed help during mealtimes, but now you only need to open the food containers and set up her tray, and she can eat independently. 2) A chart review revealed that Resident #275 was admitted to the facility on [DATE] with diagnoses of Alzheimer's and protein-calorie malnutrition. The admission MDS assessment dated [DATE] revealed Resident #275 has a Brief Interview of Mental Status score (BIMS) score of 05, which is severely cognitively impaired. Section GG for eating showed Resident #275 needed partial to moderate assistance. In an observation conducted on 03/17/25 at 11:00 AM, Resident #275 was still in the room with his breakfast tray, and there were no staff in the room. The meal ticket noted the following: hot cereal, Western egg baked, soft white toast, fruit of the day, juice, and milk. Closer observation showed Resident #275 ate about 30% of his breakfast meal. In an observation conducted on 03/17/25 at 12:53 PM, Staff F (CNA) came with the lunch tray for Resident #275. She sat down near the resident and started feeding him his lunch meal. In this observation, Staff F stated Resident #275 can eat independently, but some days, he cannot. He needs pushing and encouragement to eat his meals. In an interview conducted on 03/17/25 at 5:40 PM with Resident #275's family member, he stated Resident #275 needs help and encouragement with all his meals. An interview conducted on 03/20/25 at 8:34 AM with Staff D, Minimum Data Set Lead, who reported partial to moderate assistance during dining, means that residents can feed themselves but need some assistance. The resident needs observation during mealtimes and assistance completing their meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide an ongoing activities program to support resident's preferences for 1 of 1 sampled resident for Activities (Resident #12). The findings included: Review of the facility's policy untitled, undated, provided by the Director of Nursing documented Resident Activities policy and procedure ensures resident's rights to participate in activities to promote well-being and engagement .Individualized care planning .develop a comprehensive activity plan that includes a variety of activities, schedules and staff responsibilities . Review of Resident #12's clinical record documented an initial admission to the facility on [DATE] and readmission [DATE]. The resident's diagnoses included Contracture, Left Hand, Contracture, Left Ankle, Age-Related Nuclear Cataract, Bilateral, Spastic Hemiplegia Affecting Left Nondominant Side, Epilepsy, Neuropathy, and Chronic Pain. Review of Resident #12's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Abilities and Goals that the resident needed extensive assistance/ total assistance from the staff to complete the activities of daily living, does have upper extremities impairment and uses a wheelchair. Review of Resident #12's MDS Annual assessment dated [DATE] documented a BIMS of 15, indicating that the resident had no cognitive impairment. The resident's Activities section of the assessment documented the following: *How important is it to you to have books, newspapers and magazines to read? Somewhat important. *How important is it to you to listen to music you like? Not very important. *How important is it to you to do things with groups of people? Not important at all. *How important is it to you to do your favorites activities? Somewhat important. *How important is it to you to go outside to get fresh air when the weather is good? Very important. *How important is it to you to participate in religious services or practices? Very important. Resident #12's clinical record lacked written evidence of an activities care plan developed. On 03/17/25 at 1:03 PM, an interview was conducted with Resident #12 who stated she felt lonely in her room, could not remember short or long term things. The resident was asked if she had an I-Pad, and replied she used to have a workbook and it was lost when she was moved from another room, the facility staff couldn't find it. The resident stated she was out of bed on Wednesday, it was her choice because her legs swell up and in pain. Resident #12 was asked if someone from activities comes to her room to do any type of activity, and she stated 'No. The resident was asked if she would like to do some in-room activities, and she stated Yes. On 03/18/25 at 12:45 PM, observations revealed Resident #12 in bed, talking to her roommate. On 03/19/25 11:42 AM, an interview was conducted with the Activities Director (AD) who stated she had been working at the facility since 12/24. The AD stated she does 1:1 in room activities, walks the units daily and knows who is in bed and who is not. She asks the residents if they want company, sometimes bring the coloring and crafts, talk and read to them. The AD was asked if she keeps a record of activities provided to the resident and stated she did not do or keep a lot of in-room activities, added she was supposed to but got side-tracked and did not do it. The AD stated she goes to do room visit 1:1 once a week and sometimes pops up twice a week. The AD stated she had two Activities Assistant always and three on Wednesday, Thursday and Fridays and two on the weekends. The AD was asked about Resident # 12's activities and stated she did her makeup three (3) times a week last week, and added she mostly reads and sits to talk with her because she likes company. The AD added the resident cries because of pain, likes the makeup, brings her to music events, and added the resident gets visits from friends from church every day. The AD was asked if she brings magazines or anything like that to the resident and stated she does not bring magazines because the resident had not asked for it. The AD stated she asked the resident what she likes and offered coloring. The AD stated the department had an I-Pad, but she had not offered it to Resident #12. The AD was asked to submit written evidence of 1:1 activities for Resident #12 and stated she does not document 1:1 visits or the activities provided for Resident # 12. On 03/19/25 at 12:04 PM, a joint visit with the AD and Resident #12 was conducted. Resident #12 was up in a wheelchair. The AD asked the resident about her make up, the resident replied, you only had done it once, honey. On 03/19/25 at 12:20 PM, a side by side review of Resident #12's active/current care plans was conducted with Staff N, MDS Coordinator and MDS Lead. The MDS Lead stated when they meet for care plan conference, the IDT goes over care plans and updates or create a care plan. On 03/20/25 at 3:45 PM, during an interview, the Director of Nursing and the Administrator were apprised of Resident #12's lack of a written care plan and the lack of documentation of activities provided. The Administrator acknowledged that if it is not documented, t was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Review of Resident #46's clinical record documented an admission to the facility on [DATE] with a readmission on [DATE]. The resident's diagnoses included Dementia Disturbance, Aphasia Following other Cerebrovascular Disease, Trochanteric Fracture of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Presence of Left Artificial Hip Joint, Aftercare Following Joint Replacement Surgery, and Need for Assistance with Personal Care. Review of Resident #46's Minimum Data Set (MDS) 5 days-admission assessment dated [DATE], documented a Brief Interview of the Mental Status (BIMS) was not conducted due to resident is rarely/never understood indicating the resident had severe cognition impairment. The assessment documented under Functional Abilities and Goals; the resident was dependent on the staff to complete the activities of daily living. Review of Resident #46's care plan titled, [resident name] is at risk for complications related to left hip fracture initiated on 02/27/25 with interventions to include encourage and assist the resident with the use of adaptive equipment as indicated . Review of Resident #46's physician order dated 02/27/25 documented, Abduction Pillow while in bed every shift. Review of Resident #46's admission Notes dated 02/26/25 documented, .Primary diagnosis Left Hip fracture .Skin dry and warm to touch. Dry dressing noted to Left hip (Surgical site) . Safety and comfort measures maintained. Bed placed in low position with call light in reach. On 03/17/25 at 11:33 AM, observation revealed Resident # 46 in bed, facial grimacing, and Staff BB, CNA was at the bedside. The surveyor attempted to interview the resident, who did not answer the questions asked. An interview was conducted with Staff BB who stated the resident is out of bed sometimes and gets pain medication. Further observation did not reveal the resident had an abduction pillow. On 03/18/25 at 12:43 PM, observation revealed Resident #46 in bed being fed by Staff E, Licensed Practical Nurse (LPN). An interview was conducted with Staff E who stated Resident #46 fell last month and had a fracture, but did not know the details. Observation revealed the resident did not have an abduction pillow. On 03/19/25 at 8:10 AM, observations revealed Resident #46 in a low position bed, moaning, lying down on her left side. Observation revealed the resident did not have an abduction pillow. On 03/19/25 at 08:28 AM, observation revealed Resident # 46 in bed being fed by Staff O, CNA. The resident said hello and started to cry, and stated she had pain, unable to tell location. Observation revealed the resident did not have an abduction pillow. On 03/19/25 at 9:00 AM, an interview was conducted with Staff BB, CNA. She stated she took care of Resident #46 on 03/17/25, did the personal care by herself but asked for help when she was ready to turn her. Staff BB stated she used regular pillows when repositioning the resident. On 03/19/25 at 3:03 PM, a joint interview was conducted with Staff N, MDS Coordinator and MDS Lead. The MDS Lead was asked for Resident #46's Abduction pillow and stated the care plan was updated on 02/27/25, with an intervention to include the use of adaptive equipment. Consequently, a side-by-side observation was conducted of Resident #46's closet with the MDS Lead Staff M, Unit Manager. The observation revealed no abduction pillow in the resident's room. Staff M stated the resident brought the abduction pillow with her from the hospital (02/26/25). On 03/19/25 at 3:25 PM, an interview was conducted with Staff S, CNA who stated she works the 3-11 shift. Staff S was asked what kind of pillow she used with Resident #46 while she was in bed and stated regular pillows. Staff S was asked if she had used a special pillow with the resident and stated she had not seen one in her room. On 03/19/25 at 3:27 PM, an interview was conducted with Staff Q, CNA who stated she works the 3-11 shift. Staff S was asked what kind of pillow she used with Resident #46 while she was in bed and stated regular pillows on her back and left heel. Staff Q was asked if she had used a special pillow with the resident and she stated she had not. On 03/19/25 at 3:46 PM, during an interview, Staff M, Unit Manager stated she was not aware that Resident #46 did not have the abduction pillow. Based on record review, observation and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 3 of 31 sampled residents including a Pleur-X (a type of chest tube) being drained as ordered (Resident #73) medications being administered in a timely manner as ordered (Residents #73 and #481); and failure to ensure a resident had an Abduction Pillow in place, as ordered by the physician (Resident #46) The findings included: 1) Record review for Resident #73 revealed the resident was admitted to the facility on [DATE] with diagnoses that included, in part, the following: Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung, Pulmonary Embolism and Depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) score of 15, indicating a cognitive response. Review of the Physician's Orders for Resident #73 revealed an order dated 03/05/25 for Drain Pleur-X every day shift every Monday, Wednesday, Friday and as needed. Review of the Physician's Orders for Resident #73 revealed in part the following orders: -An order dated 02/04/25 for Albuterol Sulfate Inhalation Nebulization Solution 1.25mg/3ml inhale orally via nebulizer every 4 hours for Shortness of Breath. -An order dated 03/15/25 for Prednisone 10mg give 1 tablet by mouth one time a day for wheezing. An order dated 03/21/25 for Lasix 40mg give 1 tablet by mouth one time a day for Edema hold for Systolic Blood Pressure less than 100. -An order dated 02/21/25 for Eliquis 2.5mg give 1 tablet by mouth two times a day for Prevention of DVT/PE (Deep Vein Thrombosis/Pulmonary Embolism). -An order dated 02/03/25 for Ipratropium Bromide HFA Inhalation Aerosol 17 mcg/act 2 puff inhale orally four times a day for Shortness of Breath. Review of the Medication Administration Audit Report for Resident #73 revealed the following: -On 03/18/25 Albuterol Sulfate Inhalation Nebulization Solution 1.25mg/3ml scheduled for 8:00 AM was administered at 10:42 AM -On 03/18/25 Prednisone 10mg scheduled for 8:00 AM was administered at 10:33 AM -On 03/18/25 Lasix 40mg scheduled for 9:00 AM was administered at 10:42 AM -On 03/18/25 Eliquis 2.5mg scheduled for 9:00 AM was administered 10:33 AM -On 03/18/25 Midodrine 5mg scheduled for 9:00 AM was administered at 10:33 AM -On 03/18/25 Ipratropium Bromide scheduled for 9:00 AM was administered at 10:32 AM -On 03/18/25 Ipratropium Bromide scheduled for 12:00 PM was administered at 11:04 AM -On 03/18/25 albuterol sulfate Inhalation Nebulization Solution 1.25mg/3ml scheduled for 12:00 PM was administered at 11:04 AM. In summary the Medication Administration Audit Report for Resident #73 revealed 6 medications were given late by as much as an hour and forty-two minutes. Additionally, nebulizer breathing medications were not administered 4 hours apart as ordered, they were administered 32 minutes apart. Review of the Medication Administration Record (MAR) for Resident #73 for the month of March revealed no documentation of the Pleur-X being drained on 03/17/25. Review of the Nurse's notes for Resident #73 for 03/17/25 revealed no documentation of Pleur-X being drained or not being drained. Review of the Care Plan for Resident #73 dated 02/23/25 with a focus on Management of Pleur-X drainage and a goal of the resident will have no complications related to Pleur-X drainage. The interventions included the following: Staff will maintain appropriate function of chest tube. Monitor for chest pain. Monitor for signs and symptoms of infection, leakage or malfunction and report to Medical Doctor. Verify the appropriate equipment is at the bedside. During an interview conducted on 03/17/25 at 11:14 AM Resident #73 stated the nurse did not give him his Eliquis this morning when she came into the room at 9:00 AM this morning. He said this has been an issue in this facility with not getting medications, sometimes you do get them and sometimes they are very late. During an interview conducted on 03/18/25 at 10:00 AM with Resident #73 who stated he has a chest tube that needs to be drained 3 times a week and staff did not drain his tube yesterday all day. He was very upset and said, This is a serious life and death issue. In this interview, it was quite evident the resident was angry, irrigated and anxious. He then said to the Surveyor that he was concerned for his health. During an interview conducted on 03/18/24 at 10:30 AM with Staff L Licensed Practical Nurse (LPN) who was asked if she was aware Resident #73 did not have his Pleur-X drained yesterday, she stated she was not aware, she did not have the resident yesterday and she was not given any information in report about his Pleur-X not being drained. During an interview conducted on 03/18/25 at 10:33 AM with Staff G Licensed Practical Nurse Unit Manager who said she worked yesterday and was unaware of Resident #73 not having his Pleur-X drained yesterday. She acknowledged there was no documentation of the Pleur-X being drained and there was no progress note to indicate reason why not drained or the physician being notified. During an interview conducted on 03/18/25 at 10:45 AM with Resident #73, it was noted that he was visibly upset and anxious talking fast with a raised voice and stated his drain was not drained yesterday as it should have been. He stated that he had surgery to have the drain inserted and he desperately needs the fluid drained as the fluid builds up and causes pressure in his chest. He stated the drainage process is painful and he needs pain medication for the pain until his lung goes back to being fully inflated. During an interview conducted on 03/18/25 at 5:24 PM with the Attending Physician for Resident #73 who was asked what is the reason Resident #73 has a Pleur-X, the Attending Physician stated it is usually because fluid keeps on reaccumulating, so a catheter with a valve was put in and it is not difficult to drain. The Attending Physician went on to say it can stay in for a long time. When asked about the importance of it being drained as ordered, he said when it gets full you drain it or if the resident is out of breath. It was clarified with the Attending Physician that the Pleur-X catheter is not connected to any drainage type of collection. The Attending Physician stated he was driving and does not remember every detail of every patient and stated it would be the orders from the pulmonologist that would be followed. It was then clarified with the Attending Physician that the order was given by him. When asked what happens if it is not drained as ordered he stated it is not necessary to drain it, but if fluid is accumulating the resident would be out of breath and would need to be drained. When asked if the Pleur-X was not drained should he be informed he said he should be informed but could not recall if he was informed if the Pleur-X had not been drained. During an interview conducted on 03/19/25 at 10:00 AM with Resident #73 who was asked how he felt, he said thank you for intervening on my behalf, things really started happening. They drained my Pleur-X yesterday and he feels much better and feels confident they will not let it happen again. 2) Record review for Resident #481 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part, the following: Aftercare Following Joint Replacement Surgery, Fracture of Specified Part of Neck of Right Femur Subsequent Encounter for Closed Fracture with Routine Healing, Unspecified Atrial Fibrillation, Essential (Primary) Hypertension. Review of the MDS for Resident #481 dated 02/18/25 documented in Section C a BIMS score of 15, indicating a cognitive response. Review of the Physician's Orders for Resident #481 revealed in part, the following: An order dated 02/24/25 for Diltiazem HCl oral tablet 120 mg give 1 tablet by mouth every 12 hours for Hypertension. An order dated 02/24/25 for Sotalol HCl oral tablet 120 mg give 1 tablet by mouth every 12 hours for Arrhythmia. Review of the Medication Administration Audit Report for Resident #481 revealed the following: -On 03/13/25 Diltiazem 120 mg was scheduled to be administrated at 9:00 PM and was not given until 10:15 PM. -On 03/13/25 Sotalol 120 mg was scheduled to be administrated at 9:00 PM and was not given until 10:14 PM. -On 03/15/25 Diltiazem 120 mg was scheduled to be administrated at 9:00 PM and was not given until 03/16/25 at 12:29 AM. -On 03/15/25 Sotalol 120 mg was scheduled to be administrated at 9:00 PM and was not given until 03/16/25 at 12:28 AM. -On 03/16/25 Diltiazem 120 mg was scheduled to be administrated at 9:00 PM and was not given until 10:51 PM. -On 03/16/25 Sotalol 120 mg was scheduled to be administrated at 9:00 PM and was not given until 10:52 PM. -On 03/17/25 Diltiazem 120 mg was scheduled to be administrated at 9:00 PM and was not given until 11:02 PM. -On 03/17/25 Sotalol 120 mg was scheduled to be administrated at 9:00 PM and was not given until 10:53 PM. In summary the Medication Administration Audit Report for Resident #481 revealed cardiac medications were administered late on 8 occasions as late as 2 hours and 29 minutes. During an interview conducted on 03/17/25 at 1:05 PM with Staff A, Registered Nurse, who was asked when medication administration is considered late or early, she stated they have an hour before and an hour after the medication scheduled time to give the medication. During an interview conducted on 03/18/25 10:43 AM with Resident #481, she stated they give her heart medications late sometimes, more than two hours. When asked if she knew the names of her medications, she said Diltiazem and Sotalol. During an interview conducted on 03/18/25 at 10:00 AM with the Consultant Pharmacist who was asked about medications being given late, such as Diltiazem and Sotalol for Resident #481, she stated some could be detrimental but not life threatening. When asked about the Albuterol Sulfate and Ipratropium Bromide inhalation medications being given close together (less than 30 minutes) she stated it could be detrimental but not life threatening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) A record review revealed Resident #109 was readmitted to the facility on [DATE] at 5:32 PM with diagnoses of Dysphagia and Unspecific Protein-Calorie Malnutrition. The Significant Change Minimum Data Set assessment dated [DATE] showed Resident #109 was severely cognitively impaired. A review of the Dietitian evaluation dated 2/3/25 revealed the Resident had an admission weight of 108.6 pounds. His Ideal day weight was noted at 160 pounds, and he was readmitted with a decline in weight. The Physician's orders showed an order for tube feeding Jevity 1.5 (tube feeding formulary) at 50 milliliters (ml) an hour for 20 hours off at 8:00 AM and starting at 12:00 PM, which was placed on 2/3/25 at 3:00 PM. This was almost 22 hours after Resident #109 was admitted . In an observation conducted on 03/17/25 at 11:24 AM, Resident #109 was sitting in a chair with the tube feeding not running. Continued observation at 12:34 PM revealed a bottle of tube feeding Jevity 1.5 with a start date of 03/17/25 at 12:00 PM, running at 50 milliliters (ml) an hour. The tube feeding was at the 1000 ml mark out of a 1000 ml capacity bottle. In an observation conducted on 03/17/25 at 3:43 PM, Resident #109 was noted in a chair with the same tube feeding bag running at 50 ml an hour. The tube feeding bag was noted at the 950 ml mark out of a 1000 ml capacity bottle. This showed that only 50 ml of formulary was administered instead of about 200 ml of formulary. In an observation conducted on 03/17/25 at 5:00 PM, Resident #109 was noted in a chair with the same tube feeding bag running at 50 ml an hour. The tube feeding bag was noted at 900 ml mark out of a 1000 ml capacity bottle. This showed that only 100ml of formulary was administered instead of about 250 ml of formulary. The tube feeding bottle should have been at the 750 ml mark after 5 hours. In an interview conducted on 03/17/25 at 5:36 PM, Staff E, Licensed Practical Nurse, she stated started Resident #109's tube feeding at noon today and that it has been running continuously for the last 5 hours at 50 ml an hour. She further said, Resident #109 was tolerating his tube feeding well. In an observation conducted on 03/18/25 at 12:45 PM, Resident #109 was noted in the chair with the tube feeding Jevity 1.5 at 50 ml an hour, which started on 03/18/25 at noon time. The tube feeding was noted at the 1000 ml level out of a 1000 ml capacity bottle. Continued observation at 3:49 PM, revealed that same tube feeding bottle which was at the 900 ml level out of 1000 ml capacity bottle. This showed that only 100 ml of formulary was administered instead of about 200 ml as per order. A review of the care plan dated 02/10/25 documented to provide the tube feeding Jevity 1.5 as ordered. In an interview conducted on 03/20/25 at 8:05 AM with the facility ' s Clinical Dietitian, she stated Resident #109 tube feeding should be running at 50 ml an hour for 20 hours to meet nutritional needs. When asked about the observation done by this Surveyor on 03/17/25, she acknowledged that the tube feeding should have been around the 750 ml mark at 5:00 PM. You may see a 10-20 ml variance in the tube feeding level, but no more than that. The Clinical Dietitian said that a variance of 100-200 ml was too much, especially if Resident #109 was tolerating his tube feeding. Based on observations, interviews and record reviews, the facility failed to initiate tube feeding in a timely manner for 1 of 2 sampled residents reviewed for tube feeding (Resident #475) and failed to follow physician's orders for tube feeding for 2 of 2 sampled residents reviewed for tube feeding (Residents #475 and Resident #109). The findings included: 1) Record review for Resident #475 revealed the resident was admitted to the facility on [DATE] at 6:00 PM with diagnoses that included in part, the following: Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with Hypoxia and Gastrostomy Status. The resident did not have a completed Minimum Data Set at time of review. Review of the Physician's Orders for Resident #475 revealed in part, the following orders: An order dated 03/17/25 at 2:00 PM Enteral Feed Order every 4 hours Tube Feeding Formula Jevity. Administer 240 ml bolus feeding every 4 hours. The order was discontinued on 03/17/25 at 2:11 PM. An order dated 03/17/25 at 5:00 PM for Enteral Feed Order five times a day Tube Feeding Formula Jevity 1.5. Administer 237 ml bolus feeding every 5 cans QD every day. Flush with 120 ml (water) before and after each feeding. An order dated 03/17/25 to check for skin integrity under the abdominal binder every shift. Review of the Care Plan for Resident #475 dated 03/17/24 with a focus on the resident requires tube feeding related to Aspiration and Dysphagia. The goals were for resident to maintain adequate nutritional and hydration status and to remain free of side effects or complications related to tube feeding through review date. The interventions included in part, the following: Follow physician orders regarding nutrition order and flushes. On 03/17/25 at 11:10 AM, an observation was made of Resident # 475 lying on his side in bed with the covers off, and what appeared to be a peg tube coming out from under his shirt and draped over the resident's side. On 03/17/25 at 5:02 PM an observation was made of Staff A Registered Nurse (RN) administering tube feeding for Resident #475. Staff A RN applied a gown, entered the resident's room, washed her hands, applied gloves, touched the privacy curtain, and the bed control, then removed her gloves, washed her hands and applied gloves. The end of the PEG tube (type of feeding tube) had no cover or cap and was just clamped off. The resident did not have an abdominal binder on. Staff A RN checked for residual and there was none. The resident kept repeating Is this my food am I finally getting some food. The resident was also asking about pain medication. Staff A, RN stated he does not have any pain medication ordered, and she will have to call the doctor. Staff A RN poured Jevity 1.5 (formulary type) tube feeding from a closed system bottle that was opened and at the 450 mark and was dated 03/17/25 but had no time the bottle was opened. During an interview conducted on 03/17/25 at 11:10 AM with Resident #475 he said his stomach hurts and he is hungry and hasn't eaten in days. During an interview conducted on 03/17/25 at 04:20 PM with Staff A RN who was asked if Resident #475 had received any tube feeding today, she said yes, she gave him tube feeding at 3:02 PM today. During an interview conducted on 03/17/25 at 5:20 PM with Staff A RN who was asked about the tube feeding being provided, she said they do not have cans, so they pour it from the larger bottle. When asked if Resident #475 has an order for nothing by mouth, she acknowledged he does. When asked if a resident comes in with a PEG tube and has no orders for tube feeding or a diet, what they do, she stated they would look at the hospital paperwork to see what the resident was receiving and then call the physician within two hours to get an order. During an interview conducted on 03/20/25 at 10:00 AM with Staff G Licensed Practical Nurse Unit Manager who was asked about a resident who is admitted with a PEG tube and no tube feeding orders and no diet, she said the nurse would get the order from the physician within two hours. She checks the chart the next day as the Unit Manager to ensure all orders are in place. When asked about Resident #475 she acknowledged the resident was admitted to the facility on [DATE] at 6:00 PM and did not have an order for tube feeding until 03/17/25 at 2:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administrating of all drugs and ensure a system of records of administering all controlled drugs in sufficient detail to enable an accurate reconciliation and that drug records are in order and an account of all controlled drugs is maintained for 3 of 8 sampled residents reviewed for controlled drugs (Resident #487, #28, and 82). The findings included: 1) Record review for Resident #487 revealed the resident was admitted to the facility on [DATE] with most recent readmission on [DATE] with diagnosis that included in part the following: Chronic Obstructive Pulmonary Disease and Essential (Primary) Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented in Section C a Brief Interview of Mental Status (BIMS) could not be completed due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #487 revealed an order dated 02/24/25 for Valium Oral Tablet 5 MG (Diazepam) give 1 tablet by mouth every 4 hours as needed for Agitation for 14 Days. Review of the Medication Monitoring/Control Record for Resident #487 Diazepam 5mg documented 03/13/25 at 2:29 PM the medication was removed from the med cart. Review of the Medication Administration Record (MAR) for Resident #487 for the month of March 2025 revealed no documentation of Valium (Diazepam) 5mg being administered. In summary the Valium (Diazepam) 5mg for Resident #487 was signed on the Medication Monitoring/Control Record as removed from the med cart but not documented as being administered on the resident's Medication Administration Record. 2) Record review for Resident #28 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Displaced Intertrochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing. The MDS assessment dated [DATE] documented in Section C, a BIMS (Brief Interview for Mental Status) score of 13, indicating a cognitive response. Review of the Physician's Orders for Resident #28 revealed an order dated 04/09/24 for Oxycodone HCl Capsule 5mg give 1 capsule by mouth every 6 hours, as needed for moderate to severe pain. Review of the Medication Monitoring/Control Record for Resident #28 Oxycodone 5mg documented on 02/14/25 at 4:57 PM the medication was removed from the med cart. Review of the MAR for Resident #28 for the month of February 2025 revealed no documentation of Oxycodone 5mg being administered. In summary the Oxycodone 5mg for Resident #28 was signed on the Medication Monitoring/Control Record as removed from the cart but not documented as being administered on the resident's Medication Administration Record. 3) Record review for Resident #82 revealed the resident was admitted on [DATE] with diagnoses that included in part the following: Cerebral Atherosclerosis and Vascular Dementia Mild with Agitation. The MDS dated [DATE] Documented in Section C, a BIMS was not performed due to the resident is rarely/never understood. Review of the Physician's Orders for Resident #82 revealed an order dated 12/25/24 for Tramadol HCl Tablet 50 mg give 1 tablet by mouth every 8 hours as needed for moderate and severe pain. Review of the Medication Monitoring/Control Record for Resident #82 for Tramadol 50mg revealed no documentation of the med being signed out as removed from the med cart. Review of the Medication Administration Record for Resident #82 documented the Tramadol 50mg was administered on 03/16/25 at 12:00 AM and the Medication. In summary the Tramadol 50 mg for Resident #82 was documented as administered but not signed out on the Medication Monitoring/Control Record as removed from the med cart. During an interview conducted on 03/20/25 at 12:45 PM with the DON (Director of Nursing) who was asked who completes the monitoring or auditing of the medication reconciliation of controlled substances, she stated the Unit Managers does. During an interview conducted on 03/20/25 at 1:05 PM with Staff G -Licensed Practical Nurse Unit Manager who said she does the audit of the controlled medication by checking the Medication Monitoring/Control Record to make sure all entries have a signature, and it matches the residents Medication Administration Record. She is supposed to do this once a week, but she does it usually three times a week.

**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, for 2 out of 6 sampled residents observed during dining (Resident #66, Resident #57). The findings included: 1. A record review showed that Resident #66 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of unspecified Atrial Fibrillation and Hyperlipidemia. The Minimum Data Set (MDS) assessment end of PPS Part A Stay dated 01/09/2025 revealed the resident's Brief Interview of Mental Status (BIMS) score is 11, which indicates moderate cognitive impairment. During an observation conducted on 03/18/2025 at 12:05 PM this surveyor observed that Resident #66's meal ticket consisted of: Ground and/or soft cooked, soup [NAME] jour, ground corned beef with broth, soft cooked parslied potatoes without skin, soft cooked buttered cabbage, Jello cubes, dinner roll, margarine, condiments and add side mashed potatoes. Resident #66's tray did not have mashed potatoes, and the soft cooked parslied potatoes had the skin on it. Resident #66 was seen eating the potatoes and peeling them with her teeth. Resident #66 looked very annoyed and stated that she did not want the skin on her potatoes. During an observation conducted on 03/20/2025 at 12:21 PM this surveyor observed that Resident #66's meal ticket consisted of: Ground and/or soft cooked, soup [NAME] jour, ground beef cubes in gravy, rice with vegetables broth, soft cooked green beans, mandarin oranges, dinner roll, margarine, condiments and add side mashed potatoes. Resident #66's tray did not have ground beef cubes in gravy. 2. A record review showed that Resident #57 was admitted to the facility on [DATE] with diagnosis of Osteomyelitis and Type II Diabetes Mellitus without complications. The Minimum Data Set (MDS) Quarterly assessment review dated 11/08/2024 revealed that the resident's Brief Interview of Mental Status (BIMS) score is 15, which indicates no cognitive impairment. During an observation conducted on 03/20/2025 at 12:15 PM this surveyor observed that Resident #57's meal ticket consisted of soup the day, ground beef tips, steamed rice, green beans, juice packed mandarin oranges, dinner roll, margarine, sugar substitute, 2 peppers, a large salad with chicken on the side, diet coke, add Kens salad dressing with salads. Resident #66's tray did not have the large salad with chicken nor the Kens salad dressing. In an interview conducted on 03/20/2025 at 2:00 PM the dietary manager/director of food services stated that she has 2 checkpoints, the first one is when they receive the food from the cook and the final checkpoint is in the kitchen when placing the plate on the cart. These two checkpoints are responsible for making the meal ticket match the tray. The residents' preferences are placed in the preferences form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) Review of Resident #175's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included End Stage Renal Disease and Anxiety Disorder. Review of Resident #175's MDS admission assessment in progress dated 03/13/25 documented a BIMS score of 13, indicating the resident had no cognition impairment. Review of Resident #175's care plan titled [resident name] is at risk for malnutrition and noted with low BMI (body mass index) and impaired skin. Therapeutic/mechanical altered diet in place initiated on 03/11/25 with interventions to include NAS (no added salt) Pureed diet. On 03/17/25 at 12:26 PM, observation of the Masada's Unit in-room dining was conducted. Observation revealed Resident #175 received a pureed diet. The resident pureed meat had moderate amount of loose puree consistency with clear orange liquid pooling around other food items in the plate. Subsequently, an interview was conducted with the resident who stated he will not eat the rest of the food and asked to remove the tray. The resident had an approximately 25% intake. Resident #175's meal ticket documented Pureed Corned Beef (Photographic Evidence Obtained). On 03/18/25 at 12:39 PM, observation of Resident #175's lunch tray revealed a pureed diet. The resident's pureed meat had a moderate amount of loose pureed consistency with clear orange/brownish liquid pooling around other food items in the plate. (Photographic Evidence Obtained). 5) Review of Resident #77's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident's diagnoses included Cerebrovascular Disease, Cerebral Infarction and Anxiety Disorder. Resident #77's MDS quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 5, indicating the resident had severe cognition impairment. Review of Resident #77's care plan titled [resident name] is at risk for malnutrition . initiated on 011/28/22 revised on 04/21/24 with interventions to include regular puree diet. On 03/17/25 at 12:35 PM, observation revealed Resident #77 in bed eating lunch. The resident had a pureed diet. The pureed meat had moderate amount of loose puree consistency with clear orange liquid pooling around other food items in the plate. Observation revealed the resident poured sugar over the pureed meat and stated it had no flavor and proceeded to eat it. Subsequently, an interview was conducted with Resident #77 who stated she will not eat the rest of the other pureed items. Resident #77's meal ticket documented Pureed Corned Beef. (Photographic Evidence Obtained). On 03/18/25 at 12:36 PM, observation of Resident #77's lunch tray revealed a Pureed diet. The resident's pureed meat had a moderate amount of loose puree consistency with clear orange/brownish liquid pooling around other food items in the plate. Resident #77's meal ticket documented Pureed Hamburger. (Photographic Evidence Obtained). Based on observations, interviews and record reviews, the facility failed to provide the correct diet consistency for pureed diets for 2 of 3 visits to the main kitchen which has the potential to affect 8 residents on pureed diets and for 3 of 3 sampled residents (Resident #47, Resident #175, Resident #77). Who consume pureed diets. The findings included: A review of the facility's policy titled, Pureed - Dysphagia Level 1 showed the following: The pureed consistency is planned according to the Regular consistency, but the texture is modified to a smooth, pudding-like, lump free, pureed consistency texture for all food items. This consistency follows the guidelines set forth by the National Dysphagia Task Force. 1) During an observation conducted on 03/18/2025 at 11:45 AM of the pureed lunch meal on the tray line in the kitchen, the menu consisted of #10 scoop of pureed Hamburger, #8 scoop of pureed cooked vegetables, #8 scoop of pureed Cinnamon Apple, #16 scoop of pureed bread, Garnish of Ketchup and mustard, and condiments. A closer observation of the pureed hamburger revealed a grainy like consistency and the pureed vegetables revealed a lumpy like consistency. 2) During an observation conducted on 03/19/2025 at 11:44 AM of the pureed lunch meal on the tray line in the kitchen, the menu consisted of 6 oz of pureed soup of the day, #8 scoop pureed roasted turkey, #8 scoop pureed gravy, #8 scoop of pureed spinach with onions, ½ cup of pureed fruit cup, #16 scoop of pureed dinner roll. The surveyor sampled all pureed foods provided by the Dietary Manager, and it was noted that the pureed turkey was not smooth and small pieces of turkey was identified. 3) A record review showed that Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and other sequelae following unspecified cerebrovascular disease. The Minimum Data Set (MDS) assessment significant change dated 02/07/2025 revealed that the Brief Interview of Mental Status (BIMS) score of 12, which indicates mild to moderate cognitive impairment. During an observation conducted on 03/17/2025 at 12:09 PM in the main dining room, the pureed roll was observed lumpy with a grainy consistency. Resident #47's meal ticket consisted of Nectar Thick Pureed Soup [NAME] Jour, Pureed Corned Beef, Mashed Potatoes, Pureed Buttered Cabbage, Applesauce, Pureed Roll, Margarine and Sugar substitute, Salt, and Pepper, which matched the meal tray. During an interview conducted on 03/18/2025 at 3:20 PM the Registered Dietitian stated that they use Source Tech as their guide. The Registered Dietitian further stated that a pureed diet should be very soft like baby food, a mashed potato consistency with no lumps. It should look like a scoop and not runny. The plate should have an appeal. During an interview conducted on 03/19/2025 at 4:00PM the Speech therapist stated that she has been working in the facility for 6 months. She further stated that pureed food should have the consistency of mashed potatoes-like, no lumps or clumps. They follow the Source Tech guidelines. She further said that a pureed food should look presentable in solid form but smooth enough to swallow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to follow infection control guidelines for residents on enhanced barrier precautions for 4 of 21 sampled residents reviewed for Enhanced Barrier Precautions (Resident #39, #46, #103 and #175); and failed to follow infection control practices during dialysis treatments for 2 of 3 sampled residents reviewed for Dialysis (Resident #276 and #278). The findings included: Review of the facility's policy titled Enhanced Barrier Precautions undated documented .EBP (enhanced barrier precautions) are indicated during high contact care activities for residents .who has a chronic wound and/or indwelling medical device. High contact resident care activities include dressing, bathing/showering, transferring, .providing hygiene, changing linens .wound care . 1)Review of Resident #103's clinical record documented an initial admission on [DATE] and a discharge to a local hospital on [DATE]. Resident's diagnoses included Ventricular Premature Depolarization, Gallbladder Calculus and Hypertension. Review of Resident #103's MDS Quarterly assessment dated 01/18/ documented a Brief Interview of Mental Status (BIMS) was not conducted due to the resident is rarely/never understood. Review of Resident #103's care plan title [resident's name] has a risk for injury/infection r/t (related to) presence of indwelling catheter secondary to a dx (diagnosis) of neurogenic bladder initiated on 10/11/24. Interventions did not include following Enhanced Barrier Precautions. On 03/18/25 at 8:42 AM, observation revealed Resident #103 in bed and Staff P, CNA repositioning, and rearranging the residents cover sheet. Staff P was not wearing a gown. Observation revealed a urinary drainage bag with no privacy pouch. Consequently, an interview was conducted with Staff P who stated the resident had a foley catheter. Attempted to interview the resident who kept his eyes open and fixed looking at the surveyor and did not answer any questions asked. On 03/18/25 at 8:46 AM, observation revealed the Infection Preventionist and Staff M, UM placing a cart with Personal Protective Equipment outside Resident #103's room. Consequently, an interview was conducted with Staff M and the Infection Preventionist who they both stated the resident had a foley and they will follow EBP (Enhanced Barrier Protection). The Infection Preventionist was asked why the PPE cart was not placed before and stated the resident was moved from another room. Review of Resident #103's clinical census documented room changed on 01/01/25. 2) Review of Resident #175's clinical record documented an admission on [DATE] with no readmissions. The resident diagnoses included End Stage Renal Disease and Anxiety Disorder. Review of Resident #175's MDS admission assessment in progress dated 03/13/25 documented a BIMS score of 13 indicating that the resident had no cognition impairment. Review of Resident #175's care plan titled (resident's name) is on Enhanced-Barrier Precaution r/t (related to) sacral wound and Foley catheter initiated on 03/13/25. Interventions included ENHANCED-BARRIER Precaution: Wear gown and gloves for high-contact resident care activities (such as: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting .urinary catheter .wound care (any skin opening requiring a dressing) initiated on 03/13/25. On 03/17/25 at 12:17 PM, observation revealed Resident #175's room door wide open, and a treatment cart parked in front of the door and the resident's privacy curtain halfway open. The surveyor knocked at the door, and was allowed to enter the room, Staff I stated Staff J was doing the resident's wound. Observation revealed Staff I, CNA and Staff J, Wound Care Nurse (WCN) next to the resident's bedside, the resident had his cover down and was showing a foley tubing and his legs. Staff J stated she was finishing the resident's wound care. Observation revealed Staff J and Staff I pulled the cover sheet and blanket up. Further observation revealed Staff I and Staff J were not wearing a protective gown. Furthermore, observation revealed a Personal Protective Equipment (PPE) cart with gowns and an Enhanced Barrier Precaution (EBP) sign outside the resident's room. Subsequently, a joint interview was conducted with Staff J, WCN who stated Resident #175 had a sacrum stage II pressure ulcer and one midback stage II pressure ulcer. On 03/19/25 at 8:15 AM, observation revealed a hospice aide at Resident #175's bedside. The hospice CNA was wearing a mask and gloves, but not a protective gown. The resident had a gray color T-shirt on, lower body was uncovered, an adult brief and a foley catheter was observed. Consequently, an interview was conducted with the hospice aide who stated she did the resident upper body and was ready to do the lower body. The hospice aide was asked if she ever wore a gown while taking care of the resident with a foley. The aide stated she had not worn a gown while taking care of Resident #175 and added if the resident was on isolation, she would wear a gown, but not with resident #175. On 03/20/25 at 10:20 AM, observation revealed an EBP signage and PPE cart by Resident #175's room door. On 03/20/25 at 10:23 AM, wound care observation for Resident #175 by Staff J, WCN and assisted by Staff I, CNA. Staff J and Staff I entered the resident's room, performed hand hygiene and donned gloves. The staff did don a protective gown. Staff J removed the residents covers, repositioned by pulling the draw sheet, pulled the brief down, removed her gloves, performed hand sanitation, but did not donned a gown. Staff J provided Resident #175's wound care without wearing a gown as required. Staff I assisted Staff J during wound care and did not wear a gown. On 03/20/25 at 11:05 AM, a joint interview was conducted with Staff I and Staff J. Staff J, WCN was asked why she did not wear a gown during Resident #175's wound care and stated she usually puts a gown on but got distracted. Staff I, CNA stated she was supposed to wear a gown and forgot. Staff I and Staff J were apprised they were observed on 03/17/25 finishing Resident #175's wound care and were not wearing a gown either. Staff J stated they always wear gowns. 3) Review of Resident #46's clinical record documented an admission on [DATE] with a readmission on [DATE]. The resident diagnoses included Unspecified Dementia, Aphasia Following other Cerebrovascular Disease, and Need for Assistance with Personal Care. Review of Resident #46's Minimum Data Set (MDS) 5 days-admission assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) was not conducted due to resident is rarely/never understood indicating the resident had severe cognition impairment. The assessment documented under Functional Abilities and Goals the resident was dependent on the staff to complete the activities of daily living. Resident #46's active care plan did not include EBP care plan or wound care plan. Review of Resident #46's physician order dated 03/14/25 documented cleanse left heel blister with NS (normal saline), pat dry, apply betadine moist gauze then cover with dry gauze, wrap with kerlix daily. Physician order dated 02/26/25 documented Wound consult. Multiple observation from 03/17/25 through 03/19/25 revealed no PPE cart, no EBP signage outside Resident #46's room. On 03/19/25 at 3:38 PM, observation was conducted of transferring Resident #46 from wheelchair to bed Staff L, LPN and Staff Q, CNA. Staff L and Staff Q donned gloves but did not don a protective gown. Subsequently, an interview was conducted with Staff L who stated the resident had a left heel wound. Observation revealed Staff L removed Resident #46's sock and revealed a dry dressing to the left heel dated 03/18/25. On 03/20/25 at 10:21 AM, an interview was conducted with Staff O, CNA, who was the regular assigned CNA, stated she did not wear a gown while providing care to Resident #46. Staff O confirmed the resident had a dressing on her heel and the WCN was doing the dressing daily. The EBP signage was reviewed with Staff O who acknowledged she had to wear a gown while providing care to the resident with a wound. On 03/20/25 at 11:20 AM, an interview was conducted with Staff L, LPN who stated Resident #46 was not on contact precautions and she will not wear a gown during transfer. Consequently, a side-by-side review of EBP signage was conducted with Staff L who acknowledged transferring a resident with a wound requires to wear a gown. On 03/20/25 at 11:35 AM, an interview was conducted with Staff M, Unit Manager, who was apprised of staff not wearing a gown during high care activities for Residents with wounds and/or foley catheter, Resident #46, 103 and 175. 4. A record review revealed that Resident #276 was admitted to the facility on [DATE] with a diagnosis of End-Stage Renal Disease. The admission Minimum Data Set (MDS) dated [DATE] showed Resident #376 with a BIMS score of 10, which is moderately cognitively impaired. A physician's order dated 03/03/25 for Hemodialysis every Monday, Wednesday, and Friday was also dated 03/03/25. In an observation conducted on 03/19/25 at 9:44 AM, Staff H Patient Care Technician (PCT) was performing initiation of Central Venous Catheter (CVC) dialysis. She practiced hand hygiene and placed a pair of new gloves to create a clean surface near Resident #276's side table. She then adjusted her face shield and touched the access site without practicing hand hygiene or changing gloves. Staff H removed her gloves, placed another pair without hand hygiene, and continued cleaning the access site. She removed her gloves, cleaned her hands, and put on a new pair of gloves. While connecting the syringes to the access site, she removed her gloves and placed a new pair of gloves without practicing hand hygiene between gloves. She then connected the syringes with the same gloves to the access site. 5. A chart review showed that Resident #278 was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease and Dependence on Dialysis-an order dated 03/17/25 for Hemodialysis every Monday, Wednesday, and Friday. In an observation conducted on 03/19/25 at 12:50 PM, Staff H, who was performing a disconnection of CVC on Resident #278. She was observed touching the computer, placing a pair of gloves with no hand hygiene, and proceeded to touch Resident's #278 access site. Staff H removed her gloves, walked over to touch the supply cabinet, and placed a new pair of gloves without practicing hand hygiene before coming back to continue the disconnection of the dialysis. 6. Record review for Resident #39 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: Heart Failure, Kidney Transplant Status, Open Wound Left Lower Leg Subsequent Encounter. The Minimum Data Set, dated [DATE] 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 #39 revealed an order dated 03/13/25 for cleanse right heel wound with normal saline, path dry, apply Betadine, cover with gauze, wrap with kerlix every day shift for wound. Review of the Physician's Orders for Resident #39 revealed an order dated 03/13/25 for cleanse wound to right leg with normal saline, pat dry, apply betadine, cover with dry protective dressing every day shift for wound. Review of the Physician's Orders for Resident #39 revealed an order dated 03/18/24 for Enhanced Barrier Precaution for wound care. Review of the Skin Assessment for Resident #39 dated 03/12/24 documented in part the following: Other (not specified) Right Leg anterior-length:5.8cm-width:2.7cm- depth:0.3cm- -etiology: trauma-stage: N/A-granulation: 80%-drain: serous-amt: mild-TX (Treatment):Santyl daily. Right heel length:4.8cm-width:4cm-depth:0.5cm-etiology: pressure stage: unstageable- granulation: 10%-drain: serous- amt: mild- TX: Santyl daily On 03/18/25 at 8:55 AM an observation was made of an already in progress wound care being provided for Resident #39 performed by Staff J Wound Care Licensed Practical Nurse who was assisted by Staff I Certified Nursing Assistant (CNA) and both staff members were not wearing a gown. There was no Enhanced Barrier Precaution sign on resident's door, and no isolation cart near the Resident's door. During an interview conducted on 03/19/25 at 2:50 PM with Staff I Certified Nursing Assistant (CNA) who was asked if she knew what Enhanced Barrier Precautions (EBP) were, she stated it is a type of isolation. When asked what type of requirements are needed for EBP she said it would be any wounds and some other things. When asked how do you know who is on EBP, she said there is a sign on the door and then we can ask the nurse what type of precaution it is. When asked when a resident is on EBP what Personal Protective Equipment (PPE) is needed, she stated a gown and gloves. When asked about wound care provided and assisted on 03/18/25 for Resident #39 and not wearing a gown, she acknowledged there was no sign on the door and there was no isolation cart in front of the resident's room. During an interview conducted on 03/20/25 at 1:15 PM with Staff J Wound Care Licensed Practical Nurse who stated she has been with the facility for almost 1 year. When asked about EBP when she would wear PPE, she stated she would wear gown and gloves when they have an order for EBP and a sign on the door. When asked if a resident has a wound would they be on EBP she said yes.

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 1 of 3 visits to the main kitchen. The findings included: A review of the facility ' s policy titled Refrigerators, revised in December 2014, showed the following: The facility will ensure safe refrigerator maintenance, temperatures, and sanitation and will observe food expiration guidelines. The acceptable temperature ranges for refrigerators are 35 degrees Fahrenheit (F) to 40 degrees F. In a tour of the main kitchen conducted on 03/17/25 at 8:55 AM accompanied by the Dietary Manager, the following concerns were noted: The walk-in refrigerator on the dairy side had an internal temperature of 49 degrees F and not the necessary 40 degrees F and below. An egg platter pulled out of the dairy walk-in refrigerator had an internal temperature of 43.7 degrees F, not the necessary 40 degrees F and below. A tuna platter pulled out of the dairy walk-in refrigerator had an internal temperature of 43.5 degrees F, not the necessary 40 degrees F and below. A scoop of tuna pulled out of the dairy walk-in refrigerator had an internal temperature of 44 degrees F, not the necessary 40 degrees F and below. A container of nutritional juice drink from the dairy walk-in refrigerator had an internal temperature of 46.0 degrees F, not the necessary 40 degrees F and below. Another container of a nutritional juice drink from the dairy walk-in refrigerator had an internal temperature of 47.1 degrees F, rather than the necessary 40 degrees F and below. A large container of raw chicken exposed was noted in the walk-in meat refrigerator. The date 03/08/25 indicated the date the chicken container was placed in the refrigerator. A large container of raw meat was noted in the walk-in meat refrigerator. Its date of 03/14/25 indicated the date the meat container was placed in the refrigerator. Closer observation revealed a pool of blood on the bottom of the meat container. A bag of unidentified meat packet which was dated 03/26/25. A red bucket was tested using the facility Hydrion strips, which showed a level of 400 parts per million, indicating that too much sanitation solution was used in the red bucket. In this observation, the Dietary Manager acknowledged that too much solution was placed in the red bucket. The dry storage room was noted with a dented can of sliced pineapples that was not placed on the side with do not use sign. The dry storage room was noted with two dented cans of tomato sauce that were not placed on the side with do not use sign. An opened bottle of extra light amber honey was half-used in the dry storage area, and the date of its opening is unknown. A personal 20-ounce Styrofoam cup of coffee was noted in the food production area. A large metal container noted with a dried unidentified substance coating the surface of the metal container.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor and record a resident's pain level as ordered and failed to document administration of pain medication for 1 of 3 sampled residents (Resident #1). The findings included: Record review revealed Resident #1 was admitted to the facility from 11/12/24-12/6/24. A comprehensive assessment dated [DATE] documented the resident had pain and was care planned for pain with appropriate interventions in place. Review of Resident #1's physician orders revealed an order dated 11/12/24 to monitor and document the resident's pain level every shift. A review of the resident's Medication Administration Record (MAR) revealed the resident was monitored every shift for pain, but a pain level was not documented. A review of the resident's Medication Monitoring/Control Record revealed documentation of Tramadol (pain medication) removed for the resident on 11/20/24 at 2:30 AM, 11:20 AM, and 7:30 PM; 11/21/24 at 5:00 AM and 4:00 PM; and 11/22/24 at 7:00 PM. Further record review revealed the resident's MAR did not indicate the resident received the medications on those dates and times. An interview was conducted with the Director of Nursing (DON) on 11/19/24 at 3:00 PM and the findings were confirmed.

Based on interview and record review, the facility failed to verify if an IV (Intravenous) antibiotic needed to be ordered and administered on a scheduled basis for 1 of 1 sampled resident reviewed (Resident #1). The findings included: Record review for Resident #1 revealed the hospital sent a physician order dated 05/25/24, to the facility for Vancomycin IV (Intravenous) upon discharge, that was intended for Home Health Care (HHC). The orders on the hospital Social Service Requisition, Consult Social Service Order form that was sent to the facility, had the order as follows: Vancomycin 1g IV with each dialysis until June 25th. On 07/29/24 at 12:13 PM, an interview was conducted with Staff A, Registered Nurse (RN), who was one of the nurses who worked with Resident #1. The RN explained that the orders from the hospital would be entered into PCC by either the floor nurse or the unit manager. The RN determined that the hospital did not include the Vancomycin as part of the discharge orders that are reconciled by the nurses upon admission. On 07/29/24 at 12:51 PM, an interview was conducted with Staff B, Social Services Coordinator. Staff B stated that there is a meeting every morning with the DON (Director of Nursing), ADON (Assistant Director of Nursing), Administrator, and Social Services. She stated they discuss the new admissions and review the residents' needs. Staff B stated the document that indicated the vancomycin had come to her attention because it was sent as a Home Health Care (HHC) request for the antibiotic to be given intravenously in dialysis. This was not a nursing order according to Staff B. On 07/30/24 at 8:47 AM, an interview was conducted with a Registered Nurse (RN) from the Dialysis Center. The Dialysis Center is contracted to provide services at the facility. The RN explained that when Resident #1 was admitted , the resident's spouse told the Dialysis nurse that Resident #1 was to receive Vancomycin in dialysis by IV. When the Dialysis nurse asked the on-duty nurse for the Vancomycin the on-duty nurse told the Dialysis Nurse that Resident #1 was getting oral Vancomycin, and the on-duty nurse would be providing the medication. The Dialysis nurse was unable to provide the date of the interaction with the spouse. It was unclear if the Vancomycin was discussed when Resident #1 was admitted or afterward. There was no evidence the Vancomycin IV order from the hospital was clarified with the physician. There was no evidence the order for the Vancomycin IV was reviewed in the morning meeting for the newly admitted resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to aid with eating during mealtime observations for 1 of 2 sampled residents reviewed for Activities of Daily Living (ADLs) (Resident #41). The findings included: Resident #41 was admitted to the facility on [DATE] with a diagnosis of Dysphagia, Mild Cognitive Impairment, and Heart Disease. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #41 had a Brief Interview of Mental (BIMS) score of 6, indicating severecognitive impairment. Under section GG for eating, it was revealed that Resident #41 was coded for partial to moderate assistance for eating. This indicates Resident #41 makes less than half the effort and needs help lifting, holding or requires support of trunk or limbs during dining. A review of the Clinical Physician Orders revealed the following orders: Que resident to eat on her own and implement safer swallow strategies (small bites, single sips decrease rate and swallow) dated 12/04/23, No added salt diet mechanical soft texture with thin consistency dated 11/08/23 and referred to restorative dining dated 12/01/23. In an observation conducted on 12/05/23 at 8:25 AM, Resident #41 was noted with the breakfast tray at her bedside. In this observation, Resident #41 stated that she has a poor appetite and stomach pains. At 12:40 AM, the breakfast tray was taken out of the room and no staff interventions were noted during this observation. In an observation conducted on 12/06/23 at 8:25 AM, Resident #41 was noted to have the breakfast tray untouched at the bedside. At 9:10 AM, the breakfast tray was still new at the bedside. In this observation, Resident #41 stated that she had stomach pains and could not eat and no staff interventions were noted during this entire observation. A review of the weight log showed the following weight recorded: 11/02/23 showed a weight of 129 pounds. 11/9/23 showed a weight of 127.9 pounds. 11/16/23 showed a weight of 126.0 pounds. 11/23/23 showed a weight of 126.8 pounds. 12/1/23 indicated a weight of 123.4 pounds. A new weight was requested by the Surveyor, which showed that Resident #41 was 118.5 pounds. This showed a total weight loss of approximately 10 pounds in one month. A progress note dated 12/4/23 revealed that Resident #41 was admitted to restorative dining and staff will continue to encourage Resident #41 to eat. The Care Plan dated 10/07/23 revealed that Resident #41 is at nutritional risk related to variable intake of meals with a history of Dysphagia and mechanically altered diet. A review of the percentage meal intake for Resident #41 revealed that on 12/04/23, it was documented that she ate 51 percent to 75 percent of her breakfast meal, which was different from what was observed. Further review revealed that on 12/06/23, Resident #41 consumed 0 to 25 percent of her breakfast meal. In an interview on 12/07/23 at 1:00 PM, the full-time MDS Coordinator stated that Resident #41 is coded under section 3 for eating and needing partial to moderate assistance during dining. This means that staff must always sit near the residents to help them cut the food, encourage them, and open containers. He codes residents based on therapy assessments; his interviews with the nursing team, and any observations of the residents. When asked what the difference is between set up and partial to moderate assistance, he stated that you need to be in the room to help Resident #41 with her meals. During an interview conducted on 12/07/23 at 2:00 PM with Staff D, Certified Nursing Assistant (CNA), she stated that she is familiar with Resident #41. When asked if Resident #41 needs assistance with dining, she said she needs to be fed; if she does not get fed, she will not feed herself and look at the food. When asked how long the resident needed to be fed, she said it has been at least a few weeks. In an interview conducted on 12/07/23 at 3:00 PM with the facility ' s Administrator, she was informed of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide equipment assessed as needed by therapy for 1 of 3 sampled residents reviewed for falls (Resident #297). The findings included: Resident #297 was admitted to the facility on [DATE] with diagnoses including Stroke and Diabetes. Record review revealed a comprehensive assessment dated [DATE] that documented the resident had severe cognitive impairment and required substantial/maximal assistance with activities of daily living. A review of Resident #297's record revealed a care plan for the resident, as at risk for falls, related to episodes of incontinence, impaired mobility, and medication side effects. The resident was further care planned for the need of assistance with activities of daily living care related to multiple factors including right sided weakness and decreased mobility. Record review revealed Resident #297 had a fall out of bed with injury on 10/18/23, which required hospitalization. An interview was conducted with the Director of Nursing (DON) on 12/06/23 at 1:30 PM related to Resident #297's family's request for bedrails. The DON stated the rehabilitation (rehab) would assess a resident for the need of a side rail, and a physician order was needed for two side rails. An interview was conducted with the Rehab Director on 12/07/23 at 10:30 AM. The Rehab Director stated when a resident initially comes into the facility, they determine if a resident would benefit from a side rail using the Restorative Bed Rail Observation form. If so, would communicate with maintenance using a communication log kept in therapy. Maintenance would install the side rail. A side-by-side review with the Rehab Director of the Restorative Bed Rail Observation form for Resident #297 dated 09/20/23 revealed the resident could benefit from the use of right-side enabler (side rail) to assist with functional mobility skills. An assessment of the resident post readmission dated 10/27/23 documented the same. A side-by-side review of the maintenance communication log was conducted with the Rehab Director. The maintenance log documented a request for a right-side rail dated 10/27/23, after Resident #297's readmission to the facility post fall. The Rehab Director confirmed there was no communication of the resident's need for a side rail documented in the maintenance communication log for the resident's initial assessment dated [DATE]. The Rehab Director stated they may have given verbal instructions to maintenance for Resident #297's initial request for side rail, as she believed the resident had a side rail. The Director further stated that the resident would have been coded for having a side rail in the initial comprehensive assessment, or the DON would know how to tell if Resident #297 had a side rail on the bed as initially assessed. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 12/07/23 at 10:50 AM. The MDS Coordinator stated he was the one responsible for Resident #297's comprehensive assessments. The MDS Coordinator further stated side rails were not documented in the comprehensive assessments. An interview was conducted with the Director of Nursing (DON) on 12/07/23 at 11:00 AM. The DON stated a resident would be documented as having a side rail in the comprehensive assessment, and rehab was responsible for initiating, providing, and documenting side rails. A subsequent interview was conducted with the Rehab Director in the presence of the DON. The Rehab Director stated again they assess new residents for the need/benefit of side rails. Maintenance was responsible for providing the side rails. They put the request in the maintenance logbook. The Rehab Director further confirmed Resident #297 did not have a request in the maintenance logbook for 09/23. An interview was conducted with the Maintenance Director on 12/07/23 at 2:00 PM. The Maintenance Director stated he gets requests from therapy for side rails by the maintenance log in therapy. Once he provides the side rails, he writes done next to the request. The Maintenance Director further stated if a verbal request was made, he would still write the resident's name and that it was done in the maintenance log. If the request for side rails was not in the maintenance logbook, the resident did not receive side rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide appropriate care to prevent urinary tract infections during perineal/foley care for 1 of 1 sampled resident reviewed for Catheter Care (Residents #32). The findings included: Review of the facility's procedure for foley catheter care provided by the Infection Preventionist documented .the catheter-meatal junction is a significant portal of entry for bacteria into the urinary tract, potentially causing urinary tract infections .provide privacy. Draw cubicle curtains completely around the resident's unit .starting at the catheter-meatal junction, wash tubing using friction and circular motion outward to the surrounding perineum. Always work from the area of least contamination to areas of more contamination and always from front to back . Review of Resident #32's clinical record documented an admission to the facility on [DATE] and a readmission on [DATE]. The resident's diagnoses included Chronic Kidney Disease, Abnormalities of Gait and Mobility, Atrial Fibrillation, Mild Cognitive Impairment, Benign Prostatic Hyperplasia, Cognitive Communication Deficit, Obstructive and Reflux Uropathy. Review of Resident #32's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 4 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident requires total assistance from the staff to complete his toileting activities. Review of Resident #32's care plan titled, Resident #32 has a foley Catheter related to bph (Benign Prostatic Hyperplasia,) initiated on 01/27/23 with a revision date on 01/27/23. Review of Resident #32's physician's order dated 08/26/23 documented re-insert indwelling foley catheter . Review of Resident #32's physician's order dated 02/06/23 documented Indwelling catheter care every shift. On 12/04/23 at 11:43 AM, observation revealed Resident #32 lying in bed with a foley catheter leg bag in place and clear yellow urine noted in the bag. On 12/06/23 at 8:54 AM, an interview was conducted with Staff H , Licensed Practical Nurse (LPN) who stated Resident #32 had a foley catheter and that the Certified Nursing Assistants (CNA) were responsible to provide catheter care. Staff H stated the resident had a diagnosis of Benign Hyperplasia Prostate. On 12/06/23 at 9:45 AM, an interview was conducted with Staff A, CNA who stated she was assigned to care for Resident #32 and that she will be giving him a shower. Staff A was informed that as part of the survey process, Resident #32 was selected for perineal/Foley catheter care observation. Staff A stated that she will provide the care around 10:30 AM. On 12/06/23 at 10:41 AM, perineal/foley catheter care observation for Resident #32 performed by Staff A, CNA commenced. Observation revealed the resident's privacy (cubicle) curtains were not drawn; and blinds were open during the catheter care. Observation revealed a large urinary drainage bag covered by a privacy linen by the resident's left side of the bed. The bag contained approximately 300 cc of yellow urine. Observation revealed Staff A performed hand washing, retrieved a basin with water and donned gloves. Observation revealed Staff A, with one damped wash cloth, cleaned Resident #32's inguinal (between the legs) left and right area with one stroke down from top to bottom with the same wash cloth. Further observation revealed Staff A continued using the same wash cloth to clean the residents thighs and again wiped the inguinal/peri areas with up and down strokes breaking the infection control measures. Furthermore, observation revealed Staff A retrieved a clean wash cloth, pulled back the resident's foreskin, cleaned the area and then with the same wash cloth and without using a different area of the cloth, cleaned the catheter tubing straight down. Continuing observation revealed Staff A retrieved an alcohol pad and cleaned the foley catheter tubing port and connected a foley leg bag around the residents leg. During the observation, at 10:55 AM, the Maintenance Director knocked at the resident's door and without waiting for an answer form Staff A, he opened the door. Resident #32 was exposed, privacy curtains were not pulled, and he was covered with a sheet, privacy was not provided. Staff A was asked when she will do the resident's bottom and stated she will do it in the shower. At 11:01 AM, observation revealed Staff A, CNA assisted Resident #32 to the in room shower. The resident foley catheter tubing was connected to a leg bag attached to his leg. Observation revealed that Staff A disconnected the resident's foley leg bag and stated that she did not want the leg bag straps to get wet because it can cause skin itching. Staff A proceeded to provide the resident with his shower. Staff A left Resident #32's foley catheter disconnected and hanging down while he was sitting in a shower chair getting a shower. The foley tubing was disconnected from the bag from 11:01 AM to 11:16 AM and was exposed to potential infection. During the observation, Staff A stated that normally she pulls the privacy curtain but did not because the surveyor was in the room. Staff A confirmed the Maintenance Director opened the door. Staff A was apprised that Resident #32 was exposed to the Maintenance Director when he opened the door, and the resident was uncovered and the privacy curtain was not drawn/closed. Staff A stated that for pericare she used two wash cloths, one to clean the inguinal area, the legs and another cloth to do the penis and the tubing. On 12/06/23 at 11:34 AM, an interview was conducted with the Unit Manager and was apprised of the peri/foley catheter care observation's findings. A side by side review of the facility's foley care procedure was conducted with the Unit Manager. On 12/07/23 at 1:02 PM, a joint interview was conducted with the Infection Preventionist/Staff Development Educator and Staff A, CNA. Staff A stated that normally when a resident who has a foley catheter needs a shower, she brings the resident with the drainage bag connected to the catheter into the shower to provide a shower. Staff A stated that she was stressed-out because of the observation. Staff A stated that she cleaned the foley catheter tubing end (port) with the alcohol pad. The Infection Preventionist/Staff Development Educator stated that Staff A was to cleaned the tip of the urine bag tubing and not the foley catheter tubing port. The Infection Preventionist/Staff Development Educator stated the foley catheter had to be connected to the drainage bag not left open/disconnected from the bag while Staff A was providing the shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow the Physician's tube feeding orders for 1 of 2 residents reviewed for tube feeding (Resident #81). The findings included: A chart review showed that Resident #81 was readmitted on [DATE] with a history of Motor Vehicle Accidents resulting in multiple fractures. Resident #81 was hospitalized for three months prior to her transfer to this facility. The Order Summary Report showed the following: Regular diet, pureed texture, thin consistency for the breakfast meal tray only, which was dated 11/15/23, Enteral feeding with Jevity 1.5 (tube feeding formulary type) at 65 milliliters (ml) an hour for 20 hours to start at 10:00 AM and stopped at 6:00 AM which was dated 11/06/23. A review of Resident #81 Minimum Data Set (MDS) admission 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 Status that the resident needed total assistance from the staff to complete the activities of daily living. In an observation conducted on 12/04/23 at 12:48 PM, Resident # 81 was in her room alone, in bed, sitting in a 90-degree position, and eating a pureed diet. Further observation revealed that the tube feeding Jevity 1.5 was running at 65 ml while Resident #81 was eating her lunch tray. In an observation conducted on 12/05/23 at 3:25 PM, Resident #81 was noted in her bed with the tube feeding on hold. Resident #81's mother, who was at the bedside, stated that she paused the tube feeding to give her daughter some juice. She further noted that Resident #81 was allowed to eat breakfast alone but needed the Speech Therapist to be with her while she ate lunch. In an observation conducted on 12/06/23 at 8:42 AM, Resident #81 was noted in her room with no tube feeding running. At 8:50 AM, staff came into the room with the breakfast tray, which showed a meal ticket for a Pureed diet. Continued observation at 9:10 AM showed that Resident #81 ate a few bites of her breakfast tray. On 12/06/23 at 10:00 AM, an observation showed Resident #81 in her bed with no tube feeding running. On 12/06/23 at 11:30 AM, an observation showed Resident #81 in her bed with no tube feeding running. An observation conducted on 12/06/23 at 1:03 showed that Resident #81 was noted in her room with the tube feeding Jevity 1.5 running at 65 ml an hour. The tube feeding bottle showed that it was started on 12/06/23 at 12:20 PM. The tube feeding bottle was noted at the 1000 ml mark out of a 1000 ml capacity bottle. An interview was conducted on 12/06/23 at 1:10 PM with Staff C, Licensed Practical Nurse, who stated that Resident #81 tolerates her tube feeding well and runs for about 20 hours daily with no issues. It may be stopped during mealtimes and as needed. In an observation conducted on 12/06/23 at 6:30 PM, Resident #81 was noted in her room with the tube feeding running at 65 ml an hour. The tube feeding bag showed that it was started on 12/06/23 at 12:20 PM. The closer review showed that the tube feeding was at the 850 ml mark out of a 1000 ml capacity bottle. This showed that only 150 ml was delivered in 6 hours and not the 390 ml that should have been administered according to Physicians' orders. In an observation conducted on 12/07/23 at 8:50 AM, Resident #81 was noted in the room with her breakfast tray. Resident #81's mother, who was also at the bedside, stated that her daughter eats about 50 to 80 percent of her breakfast meals and gets a mechanical soft diet consistency for lunch but only during trials done with the Speech Therapist. A progress note dated 11/15/23 revealed the following: The speech therapist (ST) recommended at this time that the patient be at liberty for the pleasure of eating puree and thin liquids with the family. The mother has been educated on safe swallow strategies and is able to reteach/return demo strategies when assisting the patient. Resident #81 is not to receive meal trays from the kitchen and is on trials of mechanical soft consistencies to continue with ST only during dysphagia treatment. In an interview conducted on 12/07/23 at 10:38 AM, the full-time ST reported that when Resident #81 was admitted , she was on tube feeding only. After doing swallow exercises and oral motor exercises, she could manage her secretion and swallow on command. Resident #81 was then started on pureed food trials, and a Modified Barium Swallow Study (MBS) was done on 11/13/23. According to the MBS results, Resident #81 was placed on a mechanical soft diet for breakfast but tired towards the middle of the meal. The ST decided to discontinue that order and place Resident #81 on pleasure foods like pudding, but it is not for hydration or meeting any nutritional needs. The ST further stated that this past Monday, Resident #81 was started on a breakfast meal of a pureed diet, and during ST treatments, she gets trials of mechanical soft meals. When asked by the surveyor if it was okay for Resident #81 to eat her lunch while the tube feeding was running, she said, It may be okay. The ST stated that she tries to do her trials of mechanical soft consistency to not interfere with Resident #81's tube feeding scheduled times. When asked if she knew Resident #81's scheduled tube feeding times, she did not know. The Speech Therapist reported that the goal is to decrease tube feeding and slowly provide more meals by mouth. A Dietary progress note dated 11/06/23 showed a slow progressive weight decline, and it was recommended to increase the tube feeding to 65 ml an hour for 20 hours. An interview was conducted on 12/07/23 at 11:53 AM with the facility's clinical dietitian, who stated that she adjusted the tube feeding times to allow Resident #81 to be hungry enough to eat her breakfast meal. This is why the tube feeding was changed to stop at 6:00 AM and to restart at 10:00 AM. Staff told her that Resident #81 tolerates her pureed diet well but did not give her any specific percentage intake of the meals. According to the Dietitian, she will only reduce the tube feeding rate if she has a more accurate percent intake of Resident #81's meals and meets her nutritional needs by mouth to proceed further with making the tube feeding changes. An interview conducted on 12/07/23 at noon with Staff A, Certified Nursing Assistants, states that Resident #81 only eats about 25% of her breakfast meals. An interview conducted on 12/07/23 at 12:10 PM with Staff B, Certified Nursing Assistants, states that Resident #81 only eats about 30% of her breakfast meals. The percentage intake of meals documented by staff from 12/04/23 to 12/06/23 did not show any percentage intake for the breakfast meals for Resident #81. In an interview conducted on 12/07/23 at 3:00 PM with the facility ' s Administrator, she was told of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A review of the policy titled Scabies Identification, Treatment, and Environmental Cleaning, revised on 08/21/23, showed the following: Diagnosis may be established by recovering the mite from its burrow and identifying it microscopically. Failure to identify scrapings as positive does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one or two mites may cause multiple lesions. Often, diagnosis is made from signs and symptoms, and treatment is followed without scrapings, although scrapings are preferred. The facility will follow the primary physician's discretion on treatment and management. Resident #35 was admitted to the facility on [DATE] with diagnoses of Anemia, Depression, and Hypokalemia. The Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #35 has a Brief Interview of Mental Status (BIMS) score of 15, which is cognitively intact. In an interview conducted on 12/05/23 at 1:10 AM with Resident #35, she stated that she first had symptoms of itching and scratching, which started 6-8 months ago. The in-house Dermatologist treated her for the first time when the initial symptoms began. She was given a white cream for 8-10 hours to be used only once and was treated again in October of 2023 by the in-house Dermatologist, and the same treatment was done earlier with the white cream. The symptoms never went away, and she only saw the in-house Dermatologist twice in 6-8 months. She further said that she could not sleep at night and was itching and scratching. She showed the Surveyor the bites all over her legs, back, and even the bottom of her feet. The Surveyor asked Resident #35 if skin scraping had ever been done, and she said no. In an interview conducted on 12/05/23 at 1:25 PM with Resident #35's husband, he stated that his wife has been suffering from a rash all over her body for months and that he asked the Director of Nursing for an outside Dermatologist to see his wife. The Director of Nursing told him that his wife needed to see another dermatologist since the rash and the itching did not go away, but his wife did not see another Dermatologist, and the issue has not been resolved. In an interview conducted on 12/05/23 at 2:11 PM with the Director of Nursing, he stated that they decided to move forward by looking for another in-house dermatologist and keeping the current one until they get another dermatologist. They had some issues with the in-house Dermatologist, and this is why the Medical Director stepped in and told the facility that he would see the residents who had skin issues. A Progress note dated 05/02/23 showed that Resident #35 was informed that she was exposed to a resident that had scabies and, therefore, she would be placed in isolation. A review of the medical chart showed a prescription note dated 05/03/23, which was prescribed by the in-house Dermatologist for Elimite (treatment cream for scabies) to be applied to the body and washed off after 10 hours and repeated after five days. The Medication Administration Record showed that the cream was applied once on Resident #35 but was not repeated after five days as prescribed by the in-house Dermatologist. Further review did not show any follow-up notes by the in-house Dermatologist regarding the continued symptoms of itching and scratching and treatments that Resident #35 had. Continued electronic chart review showed that Resident #35's Primary Doctor ordered Elimite to the entire body, which was dated 10/21/23, and was called again on 10/26/23. Another note by the Primary Physicians, dated 11/29/23, showed that Resident #35 had a rash on the upper chest and back. He prescribed Hydrocortisone Cream (general cream for itching) and Benadryl (treats pain and itching). Based on observation, interview, and record review, the facility failed to provide needed care and services for residents with skin conditions for 5 of 5 sampled residents reviewed for skin conditions (Resident #13, #20, #34, #56, and #35). The findings included: 1. An observation was conducted of Resident #13 on 12/04/23 at 12:30 PM. The resident was observed sitting in a wheelchair in the hallway outside of her room. The resident was observed scratching her arms. An interview was conducted with the resident at the time of the observation. Resident #13 stated she has been itching for months without any relief. The resident stated they (staff) were giving her some kind of cream, but it was not working. The resident proceeded to show the surveyor a rash/red lesions on both arms, legs, and feet. The resident could not recall if she had seen a dermatologist, but stated something has to be done about it. The resident further stated her old roommate (Resident #20) has the same thing, but worse. Record review revealed Resident #13 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact and was a total two-person assist for activities of daily living. Resident #13 was care planned for a rash of the peritoneal area related to fungal infection dated 09/28/23. An intervention included to monitor skin rashes for increased spread or signs of infection. A review of Resident #13's orders revealed the following orders: 07/21/23 - Dermatology appointment 09/25/23 - Clotrimazole Cream 1% (antifungal) apply topically two times a day for fungal skin for 3 weeks. 10/02/23 - Clotrimazole Cream 1% apply topically to perineum two times a day for fungal rash for 3 weeks. 10/02/23 - Fluconazole tablet 150 mg (antifungal) one tablet a day for infection for 10 days. 10/21/23 - Elemite External Cream 5% (scabies treatment) apply topically to whole body one time for 10 hours for rash. 10/30/23 - Permethrin External Cream apply to whole body topically 1 time only for rash for 1 day. 11/01/23 - Permethrin External Cream apply to whole body topically 1 time only for rash for 1 day. 11/130/23 - Nystatin-Triamcinolone Cream (antifungal) apply to left and right foot topically two times a day for rash for 14 days. 11/30/23 - Nystatin External Powder (antifungal) apply to right breast fold, left breast fold, and perineum topically every 8 hours for rash for 14 days. A review of Resident #13's Medication Administration Record revealed the resident was administered the Elimite Cream on 10/23/23. The resident was not administered the Elimite Cream on 10/30/23 or 11/01/23. There was no documentation of communication to the physician of the medication not administered. Further review of Resident #13's record revealed no documentation of the resident being seen by a dermatologist. An interview was conducted with the Director of Nursing (DON) on 12/07/23 at 12:00 PM. The DON acknowledged the above. 2. An interview was conducted with Resident #20 on 12/04/23 at 1:00 PM. The resident stated she had an itchy skin rash for a long time. The resident stated she had not seen a dermatologist but would like to. Resident #20 stated it was frustrating and annoying due to the fact she could only use her right hand to scratch. The resident's right arm was noted with red patches. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Stroke and contracture of the left upper extremity. A comprehensive assessment dated [DATE] documented the resident as cognitively intact with upper extremity impairment of one side. Resident #20 was not care planned for any skin issues. A review of Resident #20's orders revealed the following: 05/02/23 - Permethrin External Cream 5 % Apply to Head to Toe topically one time only for Scabies until 05/03/2023 - 07:00 Apply to entire Body except eyes and peri area. 05/02/23 - Wash and shower entire body one time only until 05/03/2023 05/02/23 - Contact Isolation Precaution/ Scabies (discontinued 05/04/23) 10/21/23 - Elemite External Cream 5% (scabies treatment) apply topically to whole body one time for 10 hours for rash. 10/24/23 - Elemite External Cream 5% (scabies treatment) apply topically to whole body one time for 10 hours for rash. A review of Resident #20's Medication Administration Record revealed the resident was administered the Elimite Cream on 10/24/23 and 10/28/23. Further review of Resident #20's records revealed the resident did not have a dermatology consult and had not seen a dermatologist. There was no evidence of a follow-up on the resident's rash/condition. An interview was conducted with the Director of Nursing (DON) on 12/07/23 at 12:00 PM. The DON acknowledged the concerns. 3. An interview was conducted with Resident #34 on 12/04/23 at 3:40 PM. The resident stated he has a rash on both arms and complains of itching. Resident #34 stated he had not seen a dermatologist but would like to. The resident further stated he sees everyone in the dining area scratching. There must be something going around. The resident stated his roommate (Resident #56) was worse. Record review revealed a comprehensive assessment dated [DATE] documented the resident was cognitively intact and required set-up only for activities of daily living. Resident #34 was not care planned for any skin conditions. A review of Resident #34's orders revealed the resident was not receiving any medication for a skin rash and did not have a dermatology consult. An interview was conducted with the Director of Nursing (DON) on 12/07/23 at 12:00 PM. The DON acknowledged the above. 4. An interview was conducted with Resident #56 on 12/04/23 at 3:50 PM. The resident stated he had been itching for approximately three weeks. The resident stated they started giving him some pills and it is better, but he would still like to see a dermatologist. Record review revealed Resident #56 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident was cognitively intact. A review of Resident #56's orders revealed the following: 10/16/23 - Diphenhydramine HCl Oral Tablet 25 MG Give 1 tablet by mouth every 8 hours as needed for Itchy. 10/16/23 - Permethrin External Cream 5 % Apply to all body topically one time only for Itchy. Use the tube to cover all body for 1 Day. Leave the cream for 8 Hrs. Give resident a shower @ 6 AM. 10/16/23 - Hydroxyzine HCl Oral Tablet 10 MG Give 1 tablet by mouth two times a day for Pruritus (itching). 11/30/23 - Lotrimin AF Cream 1 % Apply to both upper extremities topically everyday shift for pruritus until 12/15/2023. Apply sparingly to both arms. A review of Resident #56's Medication Administration Record revealed the resident was administered the Permethrin Cream on 10/16/23. Further review of Resident #56's records revealed the resident did not have a dermatology consult and had not seen a dermatologist. There was no evidence of a follow-up on the resident's rash/condition. An interview was conducted with the Director of Nursing (DON) on 12/07/23 at 12:00 PM. The DON acknowledged the above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to follow physician orders for daily wound care and failed to provide wound care with appropriate technique for 1 of 1 resident (Resident #85). The findings included: Review of the facility policy titled Wound Care with a revision date of October 2010, included in the steps in the procedure is wash and dry your hands thoroughly, use a no-touch technique, wear exam gloves for holding gauze. Record review for Resident #85 revealed the resident was admitted on [DATE]. His Diagnoses included Acute Kidney Failure, Pressure Ulcer of Sacral Region, Pressure Ulcer of Right Heel, Type 2 Diabetes Mellitus, Absence of Left Leg Below Knee, Colostomy. The minimum data set (MDS) dated [DATE] revealed in Section C a brief interview for minimum status (BIMS) score of 15 which indicates intact cognitive response. Section G revealed bed mobility, transfer, toilet use all have self-performance of extensive assistance with support of one-person physical assist. Physician Order for Resident #85 dated 07/07/22 to cleanse sacral wound with Dakin's 0.25% solution, apply Collagen powder and pack with Dakin's 0.25% moisten gauzes and cover with dry dressing daily and as needed, every day shift for Sacral stage IV pressure injury. Record review for Resident #85 revealed the resident did not receive wound care on 07/18/22, 07/28/22, 07/29/22, and 08/02/22. Care plan for Resident #85 dated 6/28/22 with a focus on resident has pressure ulcers to: Sacrum stage IV and Right heel stage III and remains at high risk for further skin breakdown related to: mobility impairment, Diabetes, Renal Failure. Goal included Current skin condition will not show sign and symptoms of deterioration by the next review date. Current wound will show evidence of improvement by decreasing in size by next review date. Interventions included Ask resident to express pain or/and observe for nonverbal pain signs during treatment. Assess wound weekly to include size, tissue type, drainage, and document accordingly. On 08/10/22 at 8:30 AM an observation was conducted of wound care for Resident # 85 with Staff L, LPN. He began pulling supplies out of the treatment cart without washing his hands or using alcohol-based hand sanitizer and not wearing gloves. He then ripped open approximately 8 gauze packets and pulled the gauze out of their package with his unwashed/non-sanitized gloveless hands. This gauze was wet with the Dakin's solution and was intended to be used to clean and pack the resident's wound. When asked about what technique he was using for the wound care, he stated clean. Surveyor informed him that he did not wash/sanitize hands first, was not wearing gloves and touching the gauze with his bare hands. He then threw away the gauze, washed and gloved his hands and proceeded to gather supplies. Staff L LPN then performed the dressing change as ordered and washing his hands between glove changes. Also noted the LPN was perspiring excessively and drops of sweat were dripping into the treatment cart that was open. During an interview conducted on 08/08/22 at 10:35 AM with Resident # 85 he stated his sacral wound is a stage 4 and there is an order for the wound care to be done daily, the problem is that the wound care is not done daily. He just wants to have his wound heal so he can go back home. During an interview conducted on 08/10/22 at 1:55 PM with Staff L, LPN, he stated he has been a nurse since 2011 and has been with the facility since May 2022. He stated he works Monday to Friday every week doing wound care and on average he has 13 residents that receive wound care. When asked about the wound care he performed earlier in the day for Resident #85 he stated he should not have touched the gauze with his bare hands, and he should have washed his hands and put on gloves before gathering his supplies and He acknowledged that he has an issue with perspiration that can come in contact with wound care supplies. When asked about the daily sacral wound care not being performed for 4 days, he replied, I don't know, I was out 1 day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) ensure that it secured over-the-counter (OTC) medications for 3 of 4 residents (Residents #253, #77, and #98). The findings included: 1) Review of facility policy and procedure on 08/09/22 at 3:15 PM for Medication Storage provided by the Director of Nursing (DON) revised date 05/05/22 indicated Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles 3. General Storage Procedures: .3.2 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is not accessible by residents and visitors 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration. 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room . 2) During an observational room tour on 08/08/22 at 10:39 AM, Resident #253's room was observed with a used container of ultra-strength OTC Muscle Rub with an expiration date 05/2024, located near the resident's bed, on top of his air conditioner's rim; it was unlocked, unsecured, visible and easily accessible to other residents, employees and visitors. Resident #253 was originally admitted to the facility on [DATE] with diagnoses which included Joint Replacement surgery of the right shoulder, Bipolar Disorder, Polyneuropathy, Primary Osteoarthritis of right ankle and foot, Hypertension, and Gastroesophageal Reflux Disease (GERD). He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Photographic evidence was obtained of the tube of OTC Muscle Rub. During an interview conducted on 08/09/22 at 2:16 PM with Staff J, a Licensed Practical Nurse (LPN) and with Staff K, an (LPN)/Unit Manager (LPN/UM), for the Galilee Unit, they both indicated this resident does not self-administer any of his own medications and neither was he assessed to be able to do so. Side-by-side record review was conducted with Staff K, neither Resident #253's hard copy chart nor his computerized Point-Click-Care (PCC) medical record indicated that the resident had any self-assessment completed in order for him to be able to administer his own medications. There was no order on the Resident #253's Medication Administration Record (MAR) for this OTC medication to be administered to this resident. On 08/09/22 at 2:42 PM the Director of Nursing (DON) further acknowledged and recognized that the OTC Muscle Rub medication should not have been left at the resident's bedside. 3). On 08/08/22 at 12:23 PM, initial tour to the facility's Masada's unit revealed Resident #77 in her room. An interview was conducted with Resident #77 and she stated she had a wound vac and was getting therapy. An observation revealed a bottle of Multivitamins on top of the resident's table in plain view and two bottles of undated normal saline solution half empty on top of the night stand next to her bed (Photographic evidence taken). During the interview, the resident stated that her friend brought in the Multivitamins bottle. An inquiry was made regarding the normal saline bottles on top of her night stand and the resident stated that the normal saline bottles were left in her room by the nurse who changed her wound vac dressing. The resident stated that the wound vac dressing was changed on Mondays, Wednesday and Friday's. On 08/09/22 at 10:07 AM, a second observation revealed Resident #77 in her room sitting up in a wheelchair. Further observation revealed the Multivitamins bottle continues to be on top of the resident's table and the two normal saline bottles continues to be on top of the resident's night stand. On 08/09/22 at 1:04 PM, a third observation revealed Resident #77 in her room. Further observation revealed the Multivitamins bottle continues to be on top of the resident's table and the two normal saline bottles continues to be on top of the resident's night stand. On 08/09/22 at 1:05 PM, an interview was conducted with Staff N, a Certified Nursing Assistant (CNA) and was asked if she noticed that Resident #77 had a medication bottle on top of her table. Staff N stated she did not notice that the resident had a bottle of medication on her table. On 08/09/22 at 1:09 PM, an interview was conducted with Staff M, CNA. Staff M was asked if she noticed that Resident #77 had a bottle of Multivitamins on top of her table. Staff M stated she did not know the resident had a bottle of Vitamins on her table. Staff M stated if she see it, she will let the nurse know. Staff M confirmed that Resident #77 had a bottle of a medication on her table. Staff M was apprised that the bottle of vitamins had been on her table since Monday. On 08/09/22 at 1:32 PM, an interview was conducted with Staff H, a Registered Nurse (RN) and stated that she administered Resident #77 morning medications and did not see a bottle of Multivitamins on her table. Staff H stated the resident was not supposed to have medications in her room. Staff H stated she removed the bottle from the residents room today after Staff N, CNA told her. Staff H was apprised that Resident #77 bottle of Multivitamins was on top of her table since the survey started on 08/08/22. On 08/09/22 at 1:43 PM, an interview was conducted with the Unit Manager and stated the residents are not supposed to have medications in their room. The Unit Manager added that the resident would be assessed if they want to self-administer any medication. The Unit Manager stated that did not have any resident doing self-administration of medications at the time of the survey. Review of Resident #77 clinical record documented an admission to the facility on [DATE]. The resident diagnoses included Hypertension, Atrial Fibrillation, Deep Incisional Surgical Site and Muscle Weakness. Review of Resident #77 Minimum Data Set (MDS) 5 days assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 14 of 15 indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance with her Activities of Daily Living (ADL's) and supervision with eating. Review of Residents #77's care plans lack evidence of a care plan created related to self-administration of medications. Further review revealed lack of evidence of an assessment completion related to self-administration of medications. Review of Resident #77's Medication Administration Record (MAR) for August 2022 documented that the resident was receiving Multivitamin with Minerals tablets daily since 05/26/22. 4). On 08/09/22 at 10:16 AM, an interview was conducted with Resident #98 and she stated that she was stressed out because of being in the facility. The resident added that she might be getting something (medication) to help her relax. The resident was moving her hands from side to side and looking from side to side, appeared to be anxious. Observation revealed a bottle of lubricant eye drops on top of the resident's night stand and a bottle of Vitamin D-3 gummies on top of a dresser in front of her and her roommate's bed. During an interview, Resident #98 stated that she put the lubricant eye drops, one on each eye, twice or once a day for itching eyes and that she was taking the Vitamin D-3 gummies every day. On 08/09/22 at 10:30 AM, observation revealed Staff E, LPN in front of Resident #98's room with the medication cart. An interview was conducted with Staff E, LPN and was informed of Resident #98 feeling stressed with an anxious appearance. Staff E stated she was ready to administer the resident's medications. Staff E added the resident was getting something to relax her. On 08/09/22 at 1:48 PM, an interview was conducted with Staff E, LPN. Staff E stated she did not know Resident #98 had medications at the bedside. Consequently, a side by side review of the resident bedside was conducted with Staff E. Staff E stated she administered eyes lubricant to the resident in the morning and did not notice the bottle of lubricant eye drops on top of her night stand. Staff E stated the resident was not supposed to have medications in the room. On 08/09/22 at 2:01 PM, during an interview with the Unit Manager, it was pointed out, the location of Resident #98's bottle of Vitamin D-3 gummies. The Unit Manager was apprised that the resident also had a bottle of lubricant eye drops on top of her night stand. The Unit Manager stated the resident had not been assessed to do self-administration of medications, therefore she should not have any medications in her room. Review of Resident #98's clinical record documented an admission to the facility on [DATE] with no readmissions. The resident diagnoses included Cognitive Communication Deficit, Anxiety Disorder, and Dementia. Review of Resident #98's MDS quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 6 of 15 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed limited assistance with her ADL's and supervision with eating. Review of Resident #98's care plans lack evidence of a care plan created related to self-administration of medications. Further review revealed lack of evidence of an assessment completion related to self-administration of medications. Review of Resident #98's Medication Administration Record (MAR) for August 2022 documented that the resident was receiving Systane Ultra (a lubricant eye drops) solution one drop in both eyes twice a day for Dry Eye Syndrome since 03/08/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5) During a tour of laundry room on 08/11/22 at 12:00 PM with Director of Operations and Director of Housekeeping, the Director of Housekeeping stated that nursing staff bring bagged dirty laundry to the soiled utility room, then laundry staff bring soiled laundry to the laundry room. Laundry is open from 6:30 AM to 5:30 AM. One of 2 washing machines is not working for about a week, 1 of 3 dryers is not working for about a month. Dryers had loose lint in the lint traps. There was debris and rotten wood behind the washing machines. There was a rusty vent in the washing machine room. The floor in the clean laundry room was dirty with debris along baseboards and in corners. During a tour of the central supply room on 08/11/22 at 12:20 PM with the Director of Operations and the Central Supply Clerk, there were several boxes stacked on bare wooden pallets and bare wooden platforms. The floor was dirty with debris. Photographic evidence obtained. During an interview conducted on 08/11/22 at 12:35 PM with the Director of Operations he stated he will get working on correcting these issues. Based on observation, interview, and record review, it as determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 2 Units (Massada and Galilee), Laundry Area, and Central Supply Area. The findings included: 1) During the initial tour of the facility conducted on 8/8/22 at 9 AM, it was noted there was a large puddle of water (8 X 8) located in the Main Dining Room near the kitchen entry door. Further observation noted that there was a ceiling leak that was the cause of the large puddle. It was also noted that the water leak was also coming out of the ceiling light fixture. The surveyor requested immediate assistance due to the potential for fall and possible electrocution. Facility staff were unaware of the issues, and a yellow cone was placed in front of the puddle. 2) During environment rounds conducted on 8/8/22 and 8/9/22, and a environment tour conducted on 8/10/22 at 1 PM with the Corporate Operations Director, the following were noted: (a) Main Hallway: It was noted that there was a floor drain located outside of the main activity room. Further observation on 8/8/22 and 8/10/22 noted that the drain cover was loose and the drain was open and presented a potential trip/fall risk. 3) Masada (100 Unit): room [ROOM NUMBER]: Room floor heavily soiled and numerous black stains. room [ROOM NUMBER] - No over-bed light pull cord (A-bed), electric bed (A-bed) non-operational, bathroom portable commode seat was rust laden, room floor heavily soiled and numerous black stains, window curtains would not open/close properly, bathroom ceiling fire sprinkler had mold area around the base, and dresser drawers were broken and did not close properly. room [ROOM NUMBER] - Room entry door was in disrepair and noted to have sharp edges, and room floor was heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - Room walls had area of peeling paint and disrepair, bathroom toilet requires re-caulking to the floor, room base boards not fitting to wall, and room floor was heavily soiled and numerous black stains. room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains, broken drawers in room dresser, and room chair exterior was heavily worn. room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - Room floor was heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - Bathroom entry door in disrepair and in need of re-painting, and room floor was heavily soiled and numerous black stain areas. Medication Storage Room - repairs to room walls had not been completed (3 weeks) and no hand soap in sink dispenser. 4) Galilee (200 Unit) : Soiled Utility Room - Observation of the Specimen Refrigerator noted that there was a urine sample that was not properly labeled and documented. It was also noted that the resident was discharged from the facility 20 days ago. Electrical Room - Observation noted that the entry door was unlocked and was a potential for residents to enter the room unattended. The Manager stated that the room is to be locked at all times. Hydration Cart - The exterior of the cart was soiled, cracked, and rust laden. room [ROOM NUMBER] - Room floor was noted to be heavily soiled and numerous areas of black stains. room [ROOM NUMBER] - The room base boards and room walls were noted to have numerous areas of peeling paint, large hole in bathroom wall, and the exteriors of room and bathroom entry doors were in disrepair was areas of sharp edges. room [ROOM NUMBER] - Over-bed table exterior was soiled, room window shade was nonoperational, and dresser drawers were broken and would not close. Following the tour the findings were again confirmed with the Director of Operation. Further interview with the Director noted that a Maintenance/Housekeeping Log is located at each of the 2 nurses station. Facility staff are to report issues on the log for the issues to be addressed by the facility's maintenance and housekeeping departments, however following the tour the director stated that staff are not properly documenting specific maintenance and housekeeping issues.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that physician ordered No Concentrated sweet Diets and No Concentrated Sweet/No Added Salt diets were followed for 36 residents that included Resident #6 and Resident #64. The findings included: During the review of the approved menu for the lunch meal of 8/10/22 , it was noted that the No Concentrated Sweets Diet (NCS) and No Concentrated Sweets/No Added Salt (NCS/NAS) were to be served a #8 scoop (4 ounces) of Fruit Mix Packed in Juice. During the observation of the lunch meal in the main kitchen on 8/10/22 at 12 PM it was noted that a fruit mix was being served to NCS and NCS/NAS diets, however the surveyor requested to see the #10 cans of fruit utilized for NCS and NCA/NAS diets. The surveyor review the #10 can ingredients and it was noted that the label indicated that the fruit had been packed in Light Syrup . Following the review the surveyor informed the Food Service Director the fruit mix being utilized was incorrect for the NCS and NCS/NAS diets. The surveyor review the approved lunch menu and reviewed that the diet indicated fruit that was packed in juice. Following the observation and review, the surveyor requested a 8/10/22 diet census to indicated how many residents had physician orders for a NCS or NCS/NAS diet. The finding of the review indicated that there were 8 residents (including Resident #64) with current physician diet order of No Concentrated sweets and 29 residents (including Resident #6) with current physician order of No Concentrated Sweets/No Added Salt diet . Further investigation noted all 36 residents including Residents 6 and #64 had a current diagnoses of Diabetes Mellitus.

During observation, interview, and record review the facility failed to implement infection control policies to prevent the development and transmission of communicable diseases and infections for 7 out of 7 residents sampled (Residents #302, #303, #74, #304, #19, #305, #306). The findings included: Review of the facility policy titled Isolation Trays dated 2020 revealed any resident with a suspected or known communicable disease or infection will receive an isolation meal tray as per community guidelines. The isolation tray will consist of all disposable dishes and flatware. This includes paper plates, napkins, silverware, and condiments. No item that come in contact with the resident or resident's room will be returned to the Dining Services Department. During an observation made on 08/08/22 at 10:00 AM Residents #74, 303, 304, 305, 302, 19 and 306 were all in isolation (droplet precautions) and they all had regular dishes, regular cups, and regular silverware instead of the disposable ware. During an interview conducted on 08/08/22 at 10:30 AM with the Infection Preventionist she stated the residents that are in isolation should be receiving all meals with disposable plates, cups and plasticware. During an interview conducted on 08/08/22 at 11:00 AM with the Licensed Dietician who stated nursing is supposed to notify Dining Services Department when a resident is put on isolation or taken off isolation. She stated that on Monday morning the dish machine had 4 chemical tests conducted to ensure the machine was sanitizing properly. The 4 chlorine test strips conducted indicated no chemical level present in final rinse. Surveyor ordered to cease use of dish machine, until it was repaired. Ecolab came in on 08/08/22 at 10:52 AM machine diagnosed and found the sanitizer pump was bad. The sanitizer pump was replaced, and the lines primed with appropriate sanitizing chemicals. Now testing at 100 ppm for chlorine sanitizer. The machine is now functioning properly.

Based on observation, interview, and record review, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, that included ensure the dish machine and 3-compartment sink maintain required levels of sanitizing chemical as per regulation, proper food holding temperatures as per regulation, maintenance of food refrigeration units, and maintenance of air-conditioning ventilation system. The findings included: 1) During the initial kitchen/food service observation tour conducted on 8/8/22 at 9 AM and accompanied with the Food Service Director (FSD), the following were noted: (a) Upon entering the kitchen, it was noted that the breakfast meal was being served from the Dairy Kitchen (Kosher Kitchen). Observations noted that there were 4 ceiling air-condition vents (3 located above the tray line and 1 located in the 3-compartment sink area) the were soiled and had a heavy build-up of condensation which were steadily dripping. It was noted that the contaminated condensation was dripping down onto prepared foods located in the steam table, food preparation surfaces, food preparation equipment, clean dishware, and staff working in the areas. It was discussed with the FSD that the contaminated dripping condensation could potentially result in food borne illness and food contamination. The surveyor informed the FSD that the Dairy Kitchen should be shut down and not reopened until the air-conditioning ventilation issues was assessed and repaired. (b) Observation of the Meat Kitchen which was to be utilized for the lunch meal on 8/8/22 was observed and it was also noted that the 4 air-conditioning vents (3 vents over the tray line and 1 over the 3-compartment sink area) was also full of contaminated condensation and were continuously dripping. The surveyor requested the Director of Maintenance to view the issues and confirmed the surveyor's findings. The Maintenance Director was informed by the surveyor that the issue must be repaired prior to the lunch meal due to threat of food borne illness and food contamination. The director informed the surveyor that a air-conditioning vendor would be contacted for immediate service to assess and repair the ventilation system. (c) Observation of the dish machine room noted that the area was thick with steam from the machine. It was noted that the exhaust system located over the machine was pulling the steam out of the room. Observation of the ceiling air-conditioning vent located over the middle of the room was black mold laden and full of condensation that was steadily dripping down onto clean dishes being stored with the room. The surveyor informed the FSD that the dishes were being contaminated and could not be used until they were re-washed. During the observation it was noted that staff were washing dishes and silverware to be used for the breakfast and lunch meal. At the surveyor's request the low-temperature dish-machine was tested to ensure that the chemical sanitizing agent was present in the final rinse. Following 4 tests conducted with chemical strips provided by the facility it was determined that the dish-machine was not sanitizing dishware and silverware according to chlorine regulations. The surveyor informed the FSD that the machine could not be utilized for washing until the issues was resolved. The surveyor also informed the FSD that dishes and silverware washed on 8/8/22 could not be utilized for resident use on 8/8/22. The FSD informed the surveyor the chemical company servicing the dish-machine would be called for immediate servicing. It was also noted during the observation that there was no documentation of a log that the dish-machine was tested for sanitizing chemical levels for all meals. (d) Observation of walk-in refrigerator #1 noted that the temperature was recorded internally at 50 degrees F. The surveyor informed the FSD that the minimum required temperature of 41 degrees F or below must be maintained as per regulation requirement. The surveyor informed the FSD that the unit should not be utilized until the temperature issue was resolved. During the observation of walk-in refrigerator #1 it was also noted that the floor area was heavily stained and soiled, and that all the interior walls had large areas of peeling paint and pitting. (e) During the observation of walk-in refrigerator #2 it was noted that the interior floor was heavily soiled and the interior room walls had areas of peeling paint and heavy pitting. (f) Observation of the commercial ice machine noted that the interior walls (3) had a build-up of yellow matter which could be a potential hazardous mold. The surveyor requested that ice not be used from the machine and that the ice should be emptied and properly cleaned and sanitized prior to use. (g) Observation of the dry/canned storage room noted that the entire floor was heavily soiled and stained. (h) During the testing of the cleaning cloth buckets it was noted that 2 of the 4 buckets did not contain the required chemical sanitizing agent level as per regulation. (i) During the observation of the breakfast tray line in the Dairy Kitchen on 8/8/22 at 9 AM, the temperatures of the hot and cold foods were taken utilizing the facility calibrated bayonet thermometer. The temperature testing revealed that hot foods were not being maintained at the regulatory temperature of 135 degrees F and cold foods were not being held at the regulatory temperature of 41 degrees F or below. The temperatures were noted as follows; Milk (35 -8 ounce cartons = 60 degrees F Honey Thick Juice (20 portions) = 55 degrees F Cottage Cheese Portions = 46 degrees F Boiled Eggs (30 individual) = 48 degrees F 2) During the observation of the lunch meal being prepared in the meat kitchen located within the main kitchen on 8/8/22 at 11:30 AM, the following were noted: (a) Clean silverware was not being handled in a sanitary manner, specifically the clean silverware was located in a open dish rack and Staff B was handling each piece of silverware by the eating section with their bare hands prior to bagging. The surveyor informed the FSD that Staff B was contaminating the silverware and to cease immediately and re-wash all silverware. It was noted 15 minutes latter that Staff B was wiping each piece of silverware with a soiled rag prior to bagging. Once again, the surveyor informed the FSD that the silverware was contaminated and required re-washing and sanitizing. (b) Observation noted that a 5 pound package of commercial wrapped sliced ham was being thawed in a container of room temperature water. The surveyor informed the FSD that this thawing method is not allowed per regulation and that the ham could only be thawed in running cold water. The surveyor requested that the FSD discard the package of sliced ham. (c) During the lunch observation it was noted that staff A was bagging individual slices of bread with bare hands. Staff A had been noted to be working in the garbage/refuse area prior to the meal observation and hand washing was not observed by the surveyor. The surveyor informed the FSD to discard all bagged bread and to ensure proper hand washing and to wear gloved hands during this task. (d) During the lunch observation it was noted that the 4 soiled ceiling vents were full of condensation and continued to drip constantly onto foods located in the steam table, food preparation surfaces, food preparation equipment, clean dishware, and staff working within the area. The surveyor informed the FSD that there was a high potential of food borne illness and food contamination . 3) During a subsequent observation conducted on 8/11/22 at 11 AM , observed Housekeeping Aide enter the kitchen with housekeeping cart (open trash, broom, mops, dustpan, no hair net) pushed cart through food preparation and serving area. Surveyor asked what she doing and she stated she was cleaning in the dietary department specifically the rest rooms . FSD stated the housekeeping department are required to enter the dietary department though the back door of the department where the rest rooms are located. 4) During a subsequent observation of the main kitchen on 08/10/22 at 12 PM, it was noted that the lunch meal was being served from the Meat Section of the kitchen. Further observation noted that 1 of the ceiling mounted air-conditioning vents located directly over the food tray assembly line and was still noted to be full of condensation and was dripping down onto foods located on the steam table. The surveyor again stated to the FSD that the issue is a potential food borne illness and potentially food contamination issues and requires correction immediately. Also during the 08/10/22 observation the 3-compartment sinks in both the Dairy and Meat sections of the kitchen were being utilized to wash food preparation equipment. At the surveyor's request both 3-compartment sinks were tested for the chemical level in the sanitizing sink. Following multiple (3) testing by the FSD it was noted that both the Dairy and Meat 3-compartment sinks failed the chemical testing as per regulation. The surveyor requested that the use of the 3-compartment sinks cease, and correct the issue prior to continue use. The surveyor also stated that food preparation equipment must be rewashed and sanitized prior to use. Also during the 08/10/22 observation it was noted that the bench mounted commercial can opener was rust laden and the opening blade was dull causing a layer of metal shavings on the blade surface. The surveyor requested the commercial can open be properly cleaned to eliminate rust and that a new opening blade be installed.