**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to develop a baseline care plan that included respiratory care for Resident #49, as evidenced by: Resident #49, was admitted on [DATE] and receiving multiple respiratory treatments, did not have a baseline care plan developed until six days after admission.The findings included:On 09/09/2025 at 9:45 AM, Resident #49 was observed seated in a wheelchair watching television. The resident reported no concerns and revealed she had two weeks remained in rehabilitation following a fall at home. On 09/10/2025 at 8:34 AM, the resident actively participated in therapy, with no concerns noted or reported. During the observation on 09/11/2025 at 10:15 AM, the resident was again seated in a wheelchair, and no concerns were noted or reported. A review of the medical record for Resident #49 showed an admission date of 09/04/2025, with diagnoses including Encounter for other specified aftercare and Chronic Obstructive Pulmonary Disease (COPD). The admission Minimum Data Set (MDS) was in progress at the time of review. The Entry MDS was completed on 09/08/2025, and the Assessment Reference Date (ARD) was set for 09/10/2025. Review of Physician orders dated between 09/04/2025 and 09/09/2025 indicated that the resident received multiple active respiratory treatments. These included Budesonide (Pulmicort) 0.5 mg/2ml (0.5 milligrams per 0.5 milliliters) via nebulizer twice daily, Formoterol Tartrate (Brovana) 5 mcg/2 ml (5 micrograms per 2 milliliters) nebulization solution twice daily, and Ipratropium-Albuterol solution every six hours via nebulizer. A pulmonology consultation was ordered on 09/08/2025 for pneumonia. Additional orders included Prednisone 10 mg daily for five days, Cefuroxime 250mg orally twice daily for pneumonia, and an order dated 09/04/2025 to check oxygen saturation.Review of Progress notes from 09/07/2025 and 09/08/2025 documented treatment for pneumonia and COPD. On 09/10/2025 at 11:30 AM, the Manager of Clinical Reimbursement, MDS Registered Nurse confirmed that although the ARD was set for 09/10/2025 and baseline care plan initiation was scheduled for that day, the resident had been receiving multiple respiratory interventions since 09/04/2025. The MDS RN acknowledged that the baseline care plan had not been completed and lacked interim documentation outlining essential respiratory treatments or goals.Despite clear orders for multiple inhaled and oral medications, consults, and respiratory monitoring, the facility failed to develop or implement a baseline care plan within 48 hours of admission that addressed the resident's respiratory needs.Following the interview, on 09/10/2025 at 12:40 PM, the Director of Nursing (DON) entered the conference room and hand-delivered a newly created baseline care plan. This plan had been developed only after the surveyor's inquiry, confirming that the baseline care plan was not completed within the regulatory time frame and was created in response to surveyor involvement.A review of the facility's Policy and Procedures for Baseline Care Plan for Care Planning, effective 12/03/2004, revised 02/22/2026, and reviewed 10/16/2024, revealed the following: The policy indicated that care, treatment, and services are planned to ensure appropriateness to the resident's needs. The facility provides an individualized, interdisciplinary plan of care addressing all resident needs, strengths, limitations, and goals. Care planning is implemented through integration of assessment findings, prescribed treatment plans, and development of reasonable and measurable goals. Documentation is completed using computerized care planning. The procedure specified that an interim care plan must be completed no later than 72 hours after admission.

Based on observations, staff interviews, and records review, the facility failed to implement effective corrective actions to address previously identified deficiencies. This is evidenced by the repeated citation of F655 - Development of a Baseline Care Plan. Despite prior citations and the opportunity for corrective action, the facility did not demonstrate sustained compliance. At the time of the survey, 22 residents were residing in the facility. The findings included:Review of the facility's survey history revealed, during a recertification survey with exit date 05/15/ 2024, F655 Development of a baseline care plan was cited related to facility's failure to develop a baseline care plan for oxygen use for one resident.During this survey with exit dated 09/11/2025, the facility did not develop Resident #49's baseline care plan for respiratory care.On 09/11/2025, at 12:30 PM, a Quality Assurance and Performance Improvement (QAPI) review was conducted with the Director of Nursing and the Administrator. The facility's Quality Assurance and Performance Improvement (QAPI) policy and procedure dated February 14, 2025, was reviewed with no concerns noted. The facility has a Quality Assurance and Assessment (QAA) Committee that meets every month on the second Wednesday. The most recent meeting was on September 13, 2025. Sign-in sheets showed that all required team members attended, including representatives from nursing, therapy, social services, dietary, and environmental services.The committee's primary objective is to ensure a safe, person-centered care environment. through data-driven analysis, collaborative problem-solving. The team uses data, teamwork, and improvement plans to fix problems. Every day at 9:02 AM, staff meet to find and solve issues early. Staff can also report concerns in other ways, like talking to supervisors.The committee chooses projects based on risk and how much they affect residents and prioritizes projects based on risk and resident impact, using structured tools to help the team decide what to focus on. Progress is tracked through audits and staff feedback. Current improvement plans focus on hospital transfers and nutrition services. Other top issues include pressure ulcer prevention and fall reduction. All actions are checked and updated to make sure they work and stay in place and follow-up action revisions are conducted systematically to ensure accountability and sustained improvement.Review of the facility's Policy titled: Quality Assurance and Performance Improvement reviewed on 02/14/25I. MissionAs part of Catholic Health Services, Our Mission is to provide health care and services to those in need, to minimize human suffering, to assist people to wholeness and to nurture an awareness of their relationship with God.Il. VisionOur vision is to strive to improve the health, independence and spiritual life of the elderly, the poor, and the needy in the Archdiocese, through innovative and proactive approaches to:Managing care and providing services.Facilitating transitions across levels of care.Community partnerships and collaboration.Advocacy efforts.III. QAPI ObjectivesThe primary objectives of Quality Assurance & Performance Improvement (QAP) is to monitor, assess and improve performance of critical focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors on a continuous basis throughout the facility.

Based on observation, record review and interview, the facility failed to develop a baseline care plan for oxygen use for one (Resident #78) out of one sampled resident reviewed for oxygen therapy. The findings included: During the observational tour on 05/13/24 at 08:10 AM, Resident #78 was observed in bed receiving oxygen(O2) via nasal cannula (NC) connected to the wall oxygen supply. The resident reported that he is on oxygen at 2 liters. An observation of the oxygen flow meter revealed the oxygen was set at 4 liters per minute. (Photo Obtained) The resident reported he fell at his house in April 2024, fractured five ribs and had a pneumothorax. On 05/13/24 at 11:51 AM, Resident #78 was observed sitting up in a wheelchair and looking at his phone. He had a garden salad from home on his bedside table and he reported he preferred the salad his wife brought him. The oxygen nasal cannula was observed on, but the level was not checked at this time. On 05/14/24 at 08:33 AM, Resident #78 was observed in bed awake. A staff person from the Physical Therapy (PT) was at the residents bedside. The PT staff person reports the resident did not want to get out of bed this morning so the physical therapy would be provided in the resident's room. Observation revealed, the O2 via NC was set at 2 liters on the wall oxygen flow meter. A review of Resident #78's electronic medical record revealed, an admission date of 05/08/2024 with diagnoses to include Acute Respiratory Failure, Congestive Heart Failure (CHF) Exacerbation, Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and Pacemaker insertion. Review of the physician's orders revealed an order on 5/8/24 for 02 at 2 liters per minute. A review of Resident #78's electronic medical record revealed, a Baseline Care Plan and Summary that included the resident's admission date, diagnoses, code status, Physician, Diet order, allergies, Medications, Physical Therapy, Occupational Therapy, Consults, Problem and Care Plan Goals. The Baseline Care Plan did not include information about the resident's order for oxygen at 2 liters per minute. On 05/15/24 at 9:53 AM, interview and record with the Director of Nurses (DON) revealed that the oxygen was not included on the Baseline Care Plan and Summary and the Interim Care Plan-Admission. The DON contacted the Minimum Data Set (MDS) Coordinator for the care plan. On 05/15/24 at 10:15 AM, the DON brought a comprehensive care plan that included a care plan for the potential for shortness of breath, alteration in respiratory status due to COPD, alteration in respiratory status due to status post (s/p) exacerbation of CHF and potential for hypoxia related diagnosis of CHF. The interventions included: Administer oxygen and nebulizer treatments as ordered. This information related to oxygen use was not included on the Baseline Care Plan and Summary and the Interim Care Plan-Admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the urinary catheter care plan for one out of one (Resident #79) sampled resident reviewed for catheter care. The findings included: During tour on 05/13/24 at 08:55 AM, Resident #79 was observed sitting in a wheelchair at the sink in the resident's room. The resident was dressed, and a family member was at his bedside. A urinary catheter was observed on the right side of the wheelchair at the same level where the resident was sitting. The white side of the drainage bag was observed, and the drainage bag was not in a privacy bag. The resident's family member reported facility staff are going to give Resident #79 a leg bag for the catheter. The drainage bag was not observed to be below the resident's bladder. Observation on 05/13/24 at 09:02 AM revealed, Resident #79 being rolled out of the room in a wheelchair by a staff person from the therapy department. The urinary catheter was in the same position on the wheelchair. Observation on 05/13/24 at 09:20 AM revealed the resident was in the therapy room, sitting in the wheelchair. A gait belt was placed on him, the resident was observed standing and sitting with a therapy staff member at his side. Observation on 05/13/24 at 12:02 PM revealed, the resident sitting at bedside eating lunch. The urinary catheter bag was at the head of the resident bed and the tubing was on the resident's bed. The urinary catheter bag was observed next to the blue privacy bag. The drainage bag was not inside the privacy bag. Observation on 05/14/24 at 08:50 AM revealed, the resident was in bed, the urinary catheter was at the foot of the bed, below the bladder, the urine was amber, and appeared to have a small amount of mucous in in the tubing. A review of Resident #79's electronic medical record revealed, Resident #79 was admitted to the facility on [DATE] with diagnoses to include Urinary Retention due to an Enlarged Prostate. The resident had a physician order for 5/9/24 - Provide [ brand] catheter care every shift and on 5/10/24 - Diagnosis for [indwelling catheter] use: Urinary Retention due to enlarged prostate. A review of the residents Minimum Data Set (MDS) revealed the assessment was in the process of being completed. A review of the residents care plans revealed Care Plans for At Risk for an Infection due to the use of an indwelling catheter-dated 5/9/24. The Care Plan interventions included, Make sure drainage bag hangs below level of bladder and is covered when out of bed. This care plan was not followed. Interview on 05/14/24 at 01:49 PM with the Director of Nurses (DON) about the urinary catheter observations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the facility's policy and procedure for catheter care for one out of one resident (Resident #79) reviewed for urinary catheter care. The findings included: During tour on 05/13/24 at 08:55 AM, Resident #79 was observed sitting in a wheelchair at the sink in the resident room. The resident was dressed, and a family member was at his bedside. A urinary catheter was observed on the right side of the wheelchair at the same level where the resident was sitting. The white side of the drainage bag was observed, and the drainage bag was not in a privacy bag. The resident's family member reported that facility staff are going to give Resident #79 a leg bag for the catheter. The drainage bag was not observed to be below the residents bladder or in a privacy bag. Observation on 05/13/24 at 09:02 AM revealed, Resident #79 being rolled out of the room in a wheelchair by a staff person from the therapy department. The urinary catheter was in the same position on the wheelchair. Observation on 05/13/24 at 09:20 AM revealed the resident was in the therapy room, sitting in the wheelchair. A gait belt was placed on him, the resident was observed standing and sitting with a therapy staff member at his side. Observation on 05/13/24 at 12:02 PM revealed, the resident sitting at bedside eating lunch. The urinary catheter bag was at the head of the resident's bed and the tubing was on the resident bed. The urinary catheter bag was observed next to the blue privacy bag. The drainage bag was not inside the privacy bag. Observation on 05/14/24 at 08:50 AM revealed, the resident was in bed, the urinary catheter was at the foot of the bed, below the bladder, the urine was amber, and appeared to have a small amount of mucous in in the tubing. A review of Resident #79's electronic medical record revealed, Resident #79 was admitted to the facility on [DATE] with diagnoses to include Urinary Retention due to an Enlarged Prostate. The resident had a physician order for 5/9/24 - Provide [] catheter care every shift and on 5/10/24 - Diagnosis for [indwelling catheter] use: Urinary Retention due to enlarged prostate. A review of the residents Minimum Data Set (MDS) revealed the assessment was in the process of being completed. A review of the resident's care plans revealed, Care Plans for At Risk for an Infection due to the use of an indwelling catheter-dated 5/9/24. The Care Plan interventions included, Make sure drainage bag hangs below level of bladder and is covered when out of bed. This care plan was not followed. Interview on 05/14/24 at 01:49 PM with the Director of Nurses (DON) about the urinary catheter observations. The facility's policy for catheter care was requested. The facility policy and procedure for [] Catheter Care, effective 5/28/2008 and reviewed 4/14/2024 revealed, Policy: It is the policy of this facility that catheter care will be provided to all residents with indwelling catheters at least daily and more often as needed due to soiling with feces or when it is deemed necessary by the nurse. The Purpose: The purpose of the catheter care is to prevent possible urinary tract infections from bacteria spreading from the perineal area and external catheter into the bladder. Basic Procedures: The catheter and drainage bag should be kept as a closed system with the drainage bag kept at a level lower that the bladder to allow drainage by gravity.

Based on observation, record review and interview, the facility failed to ensure oxygen therapy was accurately administered as ordered by the physician for one (Resident #78) out of one resident reviewed for the use of oxygen. The finding included: During the observation tour on 05/13/24 at 08:10 AM, Resident #78 was observed in bed receiving oxygen(O2) via nasal cannula (NC) connected to the wall oxygen supply. The resident reported that he is on oxygen at 2 liters. An observation of the oxygen flow meter revealed the oxygen was set at 4 liters per minute. (Photo Obtained) The resident reported he fell at his house in April 2024, fractured five ribs and had a pneumothorax. The resident was working on a crossword puzzle and wasn't observed to be in distress. On 05/13/24 at 11:51 AM, Resident #78 was observed sitting up in a wheelchair and looking at his phone. He had a garden salad from home on his bedside table. He reported he preferred the salad his wife brought him. The oxygen's nasal cannula was observed on, but the level was not checked at this time. On 05/14/24 at 08:33 AM, Resident #78 was observed in bed awake. A staff person from the Physical Therapy (PT) was at the residents bedside. The PT staff person reported that the resident did not want to get out of bed this morning so the physical therapy would be provided in the resident's room. Observation revealed, the O2 via NC was set at 2 liters on the wall oxygen flow meter. A review of Resident #78's electronic medical record revealed, an admission date of 05/08/2024 with diagnoses to include Acute Respiratory Failure, Congestive Heart Failure (CHF) Exacerbation, Chronic Obstructive Pulmonary Disease (COPD) Exacerbation, Pacemaker insertion. A review of the physicians orders revealed an order on 5/8/24 for 02 2 liters/min (liters/minute). A review of Resident #78's Minimum Data Set (MDS) revealed it was incomplete and in the process of being completed. A review of Resident #78's electronic medical record revealed, a Baseline Care Plan and Summary that included the residents admission date, diagnoses, code status, Physician, Diet order, allergies, Medications, Physical Therapy, Occupational Therapy, Consults, Problem and Care Plan Goals. The Baseline Care Plan did not include information about the resident's order for oxygen at 2 liters per minute. On 05/15/24 at 9:53 AM, interview and record with the Director of Nurses (DON) revealed that the oxygen was not included on the Baseline Care Plan and Summary and the Interim Care Plan-Admission. The DON was informed the oxygen was observed at 4 liters per min on 05/13/24 and a photo was obtained. The DON contacted the Minimum Data Set (MDS) Coordinator for the care plan. On 05/15/24 at 10:15 AM, the DON brought a comprehensive care plan that included a care plan for the potential for shortness of breath, alteration in respiratory status due to COPD, alteration in respiratory status due to status post (s/p) exacerbation of CHF and potential for hypoxia related diagnosis of CHF. The interventions included Administer oxygen and nebulizer treatments as ordered. A review of the facility's policy and procedure for Respiratory effective 8/12/2019 and reviewed on 4/14/2024 revealed, Policy: It is the policy of the facility to provide respiratory therapy services to patients/residents when ordered by a physician. Purpose: To ensure that all patients/residents in the facility have access to prescribed respiratory therapy services when medically indicated. Procedures included: 2. Upon receipt of a physician order for Respiratory Therapy, the nurse will contact the respiratory therapist during the hours of respiratory therapy coverage. 3. Services provided by the respiratory therapist may include (but are not limited to) the following depending upon the clinical needs of the patient/resident: b. Provision and maintenance of respiratory equipment (e.g., O2 concentrator, O2 set-up nebulizer machine, suction machine, etc.)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to follow infection control standards and procedures during blood glucose monitoring for one (Resident # 228) out of one resident reviewed. As evidenced by Licensed Practical Nurse (Staff A) taking the entire blood glucose monitoring machine in the kit along with all the supplies enclosed into the resident's room to perform blood glucose monitoring. The findings included: On 05/13/24 at 11:42 AM during blood glucose monitoring observation for Resident #228 with Licensed Practical Nurse (Staff A), Staff A checked Resident #228's blood glucose treatment orders, proceeded to enter the resident's room with the complete blood glucose monitoring machine kit/case, applied a barrier on the overbed table, placed the blood glucose monitoring kit/case the on barrier, identified resident, explained treatment, washed hands, donned gloves, opened the blood glucose monitoring kit/case containing the machine and supplies .performed blood glucose check .dispose of supplies in biohazard bag, cleaned the machine with disinfecting wipes, let dry, washed hands exited room. Disposed of the biohazard as required washed hands .etc. Review of Resident #228's the medical records revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Type II Diabetes Mellitus. Review of the Physician's Orders Sheet for May 2024 revealed Resident #228 had orders that included but not limited to: Insulin Solution Pen Injector Subcutaneous Dose: per sliding scale order before meals and at bedtime for Diabetes Mellitus. During an interview on 05/13/24 at 11:53 AM, Staff A was asked about taking the entire blood glucose monitoring kit/case into the resident's room, Staff A stated: I should only take the supplies I need into the resident's room to perform the treatment and when I leave the room, I would discard any leftover unused supplies that were taken in the room. Interview on 05/14/24 at 01:38 PM Director of Nursing (DON) revealed the facility's policy does not directly address whether or not the nurses can take the entire blood glucose monitoring kit/case into the room during treatment, usually the nurses will place the machine and the supplies they need for treatment on a tray and then enter the room. The nurses have been trained how to maintain infection control standards during the blood glucose checks to avoid any issues or contamination. Review of the facility policy and procedures titled Blood Glucose Monitoring . revision date 6/20/2018 states: Only an operator who has demonstrated competence may perform blood glucose monitoring, utilizing the [brand] Inform II, to determine a resident's blood glucose level. Testing shall be performed upon capillary, arterial, or venous whole blood and the results will be recorded in the patient's record. Quality control is performed by the nursing staff. Fingerstick Sample Collection: Step 1 Assemble all the materials you will need to collect a blood sample Glove, skin, preparation pad, auto disabling single use lancet device, gauze, or cotton ball.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to act on a resident's request for psychiatry consultation for 1 (Resident # 176) of 1 resident reviewed for Behavioral Health. The findings included: Resident #176 was admitted to the facility on [DATE]. Resident #176's care plan, initiated on 12/27/22, documented, [Resident Name] is at risk for side effects, adverse reaction related to use of antidepressant medication required for diagnosis of depression. The goal of the care plan was documented as, Will have no side effects or adverse reaction to use of antidepressant over the next 30 days. Interventions to the care plan included - * Psychiatrist to evaluate and treat for mood state and medication review as indicated. * Maintain fall precautions. * Instruct staff on daily interventions that will respect, understand, and manage the resident's condition and support their safety and rights. * Observe for side effects, adverse reaction: dry mouth, constipation, changes in appetite, insomnia, fatigue, increased agitation or irritability, and falls. * Monitor and document moods and behaviors if they persist with treatment. * Discuss side effects of medication with resident and/or health care surrogate. Resident #176's Orders included: (Eliquis) Apixaban 2.5 mg tablet - by mouth twice a day for DVT Prophylaxis - 12/17/22 Sertraline HCI 100 Mg tablet by mouth daily for Major depressive disorder - 12/17/22 Tramadol HCI 50 mg tablet by mouth every 6 hours as needed - 12/17/22 During an interview with Resident #176 and the resident's son, on 12/27/22 at 12:53 PM, Resident #176's son stated, I think that we need to have someone see him. I told the nurse about a week ago. I believe the person for psychiatry is out for the holidays. Resident #176's son further stated, He came in here . for about a week and was feeling very nauseous and was sent to the hospital and then came back. He is a very independent person, he drives, cooks and cleans and now that he is in this state, he has been very depressed. Resident #176 echoed the statements made by his son and stated that he was feeling 'depressed' and wished to be seen by a psychiatrist/psychologist. During an interview, on 12/28/22 at 12:08 PM with Staff C, LPN, when asked about the psychiatrist services, Staff C replied, She comes every Monday. She wasn't here this week because of the holiday. Usually when we put the order, we give the secretary the order and she call to make to make the appointment. During an interview, on 12/28/22 at 12:27 PM, with Staff D, LPN, when asked of the process when a resident requests psychiatry consult, Staff D replied, in that case, I notify the psychiatry doctor right away and then and she would give an order for medication, and she would tell me that she would see him. If the doctor is out for vacation, we notify the facility doctor, and he passes by to evaluate the patient until the psychiatrist is back. On 12/28/22 at 12:34 PM, Staff C called the psychiatrist and was answered by answering service and reported that she was waiting for a call back. When it was reported to Staff C and Staff D that Resident #176 had stated that he felt 'depressed' Staff D replied, He had an order put in on 12/18/22 (as a new admission). She has not seen the patient yet. The order is for one month. His brother asked about seeing a psychiatrist, but sometimes he will wake up with a little headache. They told me about two weeks ago. I told the secretary. On 12/28/22 at 1:36 PM Medical Records reported that there was no documentation of the resident stating that he was depressed and requested to see psychiatry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review, observation and interview, the facility failed to offer and provide group activities to residents, with the potential to affect all residents in the facility, including Resident #175. The census at the time of the survey was 17 residents. The findings included: The facility's admission Packet documented, Recreational activities that are fun and therapeutic are regularly planned for residents. These include arts and crafts, exercise, films, games, and sports. We also offer group discussions of current events. A member of the Recreational Therapy department will meet with you to discuss your special interests, hobbies, and talents. Music is enjoyed regularly in the facility, especially during the holiday and birthday celebrations. People from the community of all ages, from elementary school children to senior citizens come to entertain. A monthly calendar of activities is distributed to residents and posted in your room and throughout the facility. The facility's website documented: Your collaborative care team includes: * Medical directors * Registered nurses * Licensed practical nurses * Certified nursing assistants * Dieticians * Activities coordinators * Social workers * Case managers * Occupational, physical and speech therapists The Facility Assessment, most recently reviewed on 09/02/22, documented, A monthly activity calendar is provided to the residents. The Resident council meeting is held on a monthly basis. Due to the short length of stay of our patients, each meeting held has new residents therefore we are unable to have an elected president. The Activities Calendar provided by the facility and posted at the nurse's station showed that there was only one activity per day, which consisted of: Sundays at 11:00 AM - 'Mass (Channel 11)' Mondays at 11:30 AM - - 'Sensory activity' on 12/05/22 and 12/19/22 - 'Crossword Packets' on 12/12/22 and 12/26/22 Tuesdays - - on 12/06/22 at 1:00 PM - 'Resident Council' (it was stated during the entrance conference that the facility did not have a Resident Council) - on 12/13/22 at 11:30 AM - 'Sensory Activity' - on 12/20/22 and 12/27/22 at 11:00 AM - 'Arts & Crafts 1:1' Wednesdays at 11:00 AM - 'Mass (Channel 11) Thursdays - - On 12/01/22 and 12/29/22 at 11:30 AM 'Sensory Activity' - On 12/08/2, 12/15/22 and 12/22/22 at 11:00 AM 'Arts & Crafts 1:1' Fridays at 11:30 AM - 'Crossword Packets' Saturdays 'Crossword Packets Available in Dining room' Resident #175 was admitted on [DATE]. A care plan date dated 12/23/22 indicate [Resident's name] is alert, able to make needs known and engages in activities of choice daily. The goal of the care plan was documented as, Will continue to engage in activities of choice daily through next review date as evidenced by staff observations and daily participation records. With a target date of 01/22/23. Interventions to the care plan included: * Provide arts/crafts material books-for-the-blind crossword puzzles deck of cards large print reading material magazines pen/pencil stress ball television channel listing word search for in-room activities PRN and encourage family to bring favorite games, books or leisure items from home if requested. * Provide spiritual assistance, refer to pastoral care for support and comfort measures. * Invite and escort if needed to group programs, social events daily. * Establish their likes and dislikes and what is most important to them through the activity assessment and assist to achieve personal goals related to activities during their stay. * Provide/post monthly recreation calendar of events. During an observation and interview with Resident #175, on 12/27/22 at 11:23 AM, when asked about participation in activities, Resident #175 replied, Today is the first day that I have done anything, and it was therapy. I had an operation on 12/19/22 and came here on the 21st. Every morning, They start at about 5:30 AM in the morning. at 6:00 AM they came with breakfast. Then I asked for a bath .I had breakfast today at 7:00 AM and then they took me to the bathroom. at about 9:30 AM they took me down to therapy. I was in my room for about an hour, and they took me back down again to therapy. I would like to do table games. I cannot walk. During an interview, on 12/27/22 at 12:33 PM, Staff B, OTA (Occupational Therapy Assistant) was asked about activities, Staff B replied, I walk around and go from room to room I ask them if they would like items that they can do in their room, paint things or craft things, books, word search, activity books, playing cards. Since the COVID, we haven't used the activity room. The patients could come on their own (to the Activity Room). Staff B stated that there was no Activities Director. The director left in October, they are looking for someone, but they haven't found anybody. Nobody has been asking me to take them to the Activities Room. The schedule for mealtimes showed that lunch is served to the residents from 12:00 PM to 1:00 PM. On 12/27/22 at 11:48 AM, lunch was being served to the residents in their rooms. During an interview, on 12/29/22 at approximately 9:00 AM, with the Human Resource Manager, when asked about Activities staff, the Human Resources Manager replied, We have an OTA that does activities. We had an Activities Director a long time ago and that switched over to the therapy department. During an interview, on 12/29/22 at 9:39 AM, the Administrator revealed the department went through the transition to the new therapy contractor, our OT (Occupational Therapy) ran the activities. There was no documentation of resident's participation in an activities program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to follow the approved menu to ensure that the nutritional needs of 17 of 17 facility residents (Includes sampled Resident #4, Resident #30, Resident #36, Resident #75, Resident #76, Resident #77, and Resident #78) were being met. The findings included. During the observation of the lunch tray line in the main kitchen on 12/28/22 at 11:30 AM, it was noted that the serving portion of the Chili -Texas Cowboy (entree) was a 4-ounce ladle portion and the pureed Chili was a 4-ounce scoop for Regular, Carbohydrate Controlled, Mechanical Soft, and No Added Salt diets. It was noted that bot entrees were being served in a 4-ounce dessert/vegetable dish which could not include the 3 once protein portion and 4-ounce carbohydrate portion,. A review of the approved menu production sheets and resident menus for the lunch meal on 12/28/22 both documented an 8-ounce portion to be served. At the request of the surveyor a copy of the standardized recipe for the Texas Cowboy Chili was obtained. A review of the recipe documented that the entree portion to be served was 1-1/2 cups (12 ounces). Interview with the Food Service Director and [NAME] (Staff A) during the observation revealed that they were unaware the recipe documented a 12-ounce portion, and the approved menu/production sheet documented an 8-ounce portion. it was further discussed with the FSD and Registered Dietitian that the residents were receiving an insufficient serving of the Chili entree. it was noted during the interview that the Chili portion size did not meet the minimum 3-ounce cooked protein as per the approved menu. A review of the facility diet census for 12/28/22 indicated that all 17 facility residents were affected by the entree for the lunch meal of 12/28/22. The 17 residents included sampled Resident #4, Resident #30, Resident #36, Resident #75, Resident #76, Resident #77, and Resident #78. Further review of Resident #30's clinical record indicated the resident was admitted to the facility on [DATE] clinical diagnoses included but not limited to Congested Heart Failure (CHF), Diabetes, Rectal Bleeding and Hypertension. Physician orders dated 12/22/2022 included: Daily Weights, Pureed Diet with -Nectar Consistency Liquids. Order Dated 12/23/2022 - Diabetes Snack BID (twice daily), Vitamin C 500 mg daily for vitamin deficiency, Folic Acid 1 mg at bedtime (Q HS) for vitamin deficiency. Active Critical Care Sugar Free 30 ml BID - Protein Wound healing. Glucerna 240 ml QD - Diabetic Supplement. Order dated 12/28/2022- Stage II Pressure Ulcer Coccyx. Review of the resident's weight history indicated: 12/27/22 - 141.1 pounds 12/26/22 -Refused 12/24/22 - Refused 12/23/22- Refused 12/22/22 - Refused Review of Dietary Notes dated 12/23/22 documented the resident states appetite has decreased, PO (by mouth) intake 50-75%, Active Critical Care BID for wound healing, MNA (The Mini Nutritional Assessment) scores indicate Risk For Malnutrition, BMI (Body Mass Index) =21.8 (Malnutrition).