**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #60's admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #60's Transfer Form showed on 2/21/2025 the resident was transferred to an acute care facility due to placement of a midline. Review of Resident #60's physician order, dated 2/21/2025 at 2:43 p.m. showed the facility was to send the resident to ER for re-insertion of a midline by the vascular team. Review of Resident #60's Nursing Home Transfer and Discharge Notice showed the notice was given on 2/21/2025 and effective on 3/21/2025. The form showed the resident was transferred or discharged to an acute care facility due to Your needs cannot be met in this facility, and did not include a Brief explanation to support this action. The form did not include resident representative information and was signed by the resident on 2/28/2025 and showed the resident, legal guardian, or representative received the notice on 2/28/2025. Review of Resident #60's Minimum Data Set, dated [DATE] revealed the resident's Brief Interview of Mental Status score was 10, indicating moderate cognitive impairment. An interview was conducted on 3/12/2025 at 2:12 p.m. with Staff H, Licensed Practical Nurse (LPN). The staff member reported knowing what the Nursing Home Transfer and Discharge Notice was and thought Social Services completed it. An interview was conducted on 3/12/2025 at 2:27 p.m. with the Social Services Director (SSD). The SSD confirmed doing the Nursing Home Transfer and Discharge Notice, which were typically uploaded into the resident records but may still have them in the office. The SSD stated the facility attempted to complete the Nursing Home Transfer and Discharge Notice, but 9 out of 10 times the transfer/discharge was an emergency, resident was unable to sign, and family was not in the facility so we have them sign it when they come from the hospital. The SSD was able to locate both Resident #55 and Resident #60's Nursing Home Transfer and Discharge Notices on top of her desk. The SSD stated the forms are completed then when the resident comes back we get them signed. The SSD reported being aware of the allowed time frame and stated it's an emergency and mostly wait till they come back. Review of the policy titled Social Services, Notice of Transfer and/or Discharge, undated, revealed the following: Policy Statement: The facility will permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless: A. The transfer just charges necessary for the residents welfare and the residence needs cannot be met in the facility; B. The transfer discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; C. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident; D. The health of the individuals in the facility would otherwise be endangered; E. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) and stay at the facility; or F. The first hostility ceases to operate. Policy Interpretation and Implementation: 1. Before the facility transfers or discharges a resident, the facility will notify the resident and the representative of the transfer or discharge and the reasons for the move in writing in any language and manner they understand. 5. Should the health or safety of the individuals in the facility be endangered or the health of the resident's has improved sufficiently to allow a more immediate transfer or discharge or an immediate transfer or discharge is required by the resident's urgent medical needs or the resident has not resided in the facility for 30 days, notice would be given as soon as practicable. 7. The resident, and/ or representative will be provided with the following discharge notice requirements: a. The reason for the transfer discharge; b. The effective date of the transfer discharge; c. The location to which the resident is being transferred or discharged ; d. The name, address, and telephone number of the state long term care ombudsman; e. The name, address, and telephone number of each individual or agency responsible for the protection and advocacy of mentally ill or developmentally disabled individuals (as applies); and f. Any statement that the resident has the right to appeal to the action to the state which includes the name, address, and telephone number of the state health department agency that has designated to handle appeals and transfers and discharge notices. 8. The social service director will be responsible for preparing the form(s) and for ensuring the resident/ representative receives the forms. If it is necessary to mail the form to the representative, a self-addressed stamped envelope will be included to facilitate the return of the signed form(s). The completed forms will be filed in the residence medical record under the Social Services tab. Based on record review and interviews, the facility failed to provide notice of transfer before a facility initiated transfer to two residents (Resident #11 and #60) out of three residents sampled for hospitalization. Findings Included: 1. Review of Resident #11's admission Record revealed Resident #11 had an original admission date of 9/9/2018 and a re-admission date of 3/7/2025. Resident #11 was admitted to the facility with diagnosis to include pneumonia, pleural effusion in other conditions classified elsewhere, sepsis, acute respiratory failure with hypoxia, dysphagia, oropharyngeal phase, and muscle weakness. Review of Resident #11's Change in Condition Evaluation, dated 3/4/2025 revealed under the section 1a. List the other change: Right Upper extremity shaking on and off; 02:88 on 2L [liters of oxygen]; sound congested. The Evaluation revealed under Recommendation of Primary Clinician(s): Transfer to hospital. Review of Resident #11's Nursing Home Transfer and Discharge Notice revealed notice was given on 3/7/2025 with an effective date of 3/4/2025. The notice showed Resident #11 was transferred to an acute care facility, with a documented reason, Your needs cannot be met in this facility. The notice revealed the Social Service Director (SSD) signed the notice on 3/7/2025 and Resident #11 signed the form on 3/7/2025. During an interview on 3/13/2025 at 11:56 a.m., the Nursing Home Administrator stated if a resident leaves the facility to go to a hospital it is typically an emergency, so she's not sure how the resident would sign the Nursing Home Transfer and Discharge Notice, which is why they would wait for the resident to return or would mail the form to the resident for their signature.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure Level I Preadmission Screening and Resident Review (PASRR) screenings were accurate prior to a admission to the facility and did not follow up with a Level II PASRR screen for two residents (Resident #41 and #16) of forty-one sampled residents. Findings included: 1. On 3/10/2025 at 1:45 p.m. Resident #41 was observed in her wheelchair while therapy staff were assisting down the hallway and to the therapy gym. At 1:49 p.m. while in the gym, Resident #41 appeared anxious, but was participating in all the exercises that were presented to her. Resident #41 kept saying I just want to go home and just need to go home. On 3/12/2025 at 8:00 a.m., Resident #41 was assisted to the 300 unit nurses desk and lobby area. She was seated in her wheelchair and was awaiting a transport ride to an appointment. Resident #41 was given information that the transport van would be thirty minutes late. She then started to cry and was very anxious to get out to her doctor's appointment and then planned to return home with home health services the following day. Review of Resident #41's medical record revealed she was admitted to the facility on [DATE] for short term therapy. Review of the diagnosis sheet revealed diagnoses to include adjustment disorder with mixed anxiety and depressed mood, anxiety (added 2/12/2025), and major depression (added 2/12/2025). Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed under Section C - Cognitive Patterns a Brief Interview Mental Status (BIMS) score 15 out of 15, which indicated Resident #41 was cognitively intact. Review of Resident #41's electronic medical record revealed a Level I PASRR screen dated 2/10/2025, completed prior to the resident's admission to the facility, and was signed by a Licensed Clinical Social Worker (LCSW) at a hospital. The screen did not identify Mental Illness/Suspected Mental Illness (MI/SMI) diagnoses to include major depression and anxiety. Further review of the electronic medical record revealed a second Level I PASRR screen dated 2/14/2025 for Resident #41. Review of the screen revealed it was completed by a Registered Nurse at the admitted facility. Review of Section I of the PASRR screen under MI/SMI diagnoses indicated diagnosis of major depression. The screen did not identify anxiety, per Resident #41's admission diagnosis. On 3/12/2025 at 1:50 p.m., an interview with the Minimum Data Set (MDS) Coordinator, who confirmed she, along with several other staff, are responsible for the assurance of Level I PASRR completion in a timely and accurate manner. The MDS Coordinator confirmed Resident #41 was admitted to the facility on [DATE] and there were two Level I PASRR screens that were scanned into the electronic record to include one on 2/10/2025, which was incorrect, and one on 2/14/2025, which was a corrected version. The MDS Coordinator confirmed Resident #41 had diagnoses of major depression and anxiety upon her admission, and the Level I PASRR screen that came from the hospital did not reflect MI/SMI diagnoses of either major depression or anxiety. She revealed this Level I PASRR was incorrect and the facility had to complete a new one. She verified the new and revised Level I PASRR screen now only reflected major depression as an MI/SMI diagnosis, but they failed to include anxiety. She revealed the corrected Level I was not correct to reflect all appropriate MI/SMI diagnoses. The Director of Nursing (DON), who was present for this interview, also confirmed the current corrected Level I PASRR screen for Resident #41 was not correct. 2. Review of an admission Record showed Resident #16 was admitted to the facility on [DATE] with diagnoses to include but not limited to major depressive disorder, recurrent, severe with psychotic symptoms, and anxiety disorder, unspecified Review of the State of Resident #16's Level I PASRR screen dated 1/9/2023 showed Mental Illness diagnoses listed as anxiety disorder and depressive disorder. Review of Section IV: PASRR Screen Completion revealed: Individual may be admitted to a Nursing Facility (check one of the following): No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, was marked. On 3/12/2025 at 10:00 am, an interview was conducted with the facility's MDS Coordinator, who stated the PASRRs are reviewed on admission and at the Quality-of-Care meetings to see if there was a change with a resident diagnosis. The MDS Coordinator also stated she received training on how to complete the Level II PASRR last Monday and during the training she learned a PASRR Level II is required if a resident has a serious mental illness with dementia or if the resident has an intellectual disability, or depression with behaviors that are interfering with the resident daily life. The MDS Coordinator stated she has a list of residents who's PASRR has to be redone and submitted for a Level II review and Resident # 16 is one of the residents who is on her list that require a Level II PASRR review. The MDS Coordinator stated the facility does not have a PASRR policy. On 3/12/2025 at 10:30 am, an interview was conducted with the DON. The DON stated her expectations are for the PASRR to be accurate and most of the time the PASRR is inaccurate coming in from the hospital. If the PASRR's are inaccurate, her expectations are that they correct them so the PASRR's reflect the resident accurately. The DON stated she depends on her MDS Coordinator to accurately complete the PASRR's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide catheter care and services to prevent injuries and infections for two residents (#123 and #124) of nine sampled residents who utilized indwelling catheters, during two of four days observed (3/10/2025 and 3/12/2025). Findings included: 1. On 3/10/2025 at 10:25 a.m., Resident #123's room door was observed open from the main hallway. She was observed in her room seated in her wheelchair and being visited by a family member. Resident #123 was utilizing an indwelling catheter. From the hallway, the resident was observed with the catheter bag and tubing hanging directly below the seat of the wheelchair and with the bag and approximately two inches of catheter tubing on the floor. Resident #123 was observed scooting back and forth slowly while seated in her wheelchair with the catheter tubing and bag dragging on the floor. Review of Resident #123's medical record revealed she was admitted to the facility on [DATE] and readmitted from the hospital on 2/27/2025. Review of the diagnosis sheet revealed diagnoses to include but not limited to retention of urine and neuromuscular dysfunction of bladder. Review of the current Order Summary Report for the month 3/2025, revealed the following orders for Resident #123: - Urinary Catheter Indwelling catheter size 14FR (French) with balloon size 30cc (cubic centimeters) to beside drainage bag for dx. (diagnosis) Urinary Retention - every shift related to Retention of the urine, order date 3/3/2025. A review of the current care plans with a next review date of 6/9/2025, revealed the following areas: 1. Impaired cognitive function/dementia or impaired thought process r/t (related to) BIMS (Brief Interview for Mental Status) score of 11, periods of confusion, with interventions in place as reviewed. 2. Incontinent of Urine. She has a catheter due to urinary retention and is at risk for UTI (urinary tract infection), 3/11/2025 bladder toning as ordered, with interventions to include: Observe for signs and symptoms of discomfort on urination and frequency, Catheter care as ordered, Cover drainage bag for privacy. On 3/13/2025 at 8:05 a.m., an interview was conducted with Resident #123's nurse, Staff E, Registered Nurse (RN). Staff E, RN confirmed she knew of Resident #123 and had her on her assignment since her admission. Staff E, RN also confirmed Resident #123 utilized an indwelling catheter and Resident #123 was discontinued with it yesterday on 3/12/2025. Staff E, RN said prior to the catheter being discontinued, Resident #123 utilized it at all times to include when in bed and when she is seated in her wheelchair. Staff E, RN stated when Resident #123, or any resident who utilizes an indwelling catheter, the catheter bag should be placed in a position that is off the floor and the tubing leading from the bag to the resident should be off the floor. Staff E, RN further revealed nursing staff who observe catheter bags positioned on the floor are to reposition the bag. Therapy staff can also reposition the bag and any other non-nursing staff can report the observation to nursing staff immediately. Staff E, RN confirmed catheter bag and tubing lying on the floor can present with an accident/tripping hazard, can present a risk for pulling out the tubing, and can present as an infection risk. Staff E, RN also confirmed Resident #123 does at times slowly self-propel by herself while seated in her wheelchair and she was unaware Resident #123 had her catheter bag on the floor and had tubing on the floor from excessive tension. 2. On 3/10/2025 at 12:01 p.m., Resident #124's room was approached and the door was open. From the hallway, Resident #124 was seen in her room while seated next to her bed and in a wheelchair. Resident #124 was utilizing a an indwelling catheter. The bag for the catheter was observed hanging below the seat of the wheelchair with a portion of the bag touching the floor. There were liquid contents in the bag during this observed time. The tubing to the catheter, leading from the bag to the resident, was also observed touching the floor with approximately three inches on the floor. The tubing on the floor in excess tension was observed touching the front right wheel of the wheelchair. Resident #124 was observed moving back and forth slowly with either her foot or the front wheelchair tire touching the tubing. The resident was observed with two visitors and one of the visitors repositioned the wheelchair so the resident could be facing towards them. When the visitor was repositioning the resident in the wheelchair, the tires were observed to touch and partially ran over the catheter tubing. The resident's visitor was not aware of the catheter bag and tubing on the floor when repositioning Resident #124. On 3/12/2025 at 7:20 a.m. Resident #124's room was approached and she was noted in her room, dressed for the day, and seated in her wheelchair. The residents catheter bag was touching the floor and about three inches of the catheter tubing was positioned on the floor. On 3/12/2025 at 12:00 p.m. Resident #124 was observed seated in her wheelchair next to her bed, resting with her eyes closed. The resident's catheter tubing was in excess tension with approximately two inches of the tubing on the floor. The tubing had yellow liquid contents. Review of Resident #124's medical record revealed she was admitted on [DATE]. Review of the diagnosis sheet revealed diagnoses to include chronic kidney disease, history of urinary tract infection, and obstructive and reflux uropathy. Review of Resident #124's current Order Summary Report for the month 3/2025 revealed the following orders: - Urinary Catheter Indwelling catheter size 14 fr. with balloon size 30cc for dx. urinary retention, x (every) shift related to Chronic kidney disease, order date 2/15/2025). - Check placement of catheter leg strap every shift for anchoring of catheter and tubing. Review of Resident #124's current care plans with a next review date of 5/26/2025 revealed the following areas: 1. Has history of urinary retention. Was being straight catheter intermittently and upon readmission now has an indwellling catheter. She is at risk for UTI, with interventions in place to include: Check placement of catheter leg strap every shift for anchoring of catheter and tubing, Cover drainage bag for privacy. On 3/13/2025 at 8:05 a.m., an interview was conducted with Resident #124's nurse, Staff E, RN. Staff E, RN confirmed she knew of Resident #124 and had her on her assignment since her admission. Staff E, RN also confirmed Resident #124 utilized an indwelling catheter, and that Resident #124 utilizes it at all times to include when in bed and when she is seated in her wheelchair, which is most of the day. Staff E, RN confirmed Resident #124 does at times slowly self-propel by herself while seated in her wheelchair and she was unaware there were times Resident #124 had her catheter bag on the floor with the tubing on the floor from in excess tension. On 3/13/2025 at 8:35 a.m., an interview with Staff F, Certified Nursing Assistants (CNA) and Staff G, CNA. Both confirmed they had Residents #123 and #124 on their routine work assignments. Both confirmed Resident #124 currently utilized an indwelling catheter and Resident #123 was utilizing an indwelling catheter until 3/12/2024, where it was discontinued. Staff F, CNA and Staff G, CNA both confirmed they observed both residents with portions of the catheter bag and tubing on the floor, especially when seated in a wheelchair. Staff F, CNA and Staff G, CNA also both confirmed if they see the tubing or bag on the floor, they can either reposition the bag and tubing up off the floor or they can get a nurse to reposition it, depending on the situation and how far the tubing was out and in excess tension. Staff F, CNA and Staff G, CNA revealed they find at times when either of the residents return from therapy, they find portions of the tubing on the floor and sometimes a portion of the bag on the floor. Staff F, CNA and Staff G, CNA also revealed Therapy staff are able to reposition the tubing and bag up off the floor, but sometimes they don't. Staff F, CNA sated she has reported to her nurse of instances where she found residents returned from therapy and with portions of the tubing and bag on the bare floor. Staff F, CNA and Staff G, CNA revealed Resident #124 has confusion and will sometimes try to stand up when she is seated in her wheelchair, and the tubing will become in excess tension. On 3/13/2025 at 1:20 p.m., an interview with the Physical Therapy Director revealed she and her staff, when assisting with residents and who utilize indwelling catheters, will first ensure the catheter bag and tubing are properly positioned up off the floor and with tubing free from excessive tension. She revealed they monitor the placement of the tubing and catheter bag when conducting a therapy session and if the catheter and tubing need to be repositioned, she and her staff will reposition immediately. The Physical Therapy Director also revealed she and her therapy staff will ensure the catheter and tubing are positioned appropriately and safety upon assisting the resident back to their room. She was not aware Resident #123 and #124 had catheter bags and tubing that were touching and laying on the floor. On 3/13/2025 at 10:30 a.m., the Director of Nursing (DON) provided the Catheters, Suprapubic-care of policy and procedure for review. The policy did not have a review date and revealed the following: Purpose; To provide safe and proper care of the resident with an indwelling urinary catheter, and to minimize the risk of bladder infection. Procedure: 1. Verify physician's order for catheter care. 2. Identify resident, explain procedure, and provide privacy. 7. Secure catheter tubing with a catheter strap to the inner aspect of the female thigh. 8. Position the drainage bag below the level of the resident's bladder. Secure to the bed or wheelchair in such a manner that neither the bag nor the spigot touches the floor. Coil excess tubing on bed verifying that there are no obstructions or kinks in tubing.

Based on observations, record review, and interviews, the facility failed to accurately document in the clinical record for one resident (Resident #60) of forty-one sampled residents related to a physical assessment completed during a time the resident was not in the facility. Findings included: An observation on 3/11/25 at 8:31 a.m. revealed Resident #60 was sitting up in bed with a meal in front of her. The resident did not appear to be in visible distress. Review of a Skilled Nursing Facility/Nursing Facility (SNF/NF) to Hospital Transfer form showed the resident was transferred to an acute care facility on 2/21/25 for a midline placement by the vascular team. Review of a physician order written on 2/21/25 at 2:43 p.m. instructed staff to send Resident #60 to the emergency room (ER) for re-insertion of midline by vascular team. Review of Resident #60's payor source information showed the facility stop billing on 2/21/25 and the resident became active on 2/27/25. Review of Resident #60's Daily Medicare A/Managed Care Nursing Note dated 2/22/25 at 7:07 p.m. revealed a temperature reading from 2/19/25, a pulse from 2/2/25, and blood pressure and respiration readings from 2/20/25. The note showed the resident was alert & oriented to person, there were no changes in the resident's mood and behavior patterns, the resident was incontinent of bladder, and the urine was clear with a normal odor. The resident was incontinent of bowel with an ileostomy. The resident's lung sounds were Within Normal Limits (WNL) and respiratory effort was normal. The resident had a regular heart rate and peripheral pulses were palpable. The residents' pupils were equal, round and reactive to light and accommodation (PERRLA), the hearing was adequate, and speech was clear and appropriate. The resident's pain measurement was shown as a smiling face revealing the scale of No Hurt. The resident was noted to have no new changes to skin integrity and no wound infection. The note did not reveal if the resident was on any isolation/precautions. The note showed the resident was receiving physical and occupational therapy. An interview was conducted on 3/13/25 at 9:38 a.m. with Staff H, Licensed Practical Nurse (LPN). The staff member reported if a resident was discharged , the facility discharged them from the electronic system. Staff H, LPN reviewed the assessment completed on Resident #60 on 2/22/25 and stated the nurse may have made a mistake and did not think any nurse would document on a discharged resident. The staff member stated at times and if needed they may go in and make a late entry on the resident but would not document an assessment on them. An interview was conducted on 3/13/25 at 9:47 a.m. with Staff I, LPN/Assistant Director of Nursing (ADON). Staff I, LPN ADON reported staff document on Daily Medicare with daily notes, for 3 days. She would expect a narrative note for new admissions and any long-term care residents on antibiotics should be documented on every shift. She reported a resident who had been discharged would not typically be documented on, except for a hospital follow up note, but would not document an assessment or a daily Medicare note on a discharged resident. The ADON reviewed Resident #60's chart and confirmed the resident left the faciity on 2/21/25 and thought the resident had been gone 5-6 days, thinking the resident came back on the 2/27/25. Staff I, LPN ADON stated the expectation was to assess and lay eyes on a resident when documenting and the note on 2/22/25 was not correct documentation. Review of the undated policy titled Documentation, Clinical, revealed: Policy: The facility clinical staff will document the provision of care and services according to nursing standards and regulatory requirements. When completed, documentation will accurately reflect the clinical care and other services provided to the resident and ensure that the appropriate information is available to all industry interdisciplinary team members. Documentation in the medical record of each resident should provide: 1. A complete account of the residents care treatment and response to the care. 2. Information for the physician when prescribing medications and managing care and treatments. 3. A description of care and services that can be used for measuring the quality of care provided to a resident. 4. An ongoing record of the physical and mental status of the resident. 5. Information for the development of a plan of care for each resident. 6. Elements to support quality medical care. 7. A legal record that protects the resident, physician, nurse, and the facility. 8. Documentation as recorded to support reimbursement. Documentation Guidelines: 1. All entries in the medical record should be accurate, legible, dated, and timed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to provide a bed-hold notice at the time of transfer to three (#55, #60, and #11) of three residents sampled for hospitalizations. Findings included: 1. Review of Resident #55's admission Record revealed the resident was originally admitted on [DATE]. Review of Resident #55's Nursing Notes showed on 2/2/2025 at 11:28 a.m., Resident #55 was sent to the emergency room (ER) for evaluation following an incident. Review of Resident #55's uploaded clinical documents did not include a bed-hold notice for the resident's transfer to a higher level of care on 2/2/2025. The progress notes on 2/2/2025 did not show the resident or representative was notified of the facility bed-hold notice. Review of the facility provided admission and Financial Agreement signed by Resident #55's family member and the facility's representative on 12/10/2024 described the facility's bed-hold policy. 2. Review of Resident #60's admission Record revealed the resident was originally admitted on [DATE] and readmitted on [DATE]. Review of Resident #60's Transfer Form showed on 2/21/2025 the resident was transferred to an acute care facility due to placement of a midline. Review of Resident #60's physician order, dated 2/21/25 at 2:43 p.m. showed the facility was to send the resident to ER for re-insertion of a midline by the vascular team. Review of Resident #60's uploaded documents did not reveal a copy of a bed-hold notice given to the resident's representative on 2/21/2025 and the resident's progress notes on 2/21/2025 did not reveal documentation showing the resident or representative had been notified or had received a bed-hold notice at the time of the transfer on 2/21/2025. Review of the facility provided Bed Hold Policy revealed it was part of the admission and Financial Agreement signed by Resident #60's legal representative on 2/4/2025. During an interview on 3/12/2025 at 2:27 p.m., the Social Services Director (SSD) reported making phone calls to the families and asking if they wanted a bed-hold. The SSD reported not really documenting family notifications of bed-hold notifications. 3. Review of Resident #11's admission Record revealed Resident #11 had an original admission date of 9/9/2018 and a re-admission date of 3/7/2025. Resident #11 was admitted to the facility with diagnosis to include pneumonia, pleural effusion in other conditions classified elsewhere, sepsis, acute respiratory failure with hypoxia, dysphagia, oropharyngeal phase, and muscle weakness. Review of Resident #11's Change in Condition Evaluation, dated 3/4/2025 revealed under the section 1a. List the other change: Right Upper extremity shaking on and off; 02:88 on 2L [liters of oxygen]; sound congested. The Evaluation also revealed under Recommendation of Primary Clinician(s): Transfer to hospital. Review of Resident #11's medical record did not reveal notice of a bed-hold related to the hospital transfer on 3/4/2025. During an interview on 3/13/2025 at 11:56 a.m., the Nursing Home Administrator stated residents get the bed-hold policy when they admit and they would call the residents and go over the policy if a transfer occurred. She stated she would have to talk to the Social Services Director to confirm what process she is following to document how the residents are being notified of the bed-hold process during a transfer. Review of the facility's undated policy titled Bed Hold Policy, found in the admission packet, revealed a summary of explanation will be given to the resident, legal representative, or responsible party on admission in a copy of the bed-hold policy each time the resident is transferred for hospitalization or leaves the facility on a therapeutic leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to 1. Ensure staff who worked in the kitchen initiated proper hand hygiene in between and after touching soiled dishes and before touching clean dishes in the dish machine room, during two of four days observed (3/10/2025 and 3/12/2025), and 2. failed to follow proper food safety and storage procedures for one resident (Resident # 14) of eight residents sampled. Findings included: 1. On 3/10/2025 at 9:29 a.m., the facility's kitchen was entered and toured with Staff A, Dietary Manager. Staff A, Dietary Manager confirmed they operate a low temperature dish washing machine and pointed out the machine in the front right corner of the kitchen. The dish machine area appeared with a large mechanical dish washing machine with a metal table and table chute on the right side, which was used for soiled dishes and prerinse prior to dishes going into the dish washing machine. The left side of the machine was observed with a metal table and metal chute where clean crates of dishes went after coming out of the dish washing machine. Staff B, Dietary Aide (DA) and Staff C, DA were operating the dish washing machine. Staff B, DA and Staff C, DA were both on the right side/soiled side of the machine and were placing soiled breakfast trays, dishes, cups, bowls, or eating/dining ware that came from tray carts onto the metal table chute to be pushed over to the prerinse area. Staff B, DA was observed at the prerinse station area wearing blue plastic gloves. She was observed handling soiled eating/dining ware with her hands and was using a rinse hose to rinse off large debris from the various eating/dining ware. Staff C, DA continued to take soiled eating/dining ware from tray carts and pushed them down the metal chute towards Staff B, DA for prerinsing. At 9:31 a.m. Staff B, DA, after prerinsing soiled eating and dining ware, immediately placed the eating/dining ware into plastic crates and pushed the crate of soiled eating/dining ware into the soiled side of the machine and closed the door with her gloved hands. Staff B, DA continued to receive soiled eating/dining ware from the metal table chute and prerinsed with the hose. After the dish washing machine ran its wash and rinse cycle, Staff B, DA walked over to the left side/clean side of the machine, opened the door, and pulled out the crate full of clean and sanitized eating/dining ware with her gloved hands. Staff B, DA did not remove her gloves or wash/sanitize her hands after handling soiled eating/dining ware and before handling clean and sanitized eating/dining ware. At 9:33 a.m. Staff B, DA stated the type of dish washing machine the facility used was a high temperature dish washing machine, but she was not able to state what temperatures the wash and rinse cycles get to. She then stated, I think the wash needs to get to 150 degrees [Fahrenheit] She was unsure what the rinse cycle temperature should reach. Staff B, DA confirmed there was a chemical sanitizer and they test the clean dishes with a test strip to see if there is enough sanitizer getting through the machine and onto the eating/dining ware. She was asked if she was sure the machine was a high temperature dish washing machine. Staff B, DA could not answer and then got a verbal cue from the Staff A, Dietary Manager that the machine was a low temperature, chemical sanitizing dish washing machine. Staff B, DA demonstrated the use and operation of the low temperature dish washing machine at 9:35 a.m. Staff C, DA stood back in the right side/soiled side of the machine and continued to place soiled eating/dining ware from the tray carts and on to the metal table chute. Staff B, DA immediately put on blue plastic gloves, was not observed to wash her hands prior to, and started to prerinse soiled plastic trays with the hose. She placed prerinsed trays into a plastic crate and ran the crate of soiled eating/dining ware into the soiled side of the dish washing machine. After the machine ran its wash and rinse cycle, Staff B, DA opened the door to the dish washing machine and pushed the crate of cleaned and sanitized dishes through to the left side/clean side of the machine with her gloved hands. She walked over to the left side/clean side of the machine and retrieved the crate of cleaned and sanitized eating/dining ware with her gloved hands and began to take a new chemical sanitizer test strip and placed it on one of the trays in the crate. Staff B, DA never removed her gloves or washed her hands after handling the soiled eating/dining ware and prior to handling the clean and sanitized eating/dining ware. Staff B, DA could not get a reading from the test strip, so she walked over to the right side/soiled side of the dish washing machine area and pushed through another crate of soiled eating/dining ware into the machine. While the dish washing machine was running its cycle, Staff B, DA stood near the machine to wait for the cycle to be finished. Once the wash and sanitize cycle was completed, Staff B, DA was observed walking over to the left side/clean side of the machine and retrieved the clean crate of eating/dining ware with her gloved hands and began to conduct another chemical sanitizer test with a new test strip. Staff B, DA did not remove her soiled gloves or wash her hands after handling soiled eating/dining ware. Staff B, DA was observed retrieving soiled eating/dining ware from the soiled side of the dish machine, prerinsed the eating/dining ware, placed the soiled eating/dining ware in empty crates, sent the soiled eating/dining ware through the machine to be clean and sanitized, received the clean eating/dining ware from the clean side of the machine, and handled the clean and sanitized eating/dining ware with her unchanged and unwashed hands four more times before the surveyor left the area. During most of the observation from 9:31 a.m. through to approximately 9:42 a.m., the Staff A, Dietary Manager was in the kitchen's dish washing machine room observing the operation from both Staff B, DA and Staff C, DA. Staff A, Dietary Manager did not intervene to ensure Staff B, DA washed her hands after handling soiled eating/dining ware and prior to handling clean and sanitized eating/dining ware. On 3/12/2025 at 1:43 p.m. an observation was conducted in the facility kitchen with Staff D, DA and Staff B, DA, who were observed in the dish washing machine area and were both on the right side/soiled side of the dish machine. Staff B, DA was observed taking soiled dishes, trays, cups, bowls, or eating/dining ware from received tray carts and placed the eating/dining ware on the metal table chute. She was observed pushing the eating/dining ware down the metal chute to the prerinse station where Staff D, DA was. Staff D, DA was observed with her bare hands taking a rinsing hose and was prerinsing the soiled eating/dining ware and placed the eating/dining ware in empty plastic crates to be ran through the dish washing machine. At 1:45 p.m., Staff D, DA was observed pushing a full plastic crate of eating/dining ware into the soiled side of the dish machine with her bare hands and closed the dish washing machine door for it to run its clean and sanitizer cycle. Once the machine finished its cycle, Staff D, DA walked over to the left side of the dish washing machine, opened the door, and pulled the clean and sanitized crate of eating/dining ware out and to the clean table area. Staff D, DA did not wash her hands or don gloves after handing soiled eating/dining ware and prior to handling clean and sanitized eating/dining ware. At 1:47 p.m., Staff B, DA continued to place soiled eating/dining ware on the soiled side of the dish machine table chute and Staff D, DA continued to retrieve the soiled eating ware, prerinse them, and set them in a plastic crate to be ran through the dish washing machine. Staff D, DA walked over to the left side/clean side of the dish washing machine and retrieved clean and sanitized crates of eating/dining ware with her bare hands. She was not observed to donning gloves or washing her hands after handling soiled eating/dining ware or prior to receiving and handling clean and sanitized crates of eating/dining ware. Staff D, DA continued to handle and feed crates of soiled eating/dining ware through the soiled side of the machine and received and handled crates of clean and sanitized eating/dining ware with her bare unwashed hands for four more dishwashing cycles. In between and while the dish washing machine was in cycle, Staff D, DA took plates from an already clean and sanitized crate and stacked them in her hands and arms and brought them to a metal plate holder. She did this process three times and without washing her hands after touching and handling soiled eating/dining ware and prior to touching the clean and sanitized plates. The plates were stored in a manner as if ready to use for residents at the next meal/dining service. On 3/13/2025 at 10:45 a.m., and while in the facility's kitchen, the Staff A, Dietary Manager was interviewed with relation to the dish washing process. Staff A, Dietary Manager revealed the dish machine area is composed of two sides, one soiled side on the right and one clean side on the left. Staff A, Dietary Manager revealed typically there are two staff members in the dish washing machine area. One staff member handles the soiled dishes and runs the eating/dining ware through the soiled side of the machine while another staff member works on the clean side of the machine and receives/handles only clean and sanitized eating/dining ware that came through the machine. Staff A, Dietary Manager explained there are times when she is in the dish washing machine area assisting with cleaning dishes and she will usually be on the clean side, not the soiled side. She revealed she would only be handling clean and sanitized eating/dining ware. She also confirmed if she touches or handles soiled eating/dining ware with her bare hands or gloved hands, she would remove her gloves and wash her hands, or wash her hands if she is not gloved, prior to handling clean and sanitized eating/dining ware after they come out from the dish washing machine. Staff A revealed that she saw a lack of handwashing when handling soiled eating/dining ware and during the handling of clean and sanitized eating/dining ware during the observation of Staff B, DA and Staff C, DA on 3/10/2025. On 3/13/2025 the Dietary Manager provided an undated policy titled Dishwashing Machine, which revealed: Policy: The facility will maintain dishwashing machine in a clean condition to minimize the risk of food hazards. Dish washing machines will be cleaned three times a day after each meal. Procedure: 1. Turn the dishwashing machine on. 2. Open drain valves. 3. Remove scrap trays. 4. Spray scrap trays over garbage. 5. Spray down the inside of the dishwashing machine. 6. Scrub stains inside dishwashing machine and on outside drains using an abrasive pad soaked in warm water and detergent and de-staining solution. 7. Wash the outside of the dishwashing machine and hood with a clean cloth soaked in detergent solution. 8. Wipe down with an approved sanitizing solution. 9. Wipe with clean dampened cloth. The Dietary Manager also provided an undated policy titled Hand Washing, which revealed: Policy: The facility recognizes that food-borne illness has the potential to harm elderly and frail residents. All Dietary employees will practice good hand washing practices in order to minimize the risk of infection and food borne illness. Procedure: 1. Hand-washing Stations a. Make sure hand washing stations are located in food preparation areas to encourage employees to wash their hands frequently. c. Make sure all hand-washing stations are equipped with the following: i. Hot and cold running water. ii. Hand cleaning liquid, powder or bar soap. iii. Individual, disposable towels, a continuous towel system that supplies the use with a clean towel or a heated - air hand-drying device. iv. A receptacle for disposable towels. v. A sign that indicates employees must wash hands before returning to work. 2. Hands should be washed after the following occurrences: a. Using the Restroom. b. Handling raw food (before and after). c. Touching the hair, face, or body. d. Sneezing or coughing. e. Smoking. f. Eating or drinking. g. Handling chemicals. h. Taking out garbage. i. Clearing tables. j. Touching clothing or aprons. k. Touching un-sanitized equipment, work surfaces, or wash cloths. 2. On 3/10/2025 at 9:24 AM and on 3/11/2025 at 3:00 PM, Resident # 14 was observed lying down on her bed dressed in her night gown. She was observed with rotten fruit left on her bedside table for two days. An interview was conducted following the observation with Resident # 14, who stated she was going to eat the fruit later. Review of an admission Record showed Resident # 14 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia in other diseases classified elsewhere, mild, with other behavioral disturbance and anxiety disorder, unspecified Review of a Quarterly [NAME] Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. During an interview on 3/13/2025 at 10:00 AM with the Director of Nursing (DON), the DON stated Resident #14 is difficult and she doesn't let the staff take away her food. The DON also stated the resident's husband brings her food from time to time. The DON stated Resident # 14 has had a recent decline and she's assuming the resident did not want the staff to remove the fruit from her room. The DON stated if the resident refused to discard the rotten fruit, they should have reported the behaviors to the nurse or to her. The DON stated her expectations are residents' bedside tables should be cleaned off and old food should be discarded. Review of the facility policy titled Storage of Foods Brought to Residents by Family/Visitors showed: Policy Statement: Staff must be aware of and approve, food(s) brought to a resident by family/visitors to ensure safe and sanitary storage, handling and consumption of foods. Interpretation and Implementation 7. The Nursing staff is responsible for discarding perishable foods within 3 days or before the use by/expiration date, whichever comes first. 8. The nursing and/or food service staff must discard any food prepared for the residents that shows obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates) Photographic Evidence Obtained

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to update and revise a care plan to reflect a significant weight loss for one (Resident #38) of twenty-one sampled residents. Findings Included: On 5/30/2023 at 10:00 a.m., and 1: 20 p.m., 5/31/2023 at 1:00 p.m., and 6/1/2023 at 12:00 p.m., Resident # 38, was observed lying down in her bed with her head elevated and her call light within her reach. She presented without behaviors, pain, or discomfort. The room appeared clean and well lit. A review of Resident #38's admission record showed she was admitted to the facility on [DATE], with diagnoses to include but not limited to Parkinson's Disease, Unspecified, Gastro-Esophageal, Ileus Unspecified, and Reflux Disease Without Esophagitis. A review of the most current Minimum Data Set (MDS), dated [DATE], show in Section C, a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A review of the electronic health record weights and vital record showed, on 4/3/2023 Resident #38 weighed 129.6 Lbs., on 4/18/2023 111.8 Lbs., and on 5/3/2023 110.0 Lbs. A review of the Registered Dietitian (RD) weight loss follow-up note, dated 4/19/2023, showed, Current Body Weight, CBW 111.8 lbs. (4/18/23), ht 60, Body Mass Index, BMI 21.8. Reweigh for verification, CBW represents a 13.7 % loss x 30d (4/3/23 129.6 lbs). Current diet order is clear liquid due to constipation/ KUB. Resident # 38 was previously on a regular diet, regular texture thin liquid, magic cups every day, QD, mighty shakes every day and Medpass 2.0 every day. A recommendation was made to allow nutrition supplements on Clear Liquid Diet (CLD). A review of the physician order summary sheet dated 6/1/2023, showed a diet order for thin consistency, clear liquid diet, that started on 4/17/2023 to 5/5/2023. Further review showed clear liquid diet order currently discontinued. A review of the current care plan with an initial date of 9/25/2020 and a revision date of 5/8/2023, indicated the following areas: Resident is at risk for altered nutritional status related to (r/t) Parkinson's, convulsions, HTN (hypertension), hypothyroidism, occlusion/stenosis of carotid arteries, pacemaker presence, MDD (major depressive disorder), anxiety, insomnia, GERD (Gastroesophageal reflux disease), constipation, ileus, dysphagia, recent hx clear liquid diet. A review of the care plan interventions with an initial date of 9/25/2020 and a revision date of 11/24/2020, showed to honor food preference as able, monitor s/s (signs and symptoms) of dehydration and/ or fluid overload, monitor skin integrity, monitor wt per protocol, offer supplement as ordered. Further review showed the nutritional care plan was not revised after 4/18/2023 to reflect Resident #38's weight loss. On 5/30/2023 at 1: 20 p.m., an interview was conducted with Resident #38, in her room. She said she could not recall if she had lost any weight in the previous few months because no one had ever mentioned it to her. She said she was on a clear liquid diet a month ago since she was experiencing stomach issues; therefore, if she had lost any weight, it might have been because of the clear liquid diet. She said she has a healthy appetite and consumed most of her meals. On 5/31/2023 at 5:04 p.m., an interview was conducted with the Director of Nursing (DON). The DON said she thought, [Resident #38's] weight loss was a result of the several health issues she was dealing with. [Resident #38] was on an IV (intravenous) antibiotic from April 5 through April 16 for a UTI (urinary tract infection) and suffered a seizure on April 11. We wanted to send her out to the hospital since she was experiencing gastrointestinal issues that were making her constipated, but she refused to go to the hospital at that time. After we attempted to use fleet enemas to help the resident move her bowels, her doctor was informed regarding how she was still having constipation, so he gave the go-ahead to begin her on a clear liquid diet to help soften up her bowels. On April 3, [2023], a monthly weight for [Resident #38] showed she weighed 129.6 pounds. However, because the resident began a clear liquid diet on April 17, [2023], we chose to reweigh her again on April 18, [2023], and at that time, she weighed 111.8 pounds. We reweighed her on May 3rd, [2023], and her weight was 110.0 pounds. In order to help her regain weight, the Registered Dietitian intervened at that point and placed an order to restart the resident back on her nutritional supplements. The care plan was not revised to reflect Resident #38's weight loss because truthfully everything was happening so fast during that time and she was sent out to the hospital shortly after. On 6/1/2023 at 9:36 a.m., an interview was conducted with Staff A, Registered Nurse (RN), MDS coordinator. Staff A said it was not the MDS coordinator's responsibility to update or make revisions in the nutritional care plan section. However, she did reach out to the Registered Dietitian to let her know when the care plan needed to be updated or a revision needed to be made. Staff A said the only update she made on Resident #38's care plan was when she came back from the hospital. Staff A said she did not add a revision to show the resident's weight loss on the care plan. Review of the facility policy and procedures, titled, Person Centered Care Planning, revision dated 12/2016. Showed care plans were to be revised as changes in the resident's condition warrant or when there was a change in resident's preference or choice of treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, medical record review, the facility failed to ensure one of thirty-six sampled resident's (#44) care plans related to Urinary Tract Infection (UTI) was updated to reflect the resident had a current UTI and was receiving Antibiotics. Findings included: On 7/19/2021 at 9:40 a.m. Resident #44's room was approached, and the door was open. The resident was seated in her wheelchair by the foot of the bed and was conversing with a family/visitor. At 9:55 a.m. the visitor had left the room and Resident #44 allowed this surveyor to come in the room for an interview. During interview, Resident #44 revealed that she is currently being treated and takes medications for a Urinary Tract Infection (UTI). She revealed that this was not the first time she has had a UTI. On 7/20/2021 at 8:00 a.m. an interview with a Licensed Practical Nurse, Employee A, who had Resident #44 on his assignment, confirmed Resident #44 is currently being treated for a UTI, and has had a history of UTI. He further confirmed she receives antibiotics at this time for the UTI. During record review on 7/20/2021, the electronic medical record revealed Resident #44 was admitted to the facility on [DATE] for short term rehabilitation. A review of the advance directives revealed Resident #44 was her own responsible party. A review of the admission diagnosis sheet revealed the Resident had a diagnosis to include UTI. A review of the Minimum Data Set (MDS) 5-day admission assessment dated [DATE] revealed the following: Cognition/Brief Interview Mental Status (BIMS) score - 15 of 15, which indicates Resident #44 has very high cognition and would be interviewable related to her care and services.; Bowel and Bladder - Dx [diagnosis]. UTI - checked Yes. A review of the Physician's Order Sheet (POS) dated for current month 7/2021 revealed the following orders: - UA C&S labs on time 7/23/2021 - Ampicillin 500 mg 1 PO QID for UTI for 10 days. Order date: 7/12/2021 During further review of the record for Resident #44, the nurse progress notes revealed: 1. 7/11/2021 16:30 - Notified MD of positive urine cx for UTI. New order received for Ampicillin 500 mg QID PO for 10 days and ascorbic acid 500 mg PO QD. Orders transcribe and faxed to pharmacy. 2. 7/13/2021 - Continues ABT for UTI no adverse reactions. 3. 7/14/2021 - Continues ABT for UTI with no adverse reactions. 4. 7/15/2021 - Continues ABT for UTI with no adverse reactions. 5. 7/15/2021 - Resident seen by MD and request referral to see GYN for frequent UTI. Schedule appt. Orders to D/C Roxicodone 5 mg PRN. 6. 7/16/2021 - Continues ABT for UTI with no adverse reactions. 5. 7/17/2021 - Continues ABT for UTI with no adverse reactions. 6. 7/18/2021 - Continues ABT for UTI with no adverse reactions. 7. 7/19/2021 - Continues ABT for UTI with no adverse reactions. 8. 7/20/2021 01:52 - Resident continues ABT for UTI, no adverse reactions, but c/o pain after urinating. MD is aware and appt sched with gyn, resident is aware. 9. 7/20/2021 10:33 - Resident has complaint of discomfort when urinating. MD notified of resident's discomfort, new order received and Pyridium 100 mg BID. Repeat CS UA when ABT is completed. 10. 7/20/2021 13:59 - Continues ABT for UTI. 11. 7/21/2021 01:29 - Resident continues with ABT for UTI without adverse reactions. A review of the current Care Plans with next review date 10/3/2021 revealed the following areas: - Occasionally incontinent of bowel and bladder and requires extensive assist with toileting r/t deconditioning r/t recent hospitalization, pain to LLE d/t recent left foot surgical repair, NWB to LLE, diuretic use. admitted with UTI (resolved) 7/5/2021 with interventions to include to include: Administer medications per order, Monitor/document for signs and symptoms of UTI, pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, AMS, change in bx, eating patterns - initiated 7/5/2021. Further review of the care plan indicated the UTI had resolved on 7/5/2021 and did not capture Resident #44's current UTI and with current use of Antibiotics., and without interventions and approaches related to the current UTI as of 7/11/2021. On 7/21/2021 at 1:00 p.m. an interview was held with the Care Plan Coordinator related to Resident #44. She reviewed the medical record and confirmed the resident had a resolved from a UTI on 7/5/2021 but was unaware she had another UTI as of 7/11/2021. She confirmed the care plan should be reflective and revised with the current UTI and new approaches, and interventions. She also confirmed the care plan should be reflective of the medical record and updated within three to five days. A review of the Person Centered Care Plan Policy and Procedure, with a last revision date 12/2016 revealed: The Care Plans are to be revised as changes in the resident's condition warrant or when there is a change in resident preference or choice of treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide necessary respiratory care and services, related to storage of oxygen, nebulizer, and continuous positive airway pressure (CPAP) tubing's and supplies, consistent with professional standards of practice for three (Resident #159, Resident #158, and Resident #41) of ten residents receiving respiratory treatments. Findings included: A record review revealed Resident #159 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) as per the admission face sheet. A review of the orders for Resident #159 indicated respiratory treatments with oxygen at 2 liters per minute via nasal cannula as needed and nebulizer treatments with Ipratropium-Albuterol solution 0.5-2.5 milligrams (mg) in 3 milliliters (ml) to inhale orally every six hours for shortness of breath. On 7/19/21 at 10:21 a.m. an observation of Resident #159's room revealed the oxygen tubing draped across the bed and the nebulizer tubing and mask was observed to be placed in the top drawer of the nightstand next to the resident's bed. Photographic evidence was obtained. A record review revealed Resident #158 was admitted to the facility on [DATE] with a diagnosis of hypertension, atrial fibrillation, and congestive heart failure as per the admission face sheet. A review of the orders for Resident #158 indicated respiratory treatments with oxygen at 2 liters per minute via nasal cannula as needed. On 7/19/21 at 10:26 a.m. an observation of Resident #158's room revealed the oxygen tubing was observed hanging freely from the concentrator. On 7/19/21 at 11:19 a.m. an observation of Resident #158's room revealed the oxygen tubing connected to a tank on the resident wheelchair was observed hanging from the tank and touching the floor. Photographic evidence was obtained. On 7/22/21 at 10:47 a.m. an observation of Resident #158's room revealed the oxygen tubing was rolled up and stuck into the handle of the oxygen concentrator. An empty plastic bag was hooked to the concentrator. Photographic evidence was obtained. A record review revealed Resident #41 was admitted to the facility on [DATE] with a diagnosis of sepsis, atrial fibrillation, cardiomegaly, congestive heart failure, and obstructive sleep apnea as per the admission face sheet. A review of the orders for Resident #41 indicated respiratory treatments with oxygen 1-3 liters per minute via nasal cannula, and CPAP at home settings with humidification. On 7/20/21 at 4:16 p.m. an observation of Resident #41's room revealed the CPAP tubing and mask sitting on the bedside table open to air. Photographic evidence was obtained. On 7/19/21 at 11:30 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated all respiratory care supplies should be stored in a clean plastic bag with a date on the bag. She stated the respiratory supplies are to be cleaned and changed every week. She indicated oxygen tubing, nebulizer tubing and masks, and CPAP machines and supplies are to be cleaned for each resident use and then stored back into the plastic bags. A review of the facility policy entitled Policy and procedure for storage of Respiratory Equipment-Departmental Respiratory Therapy Prevention of Infection revised November 2011 indicated the following: Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. Steps in the Procedure: Infection control considerations related to oxygen administration 7. Change the oxygen cannula and tubing every seven days, or as needed 8. Keep the oxygen cannula and tubing used prn in a plastic bag when not in use Infection control considerations related to Medication Nebulizer's/continuous aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name between uses 9. Discard the administration set up every seven days

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews and medical record review, the facility failed to ensure resident food/drink preferences were honored during two meal services, and during one of four days observed (7/20/2021), for one of thirty-six sampled residents (#44). Findings included: On 7/20/2021 at 8:40 a.m. during an interview Resident #44 was served her breakfast meal tray. The Resident indicated it was OK to stay as she was going to therapy after breakfast and wanted to complete the interview while she was eating. When the tray was placed on the over-the-bed table, the resident stated, Oh good, OK, let me see what's under the lid. The resident then said, OK this is good. The resident looked at the rest of the tray and then told Employee B, Certified Nursing Assistant (CNA), Oh we have orange juice again on my tray, and I can't have orange juice, please take it away. Employee B took the juice and left the room. The Resident interview continued related to related to choices and likes/dislikes when it came to food items on her tray. She said, I can't have orange juice as I am diabetic. She pointed to her meal ticket and stated, Even my meal ticket says no juices. A review of the resident's meal ticket for the breakfast meal indicated the following: Diet - Regular, No Added Salt, Low Concentrated Sweets; Beverages - Coffee, Water. The meal ticket further revealed: Food Dislikes - Juices. Resident #44 revealed that this happens often and confirmed she would not like to have the juice brought to her and knows better not to drink it but would rather staff follow her meal choices. On 7/20/2021 at 12:20 p.m. during lunch observation, Resident #44 was served her meal. A review of the meal ticket revealed - Food Dislikes - Juices. The resident received one plastic cup of what appeared to be red juice. An interview was conducted with Resident #44 at this time, and she revealed she does not like to receive juice and has been receiving it on and off. A review of Resident #44's electronic medical record revealed she was admitted to the facility on [DATE] for short term rehabilitation services. A review of the advance directives revealed the resident was her own responsible party. The Minimum Data Set (MDS) 5-day admission assessment dated [DATE] revealed the following: Cognition/Brief Interview Mental Status (BIMS) score - 15 of 15, which indicates Resident #44 has very high cognition and would be interviewable related to her care and services. The Physician's Order Sheet (POS), dated for the month 7/2021 revealed Resident #44 had a diet order to include: No Added Salt, Low Concentrated Sweets diet, with regular texture and thin consistency liquids. A review of the Care Plans with next review date 10/3/2021 revealed the following areas: - Resident at risk for altered nutrition status per MNA with interventions to include but not limited to: Diet as ordered, honor food preferences as able, offer alternative entrees as needed On 7/21/2021 at 1:45 p.m. an interview with the Kitchen Dietary Manager revealed staff plate food on the tray line in the kitchen, and the meal tickets have the diet order, and likes and dislikes. She revealed staff are to read each ticket and comply with the diet order and resident choices. She further revealed it is her responsibility to audit tickets and trays to ensure accuracy. She stated she was unaware residents were receiving food items of dislikes. On 7/22/2021 at 11:08 a.m. the Director of Nursing and the Dietary Manager confirmed the facility did not have a specific policy related to food preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure recliners furnished in resident rooms were maintained in ten of thirty rooms sampled with recliners. Findings included: On 7/20/21 at 3:30 p.m. a tour of the facility revealed recliners, located in resident rooms 318, 315, 316, 313, 311, 329, 113, and 159 with peeling upholstery on the backrest and arms of the chairs. Photographic evidence was obtained. On 7/21/21 at 10:00 a.m. room [ROOM NUMBER] and 322 were observed to have a recliner with peeling upholstery on the backrest. Photographic evidence was obtained. On 7/21/21 at 10:07 a.m. an interview was conducted with Staff C, housekeeper. Staff C stated she had been employed by the facility for six years, and she is responsible for cleaning all the resident rooms daily. Staff C stated she noticed the peeling on the recliners in the resident rooms, and some are worse than others. Staff C stated the recliners would peel 'fairly soon' after they were replaced. She stated the chairs are only replaced when they are broken and cannot be used by the resident. On 7/21/21 at 10:17 a.m. an interview was conducted with the Staff D, Registered Nurse (RN) Risk Manager. Staff D stated the recliners in the rooms had never been replaced to her knowledge. Staff D stated she had not noticed the peeling condition of the recliners, and no one had reported the condition of the recliners to her. On 7/21/21 at 10:23 a.m. an interview was conducted with Staff E, Certified Nurse Aide (CNA). Staff E stated she had been working at the facility for 23 years and she had no recollection of the recliners being replaced. Staff E stated a sheet or blanket is placed over the recliner chairs, so the peeling upholstery does not get on the resident when they sit in the recliner. On 7/21/21 at 10:37 a.m. an interview was conducted with the Maintenance Director. The Director stated if there are any problems with furniture the staff are to write it into the maintenance book so it can be addressed. He stated the staff had not informed him about any peeling upholstery on the recliner chairs. He stated if a recliner is broken and not working, they remove it from the room, and he gets the Administrator to approve getting a new one. On 7/21/21 at 10:42 a.m. an interview was conducted with the Director of Nursing (DON). The DON stated the staff put any maintenance concerns in the maintenance book to be addressed. She stated the staff are aware they are supposed to follow the process. The DON stated the staff should also let her know and if they cannot reach her, she has shift supervisors on every shift. The DON stated she was not aware of the condition of the recliners. The DON further stated the solution being used to clean the recliners may be breaking down the upholstery. On 7/21/21 at 11:18 a.m. an interview was conducted with the Maintenance Director. He stated he had spoken with the Administrator, and they purchased 25 recliners in 2017. He provided a map with a red dot in each room that currently has a recliner. The map indicated there are currently 30 recliners in the private rooms of the building. A review of the facility policy entitled 'Cleaning Carpeting and Cloth Furnishings' effective February 2006 and revised April 2015 indicated the following: Policy: Furnishings shall be maintained and cleaned regularly Procedure: 5. Stained or soiled upholstered furniture shall be cleaned in a manner consistent with the type of fabric and stain.