**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and a review of the facility's policy, the facility failed to revise the resident's code status in the care plan for one (Resident #68) of a total survey sample of 36 residents. Failure to update the resident's care plan for code status could result in staff confusion and the resident's wishes not being followed. The findings include: A review of Resident #68's medical record revealed an admission date of [DATE] and diagnoses including sepsis, partial intestinal obstruction, anemia, dementia-mild with mood disturbance, unspecified sequelae of cerebral infarction, major depressive disorder, schizoaffective disorder-depressive type, generalized anxiety disorder, and chronic kidney disease. A review of the resident's active Care Plan revealed the following Focus Areas, Goals and Interventions: Focus: Resident/Representative/Proxy has requested DNR (Do Not Resuscitate) status indicating (CPR) cardiopulmonary resuscitation measures are not performed (initiated [DATE], revised [DATE]). Goal: Resident or resident representative will communicate any desired changes to code status through next review (initiated: [DATE], revision: [DATE], target date: [DATE]). Interventions: Communicate resident/representative choice to appropriate staff members (initiated [DATE]). Notify physician of changes in code status preference (initiated [DATE]). Review/discuss Advanced Directives with the resident/resident representative as needed (initiated: [DATE], revision: [DATE]). Further review of the record revealed that an Advanced Directives Discussion Document was signed on [DATE] by the resident's health care proxy to establish the resident's wish to have CPR administered in the event of sudden cardiac arrest for any reason. (photographic evidence obtained) A review of the active physician's orders revealed the resident's Full Code status was ordered on [DATE] and signed by the physician on [DATE]. On [DATE] at 11:48 AM, the DNR Binder at the nurse's station was reviewed and revealed that Resident #68's status was Full Code. On [DATE] at 12:49 PM, a performance improvement plan (PIP) for Care Plan Interventions, initiated on [DATE], was reviewed, including periodic audits, which were documented as having been completed by [DATE]. No audits specific to care plan revisions/updates were made available for review. The PIP was reviewed in the monthly QAPI (Quality Assurance and Performance Improvement) meeting for three months after the plan was initiated. There was no indication that further monitoring of care plans was in place. (photographic evidence obtained) On [DATE] at 11:02 AM, an interview was conducted with Licensed Practical Nurse (LPN) A, the minimum data set (MDS) assistant. She explained that the baseline care plan was initiated by the admitting nurse and MDS staff worked on the comprehensive care plan. She explained that the purpose of the care plan was to address all of the problems the resident had and the goals and interventions they needed. She reported that all staff had access to the care plan. Care plan meetings were held at least every quarter and more often if the resident had a significant change in status. The meetings were attended by the Dietary Manager, Activities Director, Social Services, Unit Manager, and Therapy. The family comes if they want to and whoever they request to attend. Sometimes the resident wants to come, oh and me, I usually do the long-term people. She was asked what was discussed during care plan meetings. She stated, We discuss the plan, any skin issues, any concerns the resident has, any dietary issues, any problems, any discharges and what needs to be done prior to discharge. We talk about therapy issues, just a lot of different things. She was asked how often care plans were updated. She stated, Anytime we get any new orders and quarterly when we do their assessment. She explained that sometimes other staff asked the MDS staff to add things to the resident's care plan and they did so. A copy of Resident #68's care plan was requested. A review of the facility's policy titled Standards and Guidelines: Care Plans, Development Baseline and Comprehensive (effective 11/2001, revised 5/2023) revealed: 13. Assessments of residents are on-going, and care plans are revised as information about the residents and the resident's conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition b. When the desired outcome is not met c. When the resident has been readmitted to the facility from a hospital stay d. At least quarterly, in conjunction with the required quarterly (MDS) minimum data set assessment. .

Based on observations, interviews, and record review, the facility failed to serve beverages in accordance with professional standards for food service safety, by failing to clean the ice and juice machines in the kitchen. Failure to maintain the cleanliness of the ice and juice machines could result in potential health risks to any resident receiving ice or beverages from the facility's kitchen. The findings include: On 10/21/24 at 11:10 AM during the initial tour of the kitchen, the ice machine was observed with a pink slimy substance resembling pink biological growth along the entire bottom edge of the ice dispenser chute. When wiped with a clean napkin, the substance described above transferred onto the napkin. (Photographic evidence obtained). An observation of the external distribution lines of the kitchen's juice machine at the area where they delivered juice into the machine, were observed with a black slimy substance resembling biological growth on and around the lines. When wiped with a clean napkin, the substance described above transferred onto the napkin. (Photographic evidence obtained). When the findings were shown to Dietary Aide C, she reported that the kitchen staff only cleaned the juice dispenser spouts, not the delivery lines. She wiped some of the black substance off the lines and said it looked like mildew. Adjacent to the juice machine was a yellow 8-outlet power strip. Three pieces of kitchen equipment were plugged into the power strip, which was covered in a red sticky dried-on substance resembling juice splatters. The splatters were on and around the live outlets and the on/off breaker switch. When asked about the substance on the strip, Dietary Aide C acknowledged its presence. Without identifying the substance, she stated she would wipe it down with a wet rag. She was stopped from obtaining a wet rag and was reminded that it was a live outlet. A cleaning schedule for the ice machine was observed hanging on the side of the machine indicating it was last cleaned on 10/01/2024. (Photographic evidence obtained) On 10/21/24 at 11:30 AM, an interview with the Dietary Manager related to the above concerns was conducted. He stated the machines were cleaned monthly. The Dietary Manager observed the areas of concern described above and confirmed the findings. He then stated the ice machine would be cleaned immediately, and he would change the cleaning schedule to bi-weekly. He also stated the juice lines would be cleaned immediately and added to the bi-weekly cleaning schedule. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, medical record review and facility policy review, the facility failed to provide assistance with activities of daily living (ADLs), specifically nail care, for one dependant resident (#73) in a sample of 30 residents. The findings include: On 12/12/22 at 12:40 PM, Resident #73 was observed lying in bed, awake. His right hand was out of his bed covers and all fingernails were observed to be elongated with brown debris under each nail. The resident was asked if he could show his left hand. He pulled his covers back and picked up his left hand with his right hand to show his left hand. The nails were also elongated with brown debris under each nail. On 12/13/22 at 10:27 AM, Resident #73 was observed lying in bed, awake. Both hands had elongated nails with brown debris under the nails. The resident was asked if he preferred his nails to be trimmed and clean. He stated Yes, they used to trim my nails but no one has trimmed or cleaned them in months. He was asked if he had asked the staff to trim and clean his nails during that time frame. He stated, Yes, I have, many times, but no one has come back to do it. On 12/14/22 at 9:50 AM, Resident #73 was observed lying in bed, awake. Both hands had elongated nails with brown debris under the nails. He was asked when he last had a shower. He stated, This week. Yesterday. He was asked if staff tended to his nails during his shower. He stated No, they used to come by and trim my nails, but no one does that anymore; it's been months now. On 12/14/22 at 2:12 PM, Resident #73 was observed lying in bed, awake. He put his right hand out to show that his nails were trimmed and clean. He was asked if he was happy with the length of the nails. He stated yes. A medical record review revealed that Resident #73 was admitted on [DATE] with diagnoses including CVA (cerebral vascular accident) affecting the left non-dominant side, and contracture of the left hand. In a record review for Resident #73, it was revealed that a doctor's order, dated 11/28/22, read, Restorative nursing: Check and complete skin and nail hygiene as tolerated. Complete nails and skin hygiene to promote skin integrity. A review of the Minimum Data Set (MDS) quarterly assessment, dated 11/18/22, revealed a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderately impaired cognition. Further review of the MDS quarterly assessment, revealed rejection of care behaviors were not exhibited. The functional status assessment revealed that Resident #73 required extensive assistance and one person physical assistance for personal hygiene, including washing and drying hands. A review of the Care Plan revealed: Focus: 4/1/20 (revised 9/21/20) Needs assistance with ADL care, dependent on staff care, related to CVA with left-sided weakness. Goals: Will be clean, dressed and well groomed through next review date (revised 9/8/22) Will accept care daily through next review. Will be able to to complete at least one simple ADL task through the next review date. Interventions: Extensive assist with all ADLs, encourage participation in some simple upper body tasks. Focus: 11/30/22: Resident has a need for the restorative nursing program for PROM LUE. (Passive Range of Motion, Left Upper Extremity) Goal: Resident will maintain current level of function and mobility through the next review period. Interventions: PROM gentle to LUE from bed/wheelchair level. Check and complete skin and nail hygiene as tolerated. Complete nails and skin hygiene to promote skin integrity. A review of the Certified Nursing Assistants' (CNAs) Plan of Care task documentation for 11/15/22 thru 12/14/22 revealed: Personal Hygiene self performance: How resident maintains personal hygiene (including washing/drying hands): extensive assistance/one person physical assist. Behavior Symptoms: None of the above observed (rejection of care behavior not documented as observed). In an interview with CNA A on 12/14/22 at 1:34 pm, she was asked who assisted residents with nail care. She replied We do, the CNAs do. She was asked if she was caring for Resident #73 today. She replied yes. She was asked if he needed assistance with his nail care. She replied, Yes, he always tells me he wants the podiatrist to do his fingernails, but I told him they only do the toenails. He did let me me cut his fingernails and clean under them today, after four months of me asking him to do them. She was asked about the brown debris under his nails. She stated, He does refuse that too, but he let me clean them today. He only let me trim the nails on both hands but clean under right hand nails. He wouldn't let me clean under the left hand fingers. She was asked if the restorative aides worked with him. She stated, Yes, they work with him for a brace on his left hand. She was asked if they ever trimmed his nails or cleaned under his nails. She stated, Not that I'm aware of. She was asked what she did when Resident #73 refused nail care. She stated, I let the nurse know. She was asked if he ever refused showers. She stated, No, he gets showers twice a week. In an interview with Licensed Practical Nurse (LPN) B on 12/14/22 at 2:32 PM, she was asked if she was caring for Resident #73 today. She stated yes. She was asked if he had every refused fingernail trimming or cleaning. She stated No, not that I'm aware of. She was asked how she was made aware if any resident refused any aspect of their care. She stated, The CNAs will tell us; they tell the nurse. She was asked if the CNAs always let her know if a resident refused any ADL care, such as bathing, mouth care, or nail care. She stated, Yes, they do. She was asked if she charted anywhere when care was refused. She stated, Yes, I'll write a progress note, and the CNAs will mark refused in their documentation. In an interview with Occupational Therapist (OT) C on 12/14/22 at 1:53 PM, she was asked if she had seen Resident #73 for Occupational Therapy (OT). She stated yes. She was asked if she had completed a Restorative Program referral for this resident in November 2022. She stated yes. She was asked if OT provided nail care for the resident. She stated, I'm not sure. The restorative aide would be following the plan of care. She was asked if she had provided any nail care for the resident. She stated, No, we have nail brushes and emery boards to file nails. She was asked if the resident had declined or refused any care or treatments. She stated, Not with me. In an interview with LPN D on 12/14/22 at 2:50 PM, she was asked if she was the manager of the Restorative Nursing Program. She stated yes. She was asked if Resident #73 was current on restorative services. She stated yes. She was asked who created the restorative plan of care. She stated, Physical Therapy or Occupational Therapy create the plan of care during their initial evaluation. She was asked who followed that plan of care. She stated, We have two restorative aides. They are also CNAs. I also help out hands on, like if one of them is out on a transport with a resident. She was asked what was in the restorative plan of care for Resident #73. She stated, Passive range of motion to his left upper extremity is done daily, he wears a splint on his left hand, and restorative applies the splint. Ensure skin is clean and dry where the splint is, and his palm and in-between fingers. Provide nail and skin hygiene. She was asked if the resident was receiving nail care. She stated, They haven't trimmed them in a while, but they have been cleaning under them. She was asked if Resident #73 ever declined nail care. She stated, He has in the past; he has refused the cleaning sometimes. They try to do the best they can so they are charting that they are doing it. She was asked if it was charted anywhere when he refused nail care. She stated, They can put refused on the care. She was asked if anyone had charted any of his care as refused. She stated, No, they have not charted his nail care as refused. She was asked how she was made aware if the resident declined the care. She stated, Normally they tell me, but they have not told me he's refused any care. A review of the facility policy titled Activities of Daily Living, Supporting (revised 3/2018) revealed a policy statement which read: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure it provided restorative services for one (Resident #40) resident sampled for restorative care provided, from a total sample of 44 residents. This placed Resident #40 at risk for functional decline. The findings include: During an interview with Resident #40 on 4/26/21 at 11:36 AM, he was observed using a wheelchair as a mobility aid. He reported that he was supposed to be on restorative programs for stand-to-sit and for walking, but it was not happening. During another interview with Resident #40 on 4/28/21 at 09:30 AM, he revealed that he spoke with the Physical Therapy Manager/Therapist who told him his services would start on 5/03/21. A record review for Resident #40 revealed he was admitted to the facility on [DATE]. His diagnoses included, but were not limited to, coronary artery disease, heart failure, hypertension, diabetes mellitus, arthritis, osteoporosis, and morbid obesity. A review of Resident #40's Significant Change Minimum Data Set assessment, dated 3/6/21, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognitive response. The assessment was documented that he required extensive assistance of 2 people with bed mobility and transfers, and 1-person extensive assistance to walk in his room and in the corridors. His balance during transitions and walking was not steady, and he used a walker and a wheelchair as mobility aids. The care plan for Resident #40 was reviewed and documented that Resident #40 was a fall risk and non-compliant with waiting for assistance and using his walker for transfers and ambulation. Approaches included refer to physical therapy as needed. A review of Resident #40's physician's orders dated 4/19/21 read: Discontinue skilled PT services and continue with RNP (restorative nursing program). A review of the RNP Occupational Therapy Functional Maintenance Program for Resident #40, dated 4/16/21, revealed the goal: Sit to stand transfers x 5 repetitions at the hall rail or parallel bars with minimal assistance and cues for hand/foot placement, scoot to edge of chair. (Photographic evidence obtained) A review of the CNA [NAME] for Resident #40, asking how Resident #40 ambulated in corridors and his room revealed many of the fields over the last 30 days were marked not applicable. The [NAME] section titled Nursing Rehab: Transfers: Sit to stand transfers x 5 repetitions at hall rail and cues for hand/foot placement, scoot to edge of chair for staff to fill in was left blank for the past 30 days. The Nursing Rehab: Walking, assist to toilet using 2 WW (wheeled walker) from elevated EOB (edge of bed), 3 x's a week as tolerated section for staff to complete was also blank for the past 30 days. (Photographic evidence was obtained) An interview was conducted with Employee A, Restorative Certified Nursing Assistant, on 4/29/21 at 10:27 AM. She stated that Resident #40 was put on restorative services a week ago and his goals are to walk to the bathroom and move from sitting to standing position for 5 repetitions. During the interview, Employee A revealed that due to short staffing and restorative department having to finish monthly weights, they had not been able to provide Resident #40's restorative services. .

Based on observations and staff interviews, the facility failed to store dishware, covered or inverted, in a location where it was not exposed to splash, dust and other contamination. This deficient practice potentially affected all residents in the facility who took their meals from the facility's kitchen. The findings include: During a kitchen visit on 04/28/21 at 11:31 AM, the plate dispenser was observed next to the stove and partially under the vent hood. The plates were stored face-up and were not covered in a manner to prevent food, grease splatters, or dust and debris from landing on the face or lip of the plates. A second kitchen visit and interview with Employee C, Dietary [NAME] was conducted on 04/29/21 at 09:45 AM. The plate dispenser was once again observed full of plates partially under the vent hood with plates face-up not inverted. The Dietary [NAME] acknowledged the potential for cross-contamination of the eating surface of the plates and confirmed they should be stored face down or covered. During an interview with the Certified Dietary Manager on 4/29/21 at 10:00 AM, he acknowledged the potential for contamination of the eating surfaces of the plates. .